Setting:
Old Female with Fatigue and Shortness of Breath
Emergency Room (with full imaging and
laboratory capabilities) Final Diagnosis: Iron
Deficiency Anemia Secondary to
Menorrhagia
CASE AT A GLANCE (Summary Table)
Field Detail
Age 50 years old
Sex Female
Height 5'6" (168 cm)
Weight 153 lbs (69.5 kg)
BMI 24.8 kg/m² (normal)
,Field Detail
Reason for Encounter
"I have been unusually tired and a bit short of breath"
(RFE)
Emergency Room (full imaging and laboratory capabilities
Setting
available)
Key Visual Cue Alert patient, but noted to have slight pallor
SECTION 1: PATIENT DEMOGRAPHICS
Field Information
Name Elena Vasquez
Age 50 years
Sex Female
Date of Birth March 12, 1976
Race/Ethnicity White / Hispanic
Height 5'6" (168 cm)
Weight 153 lbs (69.5 kg)
BMI 24.8 kg/m² (normal range)
, Field Information
Occupation Administrative assistant
Marital Status Married x 24 years
Living Situation Lives with husband in two-story home
Emergency Room (presented to ER due to worsening symptoms over p
Setting
week)
Triage Level ESI Level 3 (urgent, stable vital signs)
Arrival Mode Walked in independently
Time of
3:45 PM (after work)
Presentation
SECTION 2: REASON FOR ENCOUNTER (RFE)
Patient's own words: "I have been unusually tired and a bit short of breath"
Additional context from triage: Patient reports that over the past week, her
fatigue has worsened to the point where she struggled to complete her workday.
She came to the ER because she "almost passed out" walking up the stairs at
home yesterday, though she did not actually lose consciousness.
SECTION 3: HISTORY OF PRESENT ILLNESS (HPI)
Onset & Duration
Gradual onset approximately 4 months ago, with significant worsening over
the past week.