History 1. How can I help you today?- Very SOB with normal activity 2. Do you have a cough?- Yes started with SOB 3. Do you feel as if you are smothering or suffocating? yes 4. Are you coughing up any sputum ? Small amount of frothy white phlegm 5. When did your difficulty breathing start?- about 2 months 6. Are you short of breath when lying down? Yes- sleeps on the recliner 7. Do you sleep with pillows to help you breath?- Sleeping with pillows didn’t work 8. Can you tell me about any current or past medical problems you have had? High blood pressure, cholesterol, stent 9. Does your difficulty breathing keep you from sleeping? Not if he sleeps in the recliner 10. Do you awaken at night short of breath? Yes-awakes 11. What treatments have you had for your difficulty breathing?- None 12. Do you have any allergies, such as medications, food and/or latex, for example? NKA 13. Do you have any pain in your chest?- No 14. Does your chest feel tight or heavy? Not sine stent surgery 6 months ago 15. Do you have any problems with: itchy scalp, skin changes, moles, thinning hair, brittle nails? no 16. Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gains, fevers, night sweats? Feeling heavy, legs and belly edema 17. Do you have any problems with: headaches that don’t go away with aspirin or Tylenol, double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, difficulty swallowing. no 18. 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? no 19. When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during the day or night or any changes in frequency? no 20. Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating, frequent urination, change in appetite? no 21. Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor? no
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- Fall '18