167.0 LB(75.9KG) ) REASON FOR ENCOUNTER DYSPNEA |
LOCATION OUTPATIENT CLINIC WITH X-RAY ,ECG AND
LABORATORY CAPABILITIES
ComprehensiveiCaseiStudy
72-Year-OldiMale,i165icm,i75.9ikg
ReasoniforiEncounter:iDyspneai(ShortnessiofiBreath)
Location:iOutpatientiCliniciwithiX-ray,iECG,iandiLaboratoryiSupport
i- HumaniCaseiAnalysisi|iEXPERTiREVIEW
1. HistoryiofiPresentiIllnessi(HPI)
Onset:iDyspneaistartedi3imonthsiago,igraduallyiprogressive.iRecentlyiw
orsenedioveritheilasti1iweek.
Duration:iInitiallyionlyiexertional,inowioccursiatirest.
Character:iReportsiorthopneai(requiresi2ipillows),inoiparoxysmalin
octurnalidyspnea.
Progression:iLimitingiabilityitoiclimbistairsioriwalki>100imeters.
AssociatediSymptoms:
o Mildinon-productiveicough.
o Occasionalipalpitations.
o Bilateraliankleiswellinginotediinievenings.
o Deniesichestipain,ifever,ihemoptysis,ioriweightiloss.
Aggravating/
AlleviatingiFactors:iWorseiwithiexertion,ibetteriwithirestiandisittingiuprig
ht.
PrecipitatingiEvents:iNoirecentirespiratoryiinfections,itravel,iorii
mmobilization.
,2. PastiMedicaliHistoryi(PMH)
Hypertensioni×i20iyears.
Typei2iDiabetesiMellitus.
Dyslipidemia.
Noiknownichronicilungidiseasei(e.g.,iCOPDioriasthma).
Noirecentihospitalizations.
3. Familyi&iSocialiHistory
Father:idiediofistrokeiati75.
Mother:ihistoryiofihypertensioniandiheartifailure.
Ex-smokeri(40ipack-years,iquiti5iyearsiago).
Noialcohol,inoidrugiuse.
Livesiwithispouse,ipreviouslyiaishopiowner.
, 4. PhysicaliExamination
General:iElderlyimale,imildirespiratoryidistress,iseatediupright.
Vitals:iBPi148/92immHg,iHRi92ibpmi(irregularlyiirregular),iRRi22,iTe
mpi36.9°C,iSpO₂i91%ioniroomiair.
CardiaciExam:iIrregularlyiirregularirhythmi(suggestiveiofiatrialifibrill
ation),idisplacediapexibeat,iS₃igallopipresent.
RespiratoryiExam:iBilateralibasalicrackles,inoiwheezes,idullnessiatiri
ghtilungibase.
Neck:iJugularivenousidistension.
Extremities:i1+ipedaliedema.
Other:iNoicyanosis,inoiclubbing.