C350 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 probl