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