YEAR OLD MALE PRESENTING WITH DIFFICULTY
BREATHING AT EMERGENCY ROOM WITH FULL
LABORATORY AND IMAGING CAPABILITIES
,PATIENT INFORMATION
Name: Lawrence Lee
Age: 70 years
Sex: Male
Height: 5′11″ (180 cm)
Weight: 164.0 lb (74.5 kg)
Location: Emergency room with full laboratory and imaging capabilities
Reason for Encounter: Difficulty breathing
Mr. Lawrence Lee is a 70-year-old male brought to the emergency department with progressive
shortness of breath over the past week, increasingly affecting his ability to breathe at rest and
during minimal exertion.
, REASON FOR ENCOUNTER
The patient presents due to progressive dyspnea that began approximately one week ago, now
present even at rest and associated with orthopnea and lower extremity swelling. The encounter
aims to identify the underlying cardiopulmonary pathology and institute appropriate diagnostic and
management measures.
Component Description
Encounter type Emergency room visit
Chief complaint Difficulty breathing
Onset ~7 days
Duration Increasing severity
Location Respiratory / cardiopulmonary system
Characteristics Dyspnea on exertion progressing to rest; orthopnea
Aggravating factors Lying flat, exertion
Relieving factors Upright position, rest
Associated symptoms Fatigue, reduced exercise tolerance, ankle swelling
Systemic concerns No fever or chills reported
Patient goals Identify cause; relieve dyspnea; restore functional status