Northern Arizona University / Bill Buxton V5 (Complete Guide)

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

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 difficulty swallowing?

32. Do you have problems with nausea vomiting constipation diarrhea coffee grounds in your

vomit dark tarry stool bright red blood in your bowel movements early satiety bloating?

33. Do you sleep with pillows to help you breath?

34. Are you SOB when lying down?

35. Do you have unusual heartbeats (palpitations)?

36. Do you have problems with muscle or joint pain redness swelling muscle cramps joint stiffness

joint swelling or redness back pain neck or shoulder pain hip pain?

37. Have you notices any bruising bleeding gums nose bleeds or other sites of increased bleeding?

38. Do you have any problems with nervousness depression lack of interest sadness memory loss

or mood changes or ever hear voices or see things that you know are not there?

39. Has drinking alcohol ever caused you problems?

40. Tell me about your diet what you normally eat

41. When you urinate have you noticed pain burning blood difficulty starting or stopping dribbling

incontinence urgency during day or night or any changes in frequency?

42. Do you have any of the following: dizziness fainting spinning room seizures, weakness

numbness tingling tremor?

43. Do you have and children? Spouse? Significant partner?

PMH/SURG/Hosp -2

Meds-2

Allergies-1

FH-0

SH-5

Prevention/Risk behaviors-2

ROS-10

Treated as an outpatient fewer hx qts versus comprehensive case might need hospitalization