Comprehensive Hx Overview
Nurse Information
• Patient name: Ariela Hernandez
• Age: 64
• Reason for visit: C/C Acute onset of dyspnea and nearsyncope
• Height and Weight;sometimes BMI: 5’3”, 200lbs
• Blood pressure:
• Pulse:
• Temp:
Breathless, clipped , Diaphoretic, cough (smoker) normal per pt, lightheaded
Wine 4-5 glasses per week
Cold 1 month ago
SHx: right knee replacement 6 weeks ago, motrin for pain
Hx: 3-4 bilateral knee pain for years decreased activity helps, 2 packs per day since age 24
FHx: mom DM, HTN,stroke age 80. dad heart attack 50, heart failure, no children, mexico born came at
age 24
Hx HTN for years (lisinopril 10mg, HTZ 25mg, menopause x years, DM,metformin XR750mg x2), knee
arthritis
Worsing Cough this am, Chronic cough (smoker) normal x5 years
Diaphoretic, lightheaded this am, upon standing
SOB x 3 hours while washing dishes, + with activity
- 5 lbs since surgery, right knee pain after surgery, increase swelling to right leg aftersurgery
Obesity
s/p knee surgery, recovering at home
Chronic leg swelling /ache for years, increases while standing
Brought in by EMS
Skin is warm and slightly diaphoretic, blanching observed
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