167.0 LB(75.9KG) ) REASON FOR ENCOUNTER DYSPNEA |
LOCATION OUTPATIENT CLINIC WITH X-RAY ,ECG AND
LABORATORY CAPABILITIES
,Comprehensive Case Study
72-Year-Old Male, 165 cm, 75.9 kg
Reason for Encounter: Dyspnea (Shortness of Breath)
Location: Outpatient Clinic with X-ray, ECG, and Laboratory Support
i-Human Case Analysis | EXPERT REVIEW
1. History of Present Illness (HPI)
• Onset: Dyspnea started 3 months ago, gradually progressive. Recently
worsened over the last 1 week.
• Duration: Initially only exertional, now occurs at rest.
• Character: Reports orthopnea (requires 2 pillows), no paroxysmal
nocturnal dyspnea.
• Progression: Limiting ability to climb stairs or walk >100 meters.
• Associated Symptoms:
o Mild non-productive cough.
o Occasional palpitations.
o Bilateral ankle swelling noted in evenings.
o Denies chest pain, fever, hemoptysis, or weight loss.
• Aggravating/Alleviating Factors: Worse with exertion, better with rest
and sitting upright.
• Precipitating Events: No recent respiratory infections, travel, or
immobilization.
, 2. Past Medical History (PMH)
• Hypertension × 20 years.
• Type 2 Diabetes Mellitus.
• Dyslipidemia.
• No known chronic lung disease (e.g., COPD or asthma).
• No recent hospitalizations.