CHF Exacerbation Case Study | i-Human Nursing & NP SOAP Note | 72-Year-Old Dyspnea PDF | Heart Failure Management

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I HUMAN CASE STUDY FOR A 72-YEAR-OLD
PATIENT PRESENTING WITH DYSPNEA WEEK 4
LATELY UPDATED – EXPERT VALUATION

Reason for Encounter:
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Evaluation of shortness of breath (dyspnea).
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Patient Demographics:
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• Age: 72 years
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• Sex: Male
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• Height: 5’8” (173 cm)
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• Weight: 198 lbs (90 kg) g; g; g; g;



• BMI: 30.1 kg/m² (Obese Class I)
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Case Mode: Learning mode
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Case Location: Outpatient clinic with laboratory and imaging capabilities
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Attempts Allowed: Unlimited g; g;




2. Chief Complaint (CC) g; g;




“I feel short of breath, especially when I walk or lie down.”
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3. History of Present Illness (HPI) g; g; g; g;




The patient is a 72-year-old male who presents with a 2-week history of
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g; progressive dyspnea. He reports initially noticing shortness of breath during
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g; exertion, such as climbing stairs or walking short distances. Over the past
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several days, symptoms have worsened, and he now experiences dyspnea with
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g; minimal activity and when lying flat at night.
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Symptom characteristics: g;




• Onset: Gradual, 2 weeks ago g; g; g; g;



• Duration: Persistent g;



• Course: Progressive worsening g; g;



• Severity: Moderate to severe g; g; g;

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• Pattern: Exertional dyspnea progressing to orthopnea
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• Associated symptoms: g;



o Fatigue
o Bilateral lower-extremity swellingg; g;



o Mild, nonproductive cough
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o Occasional nocturnal dyspnea g; g;




Negative symptoms: g;




• No chest pain
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• No fever or chills
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• No hemoptysis
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• No wheezing at rest
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• No syncope
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The patient reports sleeping on two pillows to breathe comfortably and waking
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at night with shortness of breath. He denies recent travel, prolonged
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immobilization, or known sick contacts.
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4. Past Medical History (PMH)
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• Hypertension (25 years) g; g;



• Type 2 diabetes mellitus
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• Hyperlipidemia
• Coronary artery disease with prior stent placement (5 years ago)
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• History of smoking (30 pack-years; quit 10 years ago)
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