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? This study source was downloaded by from CourseH on :23:19 GMT -05:00 / 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? / Do you have any history of lung disease? / Have you had any recent blood or lab tests? What were the results? / Have you ever had an ECG (EKG)? / Any previous medical, surgical, or dental procedures? / Have you ever been hospitalized? / Have you had any significant traumatic injuries or accidents / Have you had chicken pox, mumps, measles, or rheumatic fever? / What childhood illnesses have you had? / Do you have any allergies, such as medications, food and/or latex, for example? / Are you taking any prescription medications? / Are you taking any over-the-counter or herbal medications? / When was your last physical? / Are you immunization up to date? / Have you had a flu shot? / Have you had a pneumovax injection? / What cancer screening tests have you had, and what were the results? / What cholesterol screenings have you had, and what were the results? / When and what were the results of your last prostate exam? / 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?