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? This study source was downloaded by from CourseH on :45:34 GMT -05:00 / 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? / Do you use any recreational drugs? If so, what? / Do you now or have you ever smoked or chewed tobacco? / Tell me about your daily exercise or sports that your play. / Tell me about your social/leisure activities. / On average, how many hours per night do you sleep? / How is your family and family life? / Do you have any children? Spouse? Significant partner? / Do you have medical insurance? / Can you afford the co-pays for your clinic visits and medications? What community resources do you have access to that can provide assistance? Do you have easy/adequate access to transportation necessary for daily living and healthcare needs? / Where were you born and where did you grow up? / Do you have problems with fatigue/tiredness? / When did the fatigue/tiredness start? / Is your fatigue unrelated to physical effort? / Does your fatigue/tiredness improve after a good night’s rest? / Do you have any other symptoms associated with your fatigue/tiredness? / How severe is your fatigue/tiredness?