Bull Buxton 72 y.o. 5’8” 215 lb BMI 32.7 162/94, 92, 32, 94% RR 20 ??? SOB SOB – MSAP Fluid retention: peripheral leg edema (2+) and abdominal edema, ascites, hepatic congestion – related Elevated jugular venous pressure (JVP) – related Fine crackles in lower bases – related S3, S4 with pansystolic murmur – related Displaced PMI 2 cm lateral – related HTN – related Tachycardia – related Positive JVP with hepatojugular reflux – related 50 pack-year hx of smoking, quit 6 mo ago – unknown Cough (white frothy sputum) – unknown Indiscriminate salt intake – unknown Hx of CAD – unknown Obesity – unknown Fatigue – related Hepatomegaly – related / How can I help you today? / Do you have any other symptoms or concerns we should discuss? / Do you have pain anywhere? If so, where? / What symptom is the most distressing to you? / Can you tell me about any current or past medical problems you may have had? / Do you have heart disease and/or have you ever had a heart attack? / Have you ever been diagnosed with a congenital heart problem? Do you have any cardiovascular problems? / Do you have high blood pressure? / Do you have high cholesterol? / Do you have a history of high lipids or triglycerides? / Do you have a history of irregular heartbeats?
/ Do you have a history of heart failure? / Have you had any recent blood or lab test? What were the results? / Have you ever had an ECG (EKG)? / Any previous medical, surgical, or dental procedures? / Have you ever been hospitalized? / What childhood illnesses have you had? / Have you ever been told you have a heart murmur or valve problem? / Do you have any allergies, such as medications, food and/or latex, for example? / Are you taking any prescription medications? Metoprolol, Ramipril, Aspirin, Clopidogrel, Atorvastatin / Are you taking any over-the-counter or herbal medications? / When was your last physical? / Are your immunizations up to date? / What cancer screening tests have you had, and what were the results? / What cholesterol screening tests have you had, and what were the results? / Have you had a colonoscopy? / Have you recently traveled? Where did you go? / Tell me about the health of your grandparents, parents, and children? / Are there any diseases that run in your family? / Do you know of any genetic diseases that are found in your family? / Do your religious cultural beliefs prevent you from receiving certain types of medical care or treatment? / Do you drink alcohol? If so, what do you drink and how many drinks per day? / Has drinking alcohol ever caused you problems?
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- Spring '16
- Shelley Ashby
- cough, JVP, hepatomegaly