C350 Walter Sobchak.docx - Walter Sobchak 48 y.o 5\u20196\u201d 165 lb BMI 26.6 C\/O SOB Progressive SOB x 2 weeks \u2013 MSAP Fatigue \u2013 related Poor appetite

C350 Walter Sobchak.docx - Walter Sobchak 48 y.o...

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Walter Sobchak 48 y.o. 5’6” 165 lb BMI 26.6 C/O SOB Progressive SOB x 2 weeks – MSAP Fatigue – related Poor appetite – related Pruritus - related Hx of untreated HTN – related Hx of elevated creatinine – related Chronic NSAID use – related Hx of ulcer – unknown Alcohol use – unknown 30+ yr 1 pk/day smoker – related Family Hx of HTN and stroke – unknown Elevated BP – related AV-nicking and cotton wool spots per fundoscopy – related Fine crackles (rales) at lung bases – related Peripheral edema – related Bilateral gynecomastia – related / How can I help you today? / Do you have any other symptoms or concerns we should discuss? / Do you have any pain? If so, where? / Are you short of breath? / Do you have difficulty breathing? / When did your difficulty breathing start? / What are the events surrounding the start of your difficulty breathing? / Does anything make your difficulty breather better or worse? / Is it hard to get a deep breath or exhale? / Do you wheeze? / Are you short of breath at rest? / Do you become short of breath with exertion? / Does your breathing only get heavy with exertion? / Are you short of breath when laying down? / Are you short of breath at rest? / How much can you exercise before being short of breath? / Do you have any pain or other symptoms associated with your difficulty breathing?
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/ How severe is your difficulty breathing? / How long does your shortness of breath last? / Have you had difficulty breathing like this before? / How quickly does your difficulty breathing come on? / Do you awaken at night short of breath? / How often do you have difficulty breathing? / How quickly does your shortness of breath come on? / What treatments have you had for your difficulty breathing? / Does your chest feel tight or heavy? / Do you sleep with pillows to help you breathe? / Does your difficulty breathing keep you from sleeping? / Do you have a problem with fatigue/tiredness? / What are the events surrounding the start of your fatigue/tiredness? / Does anything make your fatigue/tiredness better or worse? / Does your fatigue/tiredness improve after a good nights sleep? / How severe is your fatigue/tiredness? / Have you gained or lost weight unintentionally, despite normal appetite and exercise? / Can you tell me about any current or past medical problems you may have had? / Do you have any cardiovascular problems?
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  • Spring '16
  • Shelley Ashby
  • Pneumothorax, shortness of breath, pulmonary edema

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