I HUMAN WEEK 4 NURSING 2501 2026 58
YEAR OLD MALE PATIENT ANSELMO LOPEZ
PRESENTING WITH CHEST PAIN AND
SHORTNESS OF BREATH AT OUTPATIENT
CARDIOLOGY CLINIC
,PATIENT INFORMATION
• Age: 58 years
• Sex: Male
• Height: 5′9″ (175 cm)
• Weight: 210 lb (95.3 kg)
• Location: Outpatient cardiology clinic
• Reason for Encounter: Chest pain and shortness of breath
Explanation: Anselmo Lopez is a 58-year-old male presenting with acute-onset
chest pain and exertional shortness of breath. The reason for encounter is to
evaluate for potential cardiovascular pathology including ischemic heart disease,
angina, or early heart failure, identify risk factors, and implement evidence-based
interventions to prevent acute complications such as myocardial infarction or
arrhythmia.
, REASON FOR ENCOUNTER
Element Description
Encounter Type Outpatient evaluation
Chief Complaint Chest pain and shortness of breath
Duration 2 days
Frequency Intermittent, worsens with activity
Associated
Fatigue, mild palpitations
Symptoms
Aggravating Factors Physical exertion, climbing stairs
Relieving Factors Rest, sitting upright
Systemic Symptoms No fever, no dizziness, no syncope
Identify cause of chest pain and improve breathing
Patient Goals
tolerance
EXPLANATION ON REASON FOR ENCOUNTER
The patient seeks medical evaluation due to recent-onset chest discomfort with
exertion and associated dyspnea. These symptoms are concerning for cardiac
ischemia or early heart failure. Prompt assessment is necessary to confirm the
etiology, evaluate cardiovascular risk factors, initiate diagnostic testing, and
implement evidence-based interventions to prevent progression to acute coronary
syndrome or decompensated heart failure. The clinical objective is also to educate
the patient on symptom recognition, risk reduction, and lifestyle modifications.
YEAR OLD MALE PATIENT ANSELMO LOPEZ
PRESENTING WITH CHEST PAIN AND
SHORTNESS OF BREATH AT OUTPATIENT
CARDIOLOGY CLINIC
,PATIENT INFORMATION
• Age: 58 years
• Sex: Male
• Height: 5′9″ (175 cm)
• Weight: 210 lb (95.3 kg)
• Location: Outpatient cardiology clinic
• Reason for Encounter: Chest pain and shortness of breath
Explanation: Anselmo Lopez is a 58-year-old male presenting with acute-onset
chest pain and exertional shortness of breath. The reason for encounter is to
evaluate for potential cardiovascular pathology including ischemic heart disease,
angina, or early heart failure, identify risk factors, and implement evidence-based
interventions to prevent acute complications such as myocardial infarction or
arrhythmia.
, REASON FOR ENCOUNTER
Element Description
Encounter Type Outpatient evaluation
Chief Complaint Chest pain and shortness of breath
Duration 2 days
Frequency Intermittent, worsens with activity
Associated
Fatigue, mild palpitations
Symptoms
Aggravating Factors Physical exertion, climbing stairs
Relieving Factors Rest, sitting upright
Systemic Symptoms No fever, no dizziness, no syncope
Identify cause of chest pain and improve breathing
Patient Goals
tolerance
EXPLANATION ON REASON FOR ENCOUNTER
The patient seeks medical evaluation due to recent-onset chest discomfort with
exertion and associated dyspnea. These symptoms are concerning for cardiac
ischemia or early heart failure. Prompt assessment is necessary to confirm the
etiology, evaluate cardiovascular risk factors, initiate diagnostic testing, and
implement evidence-based interventions to prevent progression to acute coronary
syndrome or decompensated heart failure. The clinical objective is also to educate
the patient on symptom recognition, risk reduction, and lifestyle modifications.
