GOOD DAY PO DR. ORCASITAS RESPECTFULLY INFORMING YOU OF AN ADMISSION HERE AT BROKENSHIRE MEDICAL CENTER. NAME: ABRAHAM, EULOGIO AGE/SEX: 75/M DR. ORCASITAS (PC) ROOM: 25 CC: DYSPNEA ON MILD EXERTION HPI: PT HAS A 6 YEAR HISTORY OF DYSPNEA ON MILD EXERTION, WHICH WAS RELIEVED BY REST. PATIENT TOLERATED THE SYMPTOMS NO MEDICATIONS AND NO CONSULT WAS DONE. 1 MONTH PTA, DURING AN ANNUAL CHECK UP, SERIES OF WORKUP WAS DONE. PT WAS GIVEN DISCHARGED MEDS OF PROCATEROL 25MG TAB ½ TAB BID AND ANSIMAR/DILATAIR 400MG TAB 1 TAB BID. AND REFERRAL TO DR. ORCASITAS WAS ADVISED OR FURTHER EVAL. 1 WEEK PTA, PT CONSULTED WITH DR. ORCASITAS AND WAS DIAGNOSED WITH A RIGHT UPPER LOBE PULMONARY MASS. BIOPSY WAS ADVISED. HENCE, PATIENT PRESENTED TO THIS INSTITUTION FOR FURTHER EVALUATION AND MANAGEMENT. PMH: (+) HTN (2023) (+) PTB (1990S) – COMPLETED 6 MONTHS TREATMENT (-) DM (-) BA (-) HEART DISEASE (-) LIVER/THYROID/KIDNEY DISEASE (-) STROKE (-) CANCER NO KNOWN FOOD/DRUG ALLERGIES MEDICATIONS 1. VALSARTAN + AMLODIPINE 160/5 MG TAB 1 TAB OD 2. CARVEDILOL 6.25MG TAB 1 TAB BID2 PREVIOUS ADMISSIONS: (+) HISTORY OF STAB WOUND INJURY PREVIOUS SURGERIES: (+) CYST REMOVAL (1995) IDS: NO COVID INFECTION HISTORY PRIMARY SERIES: PFIZER X 2 DOSES 1 BOOSTER NO RECENT ANTIBIOTIC USE FOR THE PAST 3 MOS FMH: (-) HTN (-) DM (-) BA (-) HEART DISEASE (-) LIVER/THYROID/KIDNEY DISEASE (-) CANCER PSH: SMOKING: FORMER SMOKER; 36 PACK YEARS, QUIT IN 2003 ALCOHOL: NON-ALCOHOLIC BEVERAGE DRINKER. OCCUPATION: RETIRED SECURITY GUARD. ROS: NO HEADACHE (+) DIZZINESS (TOLERABLE) NO FEVER NO COUGH NO NAUSEA NO VOMITING NO ABDOMINAL PAIN NO DYSURIA NO DIARRHEA NO CONSTIPATION NO NIGHT SWEATS NO CHILLS NO WEIGHT LOSS PE: VS BP: 169/80 HR: 97 RR: 19 T: 36 SPO2: 98% HT: 160.6 WT: 49.9KGS GENERAL INSPECTION: AWAKE, NIRD HEENT INSPECTION: ANICTERIC SCLERAE, PINK PALPEBRAL CONJUNCTIVAE, MOIST, PINK LIPS AND ORAL MUCOSA, NO NASAL OR GINGIVAL BLEEDING NECK INSPECTION: NO NECK VEIN ENGORGEMENT, NO CERVICAL LYMPHADENOPATHY CHEST AND LUNGS INSPECTION: CHEST SYMMETRIC, (+) LOCALIZED BULGE/FULLNESS OVER THE RIGHT POSTERIOR THORACIC REGION, APPROXIMATELY 6 INCHES IN DIAMETER. OVERLYING SKIN APPEARS INTACT, WITH NO OBVIOUS ERYTHEMA, DISCOLORATION, OR ULCERATION. NO VISIBLE CHEST WALL RETRACTIONS. AUSCULTATION: (+) BILATERAL INSPIRATORY CRACKLES (+) SOFT, NON-TENDER PALPABLE MASS OVER THE POSTERIOR RIGHT CHEST WALL CARDIOVASCULAR INSPECTION: ADYNAMIC PRECORDIUM AUSCULTATION: REGULAR RHYTHM, DISTINCT HEART SOUNDS ABDOMEN INSPECTION: NON-DISTENDED A: NORMOACTIVE BOWEL SOUNDS P: SOFT, NON-TENDER, NO PALPABLE ORGANOMEGALY EXTREMITIES INSPECTION: NO EDEMA PALPATION: FULL PULSES, CRT <2 SECONDS OPD LABS 7/16/26 FBS: 6.60H SERUM URIC ACID: 357 CREATININE: 110.35 CHOLESTEROL: 5.30H TRIGLYCERIDES: 1.20 HDL: 1.25 LDL: 3.51 ALT(SGPT): 16.00 PSA: 2.64 NG/ML HBA1C: 5.6 7/28/26 CREATININE: 106 H EGFR: 63 ML ECG 7/15/26 INTERPRETATION SINUS RHYTHM. OLD ANTEROSEPTAL WALL MYOCARDIAL INFARCTION. POOR R WAVE PROGRESSION. PREMATURE ATRIAL CONTRACTIONS. IMAGING 7/15/26 IMPRESSION: INTERVAL INCREASE IN SIZE PULMONARY NODULE, RIGHT UPPER LOBE; PLEURAL THICKENING LEFT CT SCAN THORAX 7/31/26 IMPRESSION: IMPRESSION: SUBPLEURAL MASS, RIGHT UPPER LOBE CYLINDRICAL BRONCHIECTASIS, BILATERAL CENTRILOBULAR EMPHYSEMA, BILATERAL PLEUROPARENCHYMAL BANDS, BILATERAL PLEURO-APICAL CAPPING, RIGHT ATHEROSCLEROSIS CORONARY ARTERY DISEASE BONE ISLANDS, T9 AND T11 BONE DEMINERALIZATION DEGENERATIVE JOINT DISEASE AUG 8, 2026 XPERT MTB RIF ULTRA: MTB NOT DETECTED IMEROD: MEMO: PLEASE ADMIT PATIENT >UNDER THE CARE OF DR. ORCASITAS > SECURE CONSENT TO CARE VS Q4 HOURS; I&O QSHIFT DIET: LSLF IVF: PNSS @ 40 CC/HR DIAGNOSTICS: CBC WITH PLATELET PT/APTT FOR CTGAB. ( RESPECTFULLY ASKING IF FOR REFERRAL TO INTERVENTIONAL RADIOLOGIST OF CHOICE PO DOC) THANK YOU PO DR. ORCASITAS TORREON, CHARLES-EROD. I will be endorsing this case in case of interns and residents I need to know everything from this case for not to get scolded