,I HUMAN CASE WEEK #10 A 50 YEAR OLD FEMALE REASON
FOR ENCOUNTER: FATIGUE AND SHORTNESS OF BREATH
Certainly! Here's a comprehensive clinical
case study for a 50-year-old female patient
presenting with fatigue and shortness of
breath, formatted for educational or clinical
documentation purposes.
Comprehensive Case Study: 50-Year-
Old Female with Fatigue and Shortness of
Breath
Patient: [Insert Name]
Age: 50 years
Gender: Female
,Date of Encounter: [Insert Date]
Clinician: [Insert Name]
Setting: [Insert Clinic/Hospital Name]
I. Chief Complaint
“I’ve been feeling extremely tired and out of
breath, even with minimal activity.”
II. History of Present Illness (HPI)
The patient is a 50-year-old female who
presents with a 3-week history of
progressive fatigue and shortness of breath.
She reports that her symptoms have
worsened over time, with increasing
difficulty performing daily activities such as
climbing stairs and walking short distances.
The shortness of breath is described as
exertional, occurring during routine tasks,
, and is not associated with chest pain or
palpitations. She denies any orthopnea,
paroxysmal nocturnal dyspnea, or recent
weight gain.
Additional symptoms include:
• Fatigue: Persistent and unrelieved by
rest.
• Dyspnea: Onset during light physical
activity.
• Sleep Disturbances: Difficulty falling
asleep and frequent awakenings.
• Cognitive Impairment: Complaints of
forgetfulness and difficulty
concentrating.
The patient has no known history of
cardiovascular or pulmonary disease and is
not currently taking any medications. She
denies smoking, excessive alcohol use, or
illicit drug use. There is no significant
FOR ENCOUNTER: FATIGUE AND SHORTNESS OF BREATH
Certainly! Here's a comprehensive clinical
case study for a 50-year-old female patient
presenting with fatigue and shortness of
breath, formatted for educational or clinical
documentation purposes.
Comprehensive Case Study: 50-Year-
Old Female with Fatigue and Shortness of
Breath
Patient: [Insert Name]
Age: 50 years
Gender: Female
,Date of Encounter: [Insert Date]
Clinician: [Insert Name]
Setting: [Insert Clinic/Hospital Name]
I. Chief Complaint
“I’ve been feeling extremely tired and out of
breath, even with minimal activity.”
II. History of Present Illness (HPI)
The patient is a 50-year-old female who
presents with a 3-week history of
progressive fatigue and shortness of breath.
She reports that her symptoms have
worsened over time, with increasing
difficulty performing daily activities such as
climbing stairs and walking short distances.
The shortness of breath is described as
exertional, occurring during routine tasks,
, and is not associated with chest pain or
palpitations. She denies any orthopnea,
paroxysmal nocturnal dyspnea, or recent
weight gain.
Additional symptoms include:
• Fatigue: Persistent and unrelieved by
rest.
• Dyspnea: Onset during light physical
activity.
• Sleep Disturbances: Difficulty falling
asleep and frequent awakenings.
• Cognitive Impairment: Complaints of
forgetfulness and difficulty
concentrating.
The patient has no known history of
cardiovascular or pulmonary disease and is
not currently taking any medications. She
denies smoking, excessive alcohol use, or
illicit drug use. There is no significant
