Pt. name:  Juan Manuel                          Admitting Physician:   Dr. Cane        
Age:64                                            DOB:1/27/1949                               Bed: 243
Admitting diagnosis: CHF, COPD
Pt. ID # 542768                                                Med Rec #:  78543
Wt. lbs: 200    kg: 90.9                  Ht.: 5 ft  2 in                                 Race:American- Hispanic
Major Support:  wife                                                                     Religion:Catholic

Immunizations: not current
Allergies: NKDA

History and Physical

Client Background:
Mr. Juan Manuel is a married American- Hispanic 64 yr old male,  height 5'2 , weight 200lbs.  Religion: Catholic, Occupation: construction worker with an Education level: technical school
Current Health Status:
Increasing tiredness and Shortness of Breath with ADL's, foot and ankle swelling
Past Medical History: 
History of COPD Stage II, Surgery: Hernia Repair
Psychosocial History:
Social support: family; wife of 30 yrs and two children ages 16yr old  boy is active in sports and 21yr old daughter who attends college at the local community college. Both children live at home  
Smoking History:  20 pack per year
Family History: CVD, HTN, COPD