I HUMAN CASE WEEK# 4 OF A 72 YEAR OLD REASON FOR
ENCOUNTER:DYSPENEA LOCATION:OUTPATIENT CLINIC WITHX-
RAY,ECG,and LABORATORY CAPABILITIES LATEST CASE 2025!!!
, History
Chief Complaint (CC):
“Shortness of breath.”
History of Present Illness (HPI):
The patient is a 72-year-old [male/female] who presents with progressive shortness of breath for
the past [days/weeks/months]. The dyspnea is described as [sudden/gradual] in onset, occurring
[at rest, with exertion, at night]. The patient notes associated symptoms including [cough,
wheezing, orthopnea, paroxysmal nocturnal dyspnea, chest pain, palpitations, fever, sputum
production, or leg swelling]. No recent history of trauma or exposure to sick contacts. Dyspnea is
aggravated by [activity, lying flat] and relieved by [rest, sitting upright, inhaler use].
Past Medical History (PMH):
Hypertension
Coronary artery disease / prior MI (if applicable)
Congestive heart failure
Chronic obstructive pulmonary disease (COPD) or asthma
Diabetes mellitus
Chronic kidney disease
History of smoking-related lung disease
Past Surgical History (PSH):
[CABG, valve replacement, lung surgery, etc. if relevant]
Medications:
Antihypertensives (beta-blocker, ACE inhibitor, diuretic)
Inhalers (if COPD/asthma)
Anticoagulants or antiplatelets
Statins
Other chronic meds
Allergies:
Drug, food, or environmental allergies (with reaction type).
ENCOUNTER:DYSPENEA LOCATION:OUTPATIENT CLINIC WITHX-
RAY,ECG,and LABORATORY CAPABILITIES LATEST CASE 2025!!!
, History
Chief Complaint (CC):
“Shortness of breath.”
History of Present Illness (HPI):
The patient is a 72-year-old [male/female] who presents with progressive shortness of breath for
the past [days/weeks/months]. The dyspnea is described as [sudden/gradual] in onset, occurring
[at rest, with exertion, at night]. The patient notes associated symptoms including [cough,
wheezing, orthopnea, paroxysmal nocturnal dyspnea, chest pain, palpitations, fever, sputum
production, or leg swelling]. No recent history of trauma or exposure to sick contacts. Dyspnea is
aggravated by [activity, lying flat] and relieved by [rest, sitting upright, inhaler use].
Past Medical History (PMH):
Hypertension
Coronary artery disease / prior MI (if applicable)
Congestive heart failure
Chronic obstructive pulmonary disease (COPD) or asthma
Diabetes mellitus
Chronic kidney disease
History of smoking-related lung disease
Past Surgical History (PSH):
[CABG, valve replacement, lung surgery, etc. if relevant]
Medications:
Antihypertensives (beta-blocker, ACE inhibitor, diuretic)
Inhalers (if COPD/asthma)
Anticoagulants or antiplatelets
Statins
Other chronic meds
Allergies:
Drug, food, or environmental allergies (with reaction type).
