I Human Case week #4 A 70 Year Old Male Reason For
Encounter: Difficulty breathing Case Assessment 2025
,Good Questions:
1. How can i help you today
• 1m having trouble breathing.
2. Do you have any other symptoms or concerns we should discuss • An allergic cough and
runny nose. I get the cough every year during this season.
3. Do you wheeze?
• Normally just when my allergies act up. Lately have sort of noticed wheezing at night. That’s
fairly new I guess.
4. Are you short of breath when lying down?
1m always SOB
5. Do you sleep with pillows to help you breathe? Just 1 pillows
6. Does anything make your cough better or worse? • My coughing is worse when the trees
shed pollen
7. Are you taking any prescription medications? • Yes indeed. I brought my list with me here.
Lisonopril 10mg daily, HCTZ 25mg daily, glipizide 5mg daily. Also use a CPAP machine, though
it's not really a medicine.
8. Are you taking any OTC or herbal medications?
•
Aleve for shoulder pain and Allergries for the allergies
9. Do you have any allergies?
•
Sulfa drugs, I am pretty sure I’m allergic to tree and grass pollen and ragweed
10. Do you now or have you ever smoked or chewed tobacco • I was a big time smoker in the
past. Started when I was 16. A pack a day, but i stopped 10 years ago. That was hard to do.
11. Do you have a problem with fatigue/tiredness • I sure do. I get tired when i exert. I think im
really out of shape, but i also dont sleep great due to sleep apnea, and this makes me tired
during the day too
12. Have you been having fevers? no 13. Is there any swelling in your ankles? • Sometimes.
Not bad though
, 14. Do you have a problem with generalized weakness?
• Weakness? No, I dont think i'd call it that really
15. Do you have a cough? • Not normally, but i have been coughing for the last couple
of months
16. Are you coughing up any sputum?
• Occasionally, like now. I get a cold, then bronchitis with coughing up stuff, then it goes
away. Sometimes clear. Sometimes not. Its been worse the past 2 months - coughing up
this gooey white stuff in the morning. Maybe like a few teaspoons worth. Disgusting.
17. When did your difficulty breathing start? • About 10 years ago. Past 5 years its affected me
more and more
18. Does anything make your difficulty breathing better or worse? • Sitting still is the best for my
breathing. Also it helps if i purse my lips when i breathe out
19. Do you become short of breath with exertion? •
Yes definitely. I can walk slowly to the
postbox or from room to room ok, but im out of breath going upstairs to the bedroom or just
lifting stuff
20. Are you short of breath at rest? • Yes just these past couple months
21. Do you have any pain or other symptoms associated with your difficulty breathing? •
Symptoms? Like cough with runny nose. What else do you mean?
22. Has there been any change in your difficulty breathing over time?
•
Big time! I used to be able too walk, work, and run with the best of them. But not now
23. Do you have unusual heartbeats / palpitations? No.
24. Do you have any pain in your chest? No.
25. Can you tell me about any current or past medical problems?
•
High blood pressure, sleep apnea, and type 2 DM. I’ve had the blood pressure thing for
maybe 25 years now. The DM was maybe 5 years ago. But all these are under control. I
guess that’s all I can think of that’s important.
Encounter: Difficulty breathing Case Assessment 2025
,Good Questions:
1. How can i help you today
• 1m having trouble breathing.
2. Do you have any other symptoms or concerns we should discuss • An allergic cough and
runny nose. I get the cough every year during this season.
3. Do you wheeze?
• Normally just when my allergies act up. Lately have sort of noticed wheezing at night. That’s
fairly new I guess.
4. Are you short of breath when lying down?
1m always SOB
5. Do you sleep with pillows to help you breathe? Just 1 pillows
6. Does anything make your cough better or worse? • My coughing is worse when the trees
shed pollen
7. Are you taking any prescription medications? • Yes indeed. I brought my list with me here.
Lisonopril 10mg daily, HCTZ 25mg daily, glipizide 5mg daily. Also use a CPAP machine, though
it's not really a medicine.
8. Are you taking any OTC or herbal medications?
•
Aleve for shoulder pain and Allergries for the allergies
9. Do you have any allergies?
•
Sulfa drugs, I am pretty sure I’m allergic to tree and grass pollen and ragweed
10. Do you now or have you ever smoked or chewed tobacco • I was a big time smoker in the
past. Started when I was 16. A pack a day, but i stopped 10 years ago. That was hard to do.
11. Do you have a problem with fatigue/tiredness • I sure do. I get tired when i exert. I think im
really out of shape, but i also dont sleep great due to sleep apnea, and this makes me tired
during the day too
12. Have you been having fevers? no 13. Is there any swelling in your ankles? • Sometimes.
Not bad though
, 14. Do you have a problem with generalized weakness?
• Weakness? No, I dont think i'd call it that really
15. Do you have a cough? • Not normally, but i have been coughing for the last couple
of months
16. Are you coughing up any sputum?
• Occasionally, like now. I get a cold, then bronchitis with coughing up stuff, then it goes
away. Sometimes clear. Sometimes not. Its been worse the past 2 months - coughing up
this gooey white stuff in the morning. Maybe like a few teaspoons worth. Disgusting.
17. When did your difficulty breathing start? • About 10 years ago. Past 5 years its affected me
more and more
18. Does anything make your difficulty breathing better or worse? • Sitting still is the best for my
breathing. Also it helps if i purse my lips when i breathe out
19. Do you become short of breath with exertion? •
Yes definitely. I can walk slowly to the
postbox or from room to room ok, but im out of breath going upstairs to the bedroom or just
lifting stuff
20. Are you short of breath at rest? • Yes just these past couple months
21. Do you have any pain or other symptoms associated with your difficulty breathing? •
Symptoms? Like cough with runny nose. What else do you mean?
22. Has there been any change in your difficulty breathing over time?
•
Big time! I used to be able too walk, work, and run with the best of them. But not now
23. Do you have unusual heartbeats / palpitations? No.
24. Do you have any pain in your chest? No.
25. Can you tell me about any current or past medical problems?
•
High blood pressure, sleep apnea, and type 2 DM. I’ve had the blood pressure thing for
maybe 25 years now. The DM was maybe 5 years ago. But all these are under control. I
guess that’s all I can think of that’s important.
