67-Year-Old Female with Progressive
Exertional Dyspnea: Jamie Feldman i-Human
Case Study for NURS 6512 Week 7 - Heart
Failure Diagnosis and Management
1. PATIENT BIODATA & REASON FOR ENCOUNTER
PATIENT IDENTIFICATION
,Data Category Clinical Information
Full Name Jamie Lynn Feldman
Date of Birth June 15, 1956
Age 67 years
Biological Sex Female
Height 5'6" (168 cm)
Weight 174.0 lb (79.1 kg)
BMI 28.1 kg/m² (Overweight)
Race/Ethnicity Caucasian
Location Outpatient clinic with laboratory and imaging capabilities
REASON FOR ENCOUNTER
Shortness of breath. Jamie Feldman is a 67-year-old female presenting with
progressively worsening shortness of breath that has been affecting her functional
capacity, especially on exertion. She seeks evaluation to identify underlying causes,
assess cardiac and pulmonary function, and develop an appropriate management plan .
2. CASE INTRODUCTION
Jamie Feldman is a 67-year-old Caucasian female who presents to an outpatient clinic
with laboratory and imaging capabilities, reporting progressive shortness of breath over
the past month. She has a history of Type 2 Diabetes Mellitus and Hyperlipidemia,
managed with Metformin and Simvastatin. The patient reports that her symptoms have
worsened significantly over the past 72 hours, now affecting her ability to perform
activities of daily living. She describes associated symptoms including orthopnea,
paroxysmal nocturnal dyspnea, dry cough, fatigue, and bilateral leg edema. Physical
, examination reveals tachycardia, hypertension, tachypnea, mild hypoxemia (SpO2 92%),
bibasilar crackles, S3 gallop, and bilateral pitting edema. This case presents a common
but potentially serious geriatric complaint requiring systematic assessment to
distinguish between cardiac, pulmonary, and other systemic causes of acute dyspnea .
3. CHIEF COMPLAINT
Verbatim Patient Statement:
"Doctor, I just can't catch my breath anymore. It started about two weeks ago when I
noticed getting winded walking up the stairs to my apartment. Now I'm breathless just
getting dressed or making breakfast. Yesterday, I had to sit down halfway through cooking
because I felt like I couldn't get enough air."
Clinician Interpretation:
Primary symptom: Progressive exertional dyspnea
Onset: Approximately 14 days prior to visit
Progression: Rapid worsening over past 72 hours
Current functional limitation: Activities of daily living now impaired
Associated concern: Patient expressing anxiety about symptom severity
4. QUESTIONS AND ANSWERS DURING FULL HISTORY
RESPIRATORY HISTORY INQUIRY
Q: "Can you describe what the shortness of breath feels like?"
A: "It's like I can't take a deep enough breath. My chest feels tight, and I have to work
harder to breathe."
Q: "What makes it better or worse?"
A: "Worse when I walk or do anything physical. Better when I sit completely still. Propping
up on extra pillows at night helps a little."
, Q: "Do you wake up at night short of breath?"
A: "The last three nights, I've woken up around 2 AM feeling like I'm suffocating. I have to
sit up on the edge of the bed to breathe."
CARDIOVASCULAR HISTORY INQUIRY
Q: "Have you noticed any chest pain or discomfort?"
A: "Not really pain, but sometimes a heaviness in my chest when the breathing is bad."
Q: "Any swelling in your feet or ankles?"
A: "My shoes have felt tighter the last few days, and I can see indentations from my socks."
SYMPTOM PATTERN INQUIRY
Q: "Is the shortness of breath constant or does it come and go?"
A: "It's there all the time now, but much worse with any movement."
Q: "Have you had fever, cough, or cold symptoms?"
A: "No fever that I've noticed. A dry cough started a few days ago, mostly when I'm lying
down."
FUNCTIONAL ASSESSMENT
Q: "How has this affected your daily activities?"
A: "I can't do my grocery shopping anymore. My neighbor had to get my prescriptions
yesterday. I'm afraid to shower alone."
5. HISTORY
CHRONOLOGICAL SYMPTOM PROGRESSION
Timeframe Symptom Development Functional Impact
First noticed dyspnea climbing 12 stairs to
2 weeks ago Mild limitation (slower pace neede
apartment
Moderate limitation (needed rest
1 week ago Shortness of breath walking 1 city block
breaks)
Exertional Dyspnea: Jamie Feldman i-Human
Case Study for NURS 6512 Week 7 - Heart
Failure Diagnosis and Management
1. PATIENT BIODATA & REASON FOR ENCOUNTER
PATIENT IDENTIFICATION
,Data Category Clinical Information
Full Name Jamie Lynn Feldman
Date of Birth June 15, 1956
Age 67 years
Biological Sex Female
Height 5'6" (168 cm)
Weight 174.0 lb (79.1 kg)
BMI 28.1 kg/m² (Overweight)
Race/Ethnicity Caucasian
Location Outpatient clinic with laboratory and imaging capabilities
REASON FOR ENCOUNTER
Shortness of breath. Jamie Feldman is a 67-year-old female presenting with
progressively worsening shortness of breath that has been affecting her functional
capacity, especially on exertion. She seeks evaluation to identify underlying causes,
assess cardiac and pulmonary function, and develop an appropriate management plan .
2. CASE INTRODUCTION
Jamie Feldman is a 67-year-old Caucasian female who presents to an outpatient clinic
with laboratory and imaging capabilities, reporting progressive shortness of breath over
the past month. She has a history of Type 2 Diabetes Mellitus and Hyperlipidemia,
managed with Metformin and Simvastatin. The patient reports that her symptoms have
worsened significantly over the past 72 hours, now affecting her ability to perform
activities of daily living. She describes associated symptoms including orthopnea,
paroxysmal nocturnal dyspnea, dry cough, fatigue, and bilateral leg edema. Physical
, examination reveals tachycardia, hypertension, tachypnea, mild hypoxemia (SpO2 92%),
bibasilar crackles, S3 gallop, and bilateral pitting edema. This case presents a common
but potentially serious geriatric complaint requiring systematic assessment to
distinguish between cardiac, pulmonary, and other systemic causes of acute dyspnea .
3. CHIEF COMPLAINT
Verbatim Patient Statement:
"Doctor, I just can't catch my breath anymore. It started about two weeks ago when I
noticed getting winded walking up the stairs to my apartment. Now I'm breathless just
getting dressed or making breakfast. Yesterday, I had to sit down halfway through cooking
because I felt like I couldn't get enough air."
Clinician Interpretation:
Primary symptom: Progressive exertional dyspnea
Onset: Approximately 14 days prior to visit
Progression: Rapid worsening over past 72 hours
Current functional limitation: Activities of daily living now impaired
Associated concern: Patient expressing anxiety about symptom severity
4. QUESTIONS AND ANSWERS DURING FULL HISTORY
RESPIRATORY HISTORY INQUIRY
Q: "Can you describe what the shortness of breath feels like?"
A: "It's like I can't take a deep enough breath. My chest feels tight, and I have to work
harder to breathe."
Q: "What makes it better or worse?"
A: "Worse when I walk or do anything physical. Better when I sit completely still. Propping
up on extra pillows at night helps a little."
, Q: "Do you wake up at night short of breath?"
A: "The last three nights, I've woken up around 2 AM feeling like I'm suffocating. I have to
sit up on the edge of the bed to breathe."
CARDIOVASCULAR HISTORY INQUIRY
Q: "Have you noticed any chest pain or discomfort?"
A: "Not really pain, but sometimes a heaviness in my chest when the breathing is bad."
Q: "Any swelling in your feet or ankles?"
A: "My shoes have felt tighter the last few days, and I can see indentations from my socks."
SYMPTOM PATTERN INQUIRY
Q: "Is the shortness of breath constant or does it come and go?"
A: "It's there all the time now, but much worse with any movement."
Q: "Have you had fever, cough, or cold symptoms?"
A: "No fever that I've noticed. A dry cough started a few days ago, mostly when I'm lying
down."
FUNCTIONAL ASSESSMENT
Q: "How has this affected your daily activities?"
A: "I can't do my grocery shopping anymore. My neighbor had to get my prescriptions
yesterday. I'm afraid to shower alone."
5. HISTORY
CHRONOLOGICAL SYMPTOM PROGRESSION
Timeframe Symptom Development Functional Impact
First noticed dyspnea climbing 12 stairs to
2 weeks ago Mild limitation (slower pace neede
apartment
Moderate limitation (needed rest
1 week ago Shortness of breath walking 1 city block
breaks)
