Carlow University Department of Nursing
MSN-Family/Individual Across Lifespan
History/Physical Exam (H&P) Template for ALL Clinical Practicum Courses
BB, 01/21/2021 1500:
Identifying Data and Source of the History: B
...
Carlow University Department of Nursing
MSN-Family/Individual Across Lifespan
History/Physical Exam (H&P) Template for ALL Clinical Practicum Courses
BB, 01/21/2021 1500:
Identifying Data and Source of the History: BB is a 72 y/o married male, who is a retired architect.
Source: Patient
Reliability: The source of information is the patient and is reliable.
Chief Complaint (CC): Shortness of breath
Present Illness:
BB is a 72 y/o male that came in with complaints of shortness of breath that started 2 months
ago. His shortness of breath has progressively worsened and is occurring even at rest. He feels like he is
being smothered or suffocated. This has been awakening him at night. He has been sleeping in a recliner
due to lying on his back making it worse.
He has been experiencing fatigue, that started around the same time as the shortness of breath.
It is worsened with physical effort but is present without activity. Patient feels it is getting worse.
He has a cough with white frothy sputum that started with the shortness of breath. This is
different from his usual “morning smokers cough” he has. It is worse with activity. He has not tried any
treatment for it. He denies any chest pain or pressure.
BB has noticed increased swelling in his abdomen and legs that has progressively increased over
the last month. He has no changes in his appetite, but he does admit that he does not limit his sodium
intake. His wife and him have been eating out a lot recently and eating prepared meals. These are all new
symptoms for him, that he has never experienced before.
Current Medications: Aspirin daily, Metoprolol (pt is unsure of dosages, he says he takes them as
prescribed), Ramipril (unsure of dosage, takes as prescribed), Clopidogrel (unsure of dosage, takes as
prescribed), atorvastatin (unsure of dosage, takes as prescribed), and Tylenol PRN.
Allergies: No known drug or food allergies.
Past History:
Childhood Il
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