Bill Buxton

72 yo male

5’8” (173.0 cm)

215 lbs (98.0kg)

CC: SOB

Skin:dry normal skin temp

38 required qts

Meds metoprolol, ASA, CLOPIDOGREL, RAMIPRIL, Atrovastatin

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