Lawrence Lee difficulty breathing

Lawrence Lee

70 y/o

5′ 11″ (180 cm)

164.0 lb (74.5 kg)

Reason for encounter

Difficulty breathing

Location

Emergency room with full imaging and laboratory capabilities

Get all the history questions, physical exam, and complete EHR documentation.
Interview History Questions

What is your name?
How can I help you today?
Do you have any other symptoms or concerns we should discuss?
Do you have pain anywhere? If so, where?
What symptom is the most distressing for you?
Tell me how that makes you feel.
How does this affect your life?
Do you have unusual heartbeats (palpitations)
Have you gained or lost weight unintentionally, despite normal appetite and exercise?
Have you noticed swelling in any part of your body
Do you have a cough
Do you have any other symptoms or concerns we should discuss
Do you have any pain in your chest
………….
Physical Exams Required

Weight
Height
cognitive status
SpO2
temperature
blood pressure
pulse
respiration
temperature
auscultate heart
auscultate lungs…….