Breathlessness

Name: Gerald Patrick

Age: 65 Years Old

Date of Birth: 2nd July 1959

Location: General Practice

Occupation: Retired architect

“I have been feeling quite short of breath lately".

• Onset: Have always had some form of shortness of breath - 6 weeks ago it just got progressively worse.

• Progression: Worsening over the past 6 weeks.

• Exacerbating Factors: Becomes more breathless on exertion.

• Relieving Factors: Gets a little better at rest but never goes away.

• Associated symptoms: Coughed up some blood occasionally over the past 4 weeks. No chest pain.

• Timing: Constantly there

• Precipitating Factors : Cannot seem to think of anything that may have triggered this sudden worsening of breathlessness.

• Recent illness: None

• Recent trauma: None

• Recent travel: None

• Previous episodes: Have always been breathless but they come in episodes, however this episode just never seemed to go away.

• Ideas: “I'm just worried it's something sinister”

• Expectations: “Some type of scans or tests maybe?”

• Concerns: “This is not cancer, is it?”

• Bowel habits: Normal

• Urinary habits: Normal.

• Appetite: Has been getting worse over the past couple of weeks.

• Sleep: Typically fine, but some nights I wake up drenched in sweat.

• Weight: Not too sure but I do feel like my pants are becoming looser.

• Pain in the chest/abdomen: None

• Headaches: None

• Fever: None

• Cardiology: Normal

• Ophthalmology: Normal

• Neurology: Normal

Previous hospital admissions: None

Previous surgeries: None

Medical conditions:

• "I've got this breathing problem, it's apparently called COPD."

• Hypertension

• Diabetes Mellitus Type 2

Medications:

• Metformin

• Amlodipine

• Ramipril

• Trimbow (beclometasone / formoterol / glycopyrronium bromide)

• This blue inhaler I use whenever I feel breathless

Over the counters:

• None

Allergies:

• Penicillin (anaphylaxis)

• Codeine (rash)

Paternal grandfather died from gastric cancer. Mother had breast cancer. Heart disease runs in mother's side of the family, does not know much about what type of heart disease. Everyone else generally healthy.

• Smoking: Smokes 20 cigarettes a day for the past 35 years

• Alcohol: A couple pints of beer over the weekends.

• Recreational drugs: Tried marijuana once when I was young. Only once. Never tried any other drugs.

• Diet: I usually cook at home. We try to eat healthy at home.

• Exercise: Occasionally I go out for walks.

• Ill contacts: Son recently had the flu.

• Home: Lives with wife and one of my three sons in a bungalow.

• Activities of Daily Living: Usually mobile and able to perform daily functions normally. Occasionally gets breathless when I exert myself.

• Occupation: Used to work as an architect.