Bill Buxton iHuman_Case Study - 2022/2023 | C350 iHuman_ Bill Buxton - Graded A+

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iHuman_ Bill Buxton Bill Buxton 72 yo male 5’8” (173.0 cm) 215 lbs (98.0kg) CC: SOB Skin:dry normal skin temp 38 required qts CC-2 • How can I help you today? Feeling SOB with ever... ything I do even doing nothing • Tell me about any current or past medical problems?just heart problems and all the stuff with that you know HTN and cholesterol stuff • Any other symptoms or concerns we should discuss? Body feels heavy fatigued legs and gut have been swelling • What system is the most distressing for you? Breathing problem Symptoms + Assoc Symptoms -14 1. When did your difficulty breathing start? About 2 months ago 2. Are you coughing up any sputum? White frothy phlegm NOT important 3. How severe is your difficulty breathing? Keeps me from doing a lot of things I used to do 4. How long does your SOB last? Never goes away anymore sometimes better and sometimes worse 5. Have you tred lying on your side? Try not to 6. Do you wheeze? Heard myself off /on 7. Does anything make it better or worse? Taking it easy lessens the problem 8. Have you had this before. Not like this 9. Does your SOB come and go? Constant 10. Do you have pets? no 11. What are the events surrounding the fatigue/tiredness? Think the breathing was first then the fatigue 12. How is your overall health? No diabetes, thyroid only prostrate 13. Have you gained/lost weight unintentionally despite normal appetite & exercise? Got to be way up with all the swelling in my legs and belly 14. When did you notice the weight? Crept up over the last month 15. When did your swelling start? 2 months ago 16. What are the events surrounding the start of your swelling problem? Developed SOB it gradually got worse 17. Anything make it better/worse? Don’t know 18. Does your swelling come and go? NO 19. What treatments have you done for swelling? Not been compliant with limiting salt intake 20. How long have you had HTN? Several years 21. Do you have any chest pain? Not pain particularly 22. Abdominal pain? No 23. How severe HTN? It controlled 24. Have you ever been hospitalized? 25. Do you have any allergies? 26. Are you taking any prescription medication? 27. Taking any over the counter or herbal meds? 28. Do you drink alcohol? If so what do you drink and how many drinks per day? 29. Do you now or have you ever smoked or chewed tobacco? 30. Do you have any of the following problems: fatigue difficulty sleeping unintentional wgt loss or gain fevers night sweats? 31. Do you have any problems with Headaches that don’t go away with asa or Tylenol, doubled or blurred vision, difficulty with night vision, problems hearing ear pain sinus problems chronic sore throats - - - - - - - Continued [Show More]

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