iHuman_ Bill Buxton
Bill Buxton
72 yo male
5’8” (173.0 cm)
215 lbs (98.0kg)
CC: SOB
Skin:dry normal skin temp
38 required qts
CC-2
• How can I help you today? Feeling SOB with everything I do even doing not
...
iHuman_ Bill Buxton
Bill Buxton
72 yo male
5’8” (173.0 cm)
215 lbs (98.0kg)
CC: SOB
Skin:dry normal skin temp
38 required qts
CC-2
• How can I help you today? Feeling SOB with everything I do even doing nothing
• Tell me about any current or past medical problems?just heart problems and all the stuff with that you know HTN and cholesterol stuff
• Any other symptoms or concerns we should discuss? Body feels heavy fatigued legs and gut have been swelling
• What system is the most distressing for you? Breathing problem
Symptoms + Assoc Symptoms -14
1. When did your difficulty breathing start? About 2 months ago
2. Are you coughing up any sputum? White frothy phlegm NOT important
3. How severe is your difficulty breathing? Keeps me from doing a lot of things I used to do
4. How long does your SOB last? Never goes away anymore sometimes better and sometimes worse
5. Have you tred lying on your side? Try not to
6. Do you wheeze? Heard myself off /on
7. Does anything make it better or worse? Taking it easy lessens the problem
8. Have you had this before. Not like this
9. Does your SOB come and go? Constant
10. Do you have pets? no
11. What are the events surrounding the fatigue/tiredness? Think the breathing was first then the fatigue
12. How is your overall health? No diabetes, thyroid only prostrate
13. Have you gained/lost weight unintentionally despite normal appetite & exercise? Got to be way up with all the swelling in my legs and belly
14. When did you notice the weight? Crept up over the last month
15. When did your swelling start? 2 months ago
16. What are the events surrounding the start of your swelling problem? Developed SOB it gradually got worse
17. Anything make it better/worse? Don’t know
18. Does your swelling come and go? NO
19. What treatments have you done for swelling? Not been compliant with limiting salt intake
20. How long have you had HTN? Several years
21. Do you have any chest pain? Not pain particularly
22. Abdominal pain? No
23. How severe HTN? It controlled
24. Have you ever been hospitalized?
25. Do you have any allergies?
26. Are you taking any prescription medication?
27. Taking any over the counter or herbal meds?
28. Do you drink alcohol? If so what do you drink and how many drinks per day?
29. Do you now or have you ever smoked or chewed tobacco?
30. Do you have any of the following problems: fatigue difficulty sleeping unintentional wgt loss or gain fevers night sweats?
31. Do you have any problems with Headaches that don’t go away with asa or Tylenol, doubled or blurred vision, difficulty with night vision, problems hearing ear pain sinus problems chronic sore throats
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