, Patient Information
Age: 50 years
Gender: Female
Height: 5’4” (162.6 cm)
Weight: 165 lb (75 kg, BMI 28.3 kg/m², overweight)
Reason for Encounter: Fatigue and shortness of breath for 3
months, presenting to primary care clinic in 2024.
History of Present Illness
A 50-year-old female presents to the primary care clinic complaining of
progressive fatigue and shortness of breath (dyspnea) for the past 3
months. The patient describes the fatigue as a persistent sense of low
energy that worsens with daily activities, such as climbing stairs or
performing household chores. She reports dyspnea on exertion (DOE),
particularly when walking briskly or climbing one flight of stairs, which
is new for her. She denies dyspnea at rest, orthopnea, or paroxysmal
nocturnal dyspnea. The symptoms have gradually worsened, and she
now feels limited in her ability to engage in physical activities she
previously managed without issue. Associated symptoms include
occasional palpitations, described as a “fluttering” sensation in her
chest, occurring 2-3 times per week, lasting a few seconds, and