CHANA KUMAR AN 85 YEAR OLD FEMALE WEEK*7
(CLASS 6512) REASON FOR ENCOUNTER: FATIGUE AND
DYSPNEA [WALDEN UNIVERSITY] COMPREHESIVE
CASE STUDY
Patient Overview
Name: Chana Kumar
Age: 85 years
Sex: Female
Height: 5'2" (157.0 cm)
1
,Weight: 122 lb (55.0 kg)
BMI: 22.3
Chief Complaint: Fatigue
"Yesterday I had a situation at water aerobics that was very alarming. I got gradually more and
more short of breath, and then it got even more severe, my heart started racing. I was really
faint/panicked. When my instructor took my pulse it was 120 and regular. That’s really unusu
for me. It got better after I rested for 20 minutes. But she insisted I get evaluated before she
would let me back in the class."
Clinical Notes:
• Pulse: 120, regular
• Shortness of breath with physical exertion Condition improves with rest Feeling
tired:
"I've been feeling quite physically tired over the last 2 months: fatigued with just
about all activity, generally weak all over, and more easily winded."
• Skin: Warm and dry Knee pain
• Symptoms:
o Tiredness and fatigue
o Racing heart o Nervousness about
symptoms o No energy to complete daily chores
• "I was quite short of breath yesterday and thought it would be best if I saw a doctor."
• Mental status: Alert and oriented to place, time, and situation
• History of generalized weakness: Began two months ago Increased fatigue with
exertion History of Present Illness (HPI):
• Chana Kumar is an 85-year-old female who presents with complaints of fatigue,
shortness of breath with exertion, and a racing heart. Two months ago, she began
experiencing generalized weakness and increased fatigue with minimal activity. She no
reports feeling physically tired with nearly all activity, describes being easily winded,
and notes no energy to complete daily chores.
• She had a concerning episode during a water aerobics class where she became
progressively short of breath and developed palpitations. Her heart rate was measured a
120 bpm and regular during the event. She felt faint and panicked. Symptoms improved
with 20 minutes of rest.
2
, • She also reports pain in her knees, warm and dry skin, and feeling more tired with
exertion. She is alert and oriented to place, time, and situation but is worried about
what’s going on and sought evaluation due to ongoing symptoms.
Physical Examination:
General:
o Oriented to place, time, and situation
o Appears tired but alert
o Skin:
o Warm and dry Cardiovascular:
o Pulse: 120 bpm, regular o Reports
episodes of a racing heart Respiratory:
o Shortness of breath with physical
exertion o Symptoms improve with rest
Musculoskeletal:
o Reports bilateral knee pain o
Generalized weakness noted Neurological:
o No acute changes in mental status o
Alert and oriented x3
Assessment:
Chana Kumar is an 85-year-old female presenting with a 2-month history of and episodes of
(HR 120, regular). Symptoms improve with rest. She also reports bilateral knee pain, no
energy for daily chores, and recent functional decline. She is alert and oriented but concerned
about her health.
Differential Diagnoses:
1. Heart Failure (HF) + possibly HFpEF o Elderly age, fatigue, SOB with exertion,
racing heart, and improvement with rest support this. o Preserved ejection fraction
heart failure is common in elderly women with preserved BP and HR.
2. Anemia o Could explain generalized weakness, fatigue, and SOB with activity.
3. Deconditioning o Functional decline due to age-related muscle loss or lack of
physical activity.
4. Atrial Fibrillation (Paroxysmal) o Although rhythm was noted as regular, episodes
of palpitations and elevated HR may indicate intermittent arrhythmia.
3
(CLASS 6512) REASON FOR ENCOUNTER: FATIGUE AND
DYSPNEA [WALDEN UNIVERSITY] COMPREHESIVE
CASE STUDY
Patient Overview
Name: Chana Kumar
Age: 85 years
Sex: Female
Height: 5'2" (157.0 cm)
1
,Weight: 122 lb (55.0 kg)
BMI: 22.3
Chief Complaint: Fatigue
"Yesterday I had a situation at water aerobics that was very alarming. I got gradually more and
more short of breath, and then it got even more severe, my heart started racing. I was really
faint/panicked. When my instructor took my pulse it was 120 and regular. That’s really unusu
for me. It got better after I rested for 20 minutes. But she insisted I get evaluated before she
would let me back in the class."
Clinical Notes:
• Pulse: 120, regular
• Shortness of breath with physical exertion Condition improves with rest Feeling
tired:
"I've been feeling quite physically tired over the last 2 months: fatigued with just
about all activity, generally weak all over, and more easily winded."
• Skin: Warm and dry Knee pain
• Symptoms:
o Tiredness and fatigue
o Racing heart o Nervousness about
symptoms o No energy to complete daily chores
• "I was quite short of breath yesterday and thought it would be best if I saw a doctor."
• Mental status: Alert and oriented to place, time, and situation
• History of generalized weakness: Began two months ago Increased fatigue with
exertion History of Present Illness (HPI):
• Chana Kumar is an 85-year-old female who presents with complaints of fatigue,
shortness of breath with exertion, and a racing heart. Two months ago, she began
experiencing generalized weakness and increased fatigue with minimal activity. She no
reports feeling physically tired with nearly all activity, describes being easily winded,
and notes no energy to complete daily chores.
• She had a concerning episode during a water aerobics class where she became
progressively short of breath and developed palpitations. Her heart rate was measured a
120 bpm and regular during the event. She felt faint and panicked. Symptoms improved
with 20 minutes of rest.
2
, • She also reports pain in her knees, warm and dry skin, and feeling more tired with
exertion. She is alert and oriented to place, time, and situation but is worried about
what’s going on and sought evaluation due to ongoing symptoms.
Physical Examination:
General:
o Oriented to place, time, and situation
o Appears tired but alert
o Skin:
o Warm and dry Cardiovascular:
o Pulse: 120 bpm, regular o Reports
episodes of a racing heart Respiratory:
o Shortness of breath with physical
exertion o Symptoms improve with rest
Musculoskeletal:
o Reports bilateral knee pain o
Generalized weakness noted Neurological:
o No acute changes in mental status o
Alert and oriented x3
Assessment:
Chana Kumar is an 85-year-old female presenting with a 2-month history of and episodes of
(HR 120, regular). Symptoms improve with rest. She also reports bilateral knee pain, no
energy for daily chores, and recent functional decline. She is alert and oriented but concerned
about her health.
Differential Diagnoses:
1. Heart Failure (HF) + possibly HFpEF o Elderly age, fatigue, SOB with exertion,
racing heart, and improvement with rest support this. o Preserved ejection fraction
heart failure is common in elderly women with preserved BP and HR.
2. Anemia o Could explain generalized weakness, fatigue, and SOB with activity.
3. Deconditioning o Functional decline due to age-related muscle loss or lack of
physical activity.
4. Atrial Fibrillation (Paroxysmal) o Although rhythm was noted as regular, episodes
of palpitations and elevated HR may indicate intermittent arrhythmia.
3
