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I- HUMAN CASE STUDY FOR A 72-YEAR-OLD
PATIENT PRESENTING WITH DYSPNEA WEEK 4
LATELY UPDATED – EXPERT VALUATION
Reason for Encounter:
Evaluation of shortness of breath (dyspnea).
Patient Demographics:
• Age: 72 years
• Sex: Male
• Height: 5’8” (173 cm)
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• Weight: 198 lbs (90 kg)
• BMI: 30.1 kg/m² (Obese Class I)
Case Mode: Learning mode
Case Location: Outpatient clinic with laboratory and imaging capabilities
Attempts Allowed: Unlimited
2. Chief Complaint (CC)
“I feel short of breath, especially when I walk or lie down.”
3. History of Present Illness (HPI)
The patient is a 72-year-old male who presents with a 2-week history of
progressive dyspnea. He reports initially noticing shortness of breath during
exertion, such as climbing stairs or walking short distances. Over the past several
days, symptoms have worsened, and he now experiences dyspnea with minimal
activity and when lying flat at night.
Symptom characteristics:
• Onset: Gradual, 2 weeks ago
• Duration: Persistent
• Course: Progressive worsening
• Severity: Moderate to severe
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• Pattern: Exertional dyspnea progressing to orthopnea
• Associated symptoms:
o Fatigue
o Bilateral lower-extremity swelling
o Mild, nonproductive cough
o Occasional nocturnal dyspnea
Negative symptoms:
• No chest pain
• No fever or chills
• No hemoptysis
• No wheezing at rest
• No syncope
The patient reports sleeping on two pillows to breathe comfortably and waking at
night with shortness of breath. He denies recent travel, prolonged immobilization,
or known sick contacts.
4. Past Medical History (PMH)
• Hypertension (25 years)
• Type 2 diabetes mellitus
• Hyperlipidemia
• Coronary artery disease with prior stent placement (5 years ago)
• History of smoking (30 pack-years; quit 10 years ago)
I- HUMAN CASE STUDY FOR A 72-YEAR-OLD
PATIENT PRESENTING WITH DYSPNEA WEEK 4
LATELY UPDATED – EXPERT VALUATION
Reason for Encounter:
Evaluation of shortness of breath (dyspnea).
Patient Demographics:
• Age: 72 years
• Sex: Male
• Height: 5’8” (173 cm)
,2|Page
• Weight: 198 lbs (90 kg)
• BMI: 30.1 kg/m² (Obese Class I)
Case Mode: Learning mode
Case Location: Outpatient clinic with laboratory and imaging capabilities
Attempts Allowed: Unlimited
2. Chief Complaint (CC)
“I feel short of breath, especially when I walk or lie down.”
3. History of Present Illness (HPI)
The patient is a 72-year-old male who presents with a 2-week history of
progressive dyspnea. He reports initially noticing shortness of breath during
exertion, such as climbing stairs or walking short distances. Over the past several
days, symptoms have worsened, and he now experiences dyspnea with minimal
activity and when lying flat at night.
Symptom characteristics:
• Onset: Gradual, 2 weeks ago
• Duration: Persistent
• Course: Progressive worsening
• Severity: Moderate to severe
, 3|Page
• Pattern: Exertional dyspnea progressing to orthopnea
• Associated symptoms:
o Fatigue
o Bilateral lower-extremity swelling
o Mild, nonproductive cough
o Occasional nocturnal dyspnea
Negative symptoms:
• No chest pain
• No fever or chills
• No hemoptysis
• No wheezing at rest
• No syncope
The patient reports sleeping on two pillows to breathe comfortably and waking at
night with shortness of breath. He denies recent travel, prolonged immobilization,
or known sick contacts.
4. Past Medical History (PMH)
• Hypertension (25 years)
• Type 2 diabetes mellitus
• Hyperlipidemia
• Coronary artery disease with prior stent placement (5 years ago)
• History of smoking (30 pack-years; quit 10 years ago)
