CHARLES PETERSON 72-YEAR-OLD MALE FALL WITH
SUSPECTED CLOSED HEAD INJURY PRESENTING TO
HOSPITAL UTI
Patient Demographics
• Name: Eleanor Vasquez
• Age: 68 years
• Gender: Female
• Ethnicity: Hispanic
, • Code Status: Full code
• Advance Directive: Durable power of attorney for healthcare (son)
• Living Situation: Lives with husband in single-story home
• Primary Care Provider: Yes
Chief Complaint
“I can’t catch my breath and my chest feels heavy for the past 3 hours.”
History of Present Illness (HPI)
Mrs. Vasquez presents to the Emergency Department via private vehicle,
accompanied by her husband. She reports onset of substernal chest pressure and
progressive dyspnea approximately 3 hours ago while resting after lunch. The
chest heaviness is non-radiating, described as 6/10 intensity, worse with deep
inspiration and any exertion, partially relieved by sitting forward. She denies
complete relief with rest.
Associated symptoms include diaphoresis, nausea without vomiting, and
profound fatigue. She reports feeling “lightheaded” but no syncope. No cough,
fever, chills, or hemoptysis. No leg swelling or calf pain.
She delayed presentation because she thought it was “just indigestion” but her
husband insisted on coming after she became pale and clammy.
Timeline:
• 12:00 PM – Ate lunch (usual meal)
• 1:00 PM – Chest heaviness began
• 2:00 PM – Took 2 Tums (no relief)
• 3:00 PM – Husband drove her to ED
• 4:00 PM – Arrival at triage
Review of Systems (ROS)
• General: Fatigue, diaphoresis. No fever.
• Cardiovascular: Chest pressure, dyspnea, lightheadedness. No palpitations.
SUSPECTED CLOSED HEAD INJURY PRESENTING TO
HOSPITAL UTI
Patient Demographics
• Name: Eleanor Vasquez
• Age: 68 years
• Gender: Female
• Ethnicity: Hispanic
, • Code Status: Full code
• Advance Directive: Durable power of attorney for healthcare (son)
• Living Situation: Lives with husband in single-story home
• Primary Care Provider: Yes
Chief Complaint
“I can’t catch my breath and my chest feels heavy for the past 3 hours.”
History of Present Illness (HPI)
Mrs. Vasquez presents to the Emergency Department via private vehicle,
accompanied by her husband. She reports onset of substernal chest pressure and
progressive dyspnea approximately 3 hours ago while resting after lunch. The
chest heaviness is non-radiating, described as 6/10 intensity, worse with deep
inspiration and any exertion, partially relieved by sitting forward. She denies
complete relief with rest.
Associated symptoms include diaphoresis, nausea without vomiting, and
profound fatigue. She reports feeling “lightheaded” but no syncope. No cough,
fever, chills, or hemoptysis. No leg swelling or calf pain.
She delayed presentation because she thought it was “just indigestion” but her
husband insisted on coming after she became pale and clammy.
Timeline:
• 12:00 PM – Ate lunch (usual meal)
• 1:00 PM – Chest heaviness began
• 2:00 PM – Took 2 Tums (no relief)
• 3:00 PM – Husband drove her to ED
• 4:00 PM – Arrival at triage
Review of Systems (ROS)
• General: Fatigue, diaphoresis. No fever.
• Cardiovascular: Chest pressure, dyspnea, lightheadedness. No palpitations.
