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WEEK #7 CASE STUDY Comprehensive Case Study: 60-Year-Old Female Patient with Shortness Of Breath

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WEEK #7 CASE STUDY Comprehensive Case Study: 60-Year-Old Female Patient with Shortness Of Breath (CLASS 6550) i-Human Case Analysis. WALDEN UNIVERSITY

Institution
Nursing
Course
Nursing

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Good Questions:
1. How can i help you today

, • 1m having trouble breathing.
2. Do you have any other symptoms or concerns we should discuss • An allergic cough and
runny nose. I get the cough every year during this season.
3. Do you wheeze? • Normally just when my allergies act up. Lately have sort of noticed
wheezing at night. That’s fairly new I guess.
4. Are you short of breath when lying down?
1m always SOB
5. Do you sleep with pillows to help you breathe? Just 1 pillows


6. Does anything make your cough better or worse? • My coughing is worse when the trees
shed pollen

7. Are you taking any prescription medications? • Yes indeed. I brought my list with me here.
Lisonopril 10mg daily, HCTZ 25mg daily, glipizide 5mg daily. Also use a CPAP machine, though
it's not really a medicine.
8. Are you taking any OTC or herbal medications?



Aleve for shoulder pain and Allergries for the allergies
9. Do you have any allergies?



Sulfa drugs, I am pretty sure I’m allergic to tree and grass pollen and ragweed

10. Do you now or have you ever smoked or chewed tobacco • I was a big time smoker in the
past. Started when I was 16. A pack a day, but i stopped 10 years ago. That was hard to do.


11. Do you have a problem with fatigue/tiredness • I sure do. I get tired when i exert. I think im
really out of shape, but i also dont sleep great due to sleep apnea, and this makes me tired
during the day too


12. Have you been having fevers? no 13. Is there any swelling in your ankles? • Sometimes.
Not bad though
14. Do you have a problem with generalized weakness?
• Weakness? No, I dont think i'd call it that really
15. Do you have a cough? • Not normally, but i have been coughing for the last couple of
months
16. Are you coughing up any sputum?

, • Occasionally, like now. I get a cold, then bronchitis with coughing up stuff, then it goes
away. Sometimes clear. Sometimes not. Its been worse the past 2 months - coughing up
this gooey white stuff in the morning. Maybe like a few teaspoons worth. Disgusting.


17. When did your difficulty breathing start? • About 10 years ago. Past 5 years its affected me
more and more

18. Does anything make your difficulty breathing better or worse? • Sitting still is the best for
my breathing. Also it helps if i purse my lips when i breathe out

19. Do you become short of breath with exertion? • Yes definitely. I can walk slowly to the
postbox or from room to room ok, but im out of breath going upstairs to the bedroom or
just lifting stuff

20. Are you short of breath at rest? • Yes just these past couple months

21. Do you have any pain or other symptoms associated with your difficulty breathing? •
Symptoms? Like cough with runny nose. What else do you mean?


22. Has there been any change in your difficulty breathing over
time? Big time! I used to be able too walk, work, and run with the best of
them. But not now


23. Do you have unusual heartbeats / palpitations? No.
24. Do you have any pain in your chest? No.




25. Can you tell me about any current or past medical problems?


• High blood pressure, sleep apnea, and type 2 DM. I’ve had the blood pressure thing for
maybe 25 years now. The DM was maybe 5 years ago. But all these are under control. I
guess that’s all I can think of that’s important.
26. Any recent acute or chronic infections? No.

27. Any previous medical, surgical, or dental procedures? • I had my gall bladder removed 20
years ago. I had an accident 30 years back and i had a surgery to fix my shoulder and for the
wound in my leg. I guess that’s the big stuff
28. Have you ever been hospitalized? • Just when i had to have some surgery

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Institution
Nursing
Course
Nursing

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Uploaded on
July 7, 2025
Number of pages
21
Written in
2024/2025
Type
CASE
Professor(s)
Unknown
Grade
Unknown
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