Ihuman Bill Buxton - 72 yrs Old Male CC: Shortness of breath

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Carlow University Department of Nursing MSN-Family/Individual Across Lifespan History/Physical Exam (H&P) Template for ALL Clinical Practicum Courses BB, 01/21/2021 1500: Identifying Data and Sou... rce of the History: BB is a 72 y/o married male, who is a retired architect. Source: Patient Reliability: The source of information is the patient and is reliable. Chief Complaint (CC): Shortness of breath Present Illness: BB is a 72 y/o male that came in with complaints of shortness of breath that started 2 months ago. His shortness of breath has progressively worsened and is occurring even at rest. He feels like he is being smothered or suffocated. This has been awakening him at night. He has been sleeping in a recliner due to lying on his back making it worse. He has been experiencing fatigue, that started around the same time as the shortness of breath. It is worsened with physical effort but is present without activity. Patient feels it is getting worse. He has a cough with white frothy sputum that started with the shortness of breath. This is different from his usual “morning smokers cough” he has. It is worse with activity. He has not tried any treatment for it. He denies any chest pain or pressure. BB has noticed increased swelling in his abdomen and legs that has progressively increased over the last month. He has no changes in his appetite, but he does admit that he does not limit his sodium intake. His wife and him have been eating out a lot recently and eating prepared meals. These are all new symptoms for him, that he has never experienced before. Current Medications: Aspirin daily, Metoprolol (pt is unsure of dosages, he says he takes them as prescribed), Ramipril (unsure of dosage, takes as prescribed), Clopidogrel (unsure of dosage, takes as prescribed), atorvastatin (unsure of dosage, takes as prescribed), and Tylenol PRN. Allergies: No known drug or food allergies. Past History: Childhood Illness- None Medical- Hypertension (pt unsure of the date, states “several years ago”) Hyperlipidemia (pt unsure of the date of diagnosis) Surgical- Pt had a stent 6 months ago Hospitalizations- 6 months ago after stent placement. Psychiatric- none Health maintenance: Immunizations are up-to-date. He is not up-to-date on his preventive screenings. Family History: Father: deceased in his 60s, heart disease. Died from a coronary event per pt. Mother: deceased in her 70s, heart disease. Died from a coronary event per pt. Personal and Social History: Status: Retired architect [Show More]

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