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This is a hospital Admission and Physical Examination report. Read the report and answer the question.
ADMISSION HISTORY AND PHYSICAL EXAMINATION
PATIENT NAME: OTT, George HOSPITAL NUMBER: 208-333-7943 DATE OF ADMISSION: November 19, 20xx
HISTORY OF PRESENT ILLNESS This 65-year-old Caucasian male was evaluated by me in the emergency department on the above date, complaining of progressive shortness of breath, coughing, fever, and fatigue.
PAST HISTORY The patient was a coal miner for 25 years before he retired on disability with black lung disease at age 55. He currently smokes 2 packs of cigarettes per day and has done so for the past 22 years. Surgical history of an appendectomy in the remote past. Chest x-ray done recently showed a suspicious lesion in the LLL; a bronchoscopy was performed and a biopsy was done, but the biopsy results were negative for malignancy.
PHYSICAL EXAMINATION VITAL SIGNS: Pulse 110, respiratory rate 42 per minute, temperature 100.6, blood pressure 156/96.
GENERAL: The patient appears older than his stated age and quite tired at this time. HEENT: Negative, except for slight cyanosis of the lips. The neck is supple and free of any masses.
CHEST: There is an increased anteroposterior diameter to the chest. There are no intercostal retractions during inspiration.
There are diffuse expiratory wheezes, but no rales or rhonchi . HEART: Normal heart sounds without murmur, gallop, or rub.
ABDOMEN: Soft and nontender.
EXTREMITIES: Normal with full range of motion noted. There was no clubbing of the fingers noted.
LABORATORY DATA Complete blood count showed an elevated white blood cell count of 17,600 with 80 segs, 4 bands, and 2 lymphs. Oximeter showed 70 precents saturation. Sputum was sent for C&S. Chest x-ray: Patchy infiltrates from the apex to the midlung on the right with some consolidative changes involving the entire right lower lobe. There is no pleural fluid noted. There is a density seen in the left lower lobe posterolaterally, which extends to the pleural surface. It is most probably focal scarring or atelectasis from old inflammation.
- Right-sided pneumonia.
- Chronic obstructive pulmonary disease, secondary to anthracosis and smoking.
This patient has dyspnea. What phrase in the History of Present Illness says the same thing?_____________________________ What is the medical abbreviation for this phrase?___________________________________________