Exam (elaborations) NURSING
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?
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