LAWRENCE LEE -70 YEAR OLD PATIENT
REASON FOR ENCOUNTER; DIFFICULTY
BREATHING. LATEST CASE (Chamberlain
University) NR 509
, NR 509 – Patient Encounter Summary
Patient: Lawrence Lee
Age: 70 years
Reason for Encounter: Difficulty breathing
Chief Complaint (CC)
“I'm having trouble breathing.”
History of Present Illness (HPI)
Mr. Lawrence Lee is a 70-year-old male who presents with increasing difficulty breathing for
the past 2 days. He reports wheezing, chest tightness, and a productive cough producing
yellow-white sputum. Symptoms are worse at night, waking him due to shortness of breath. He
denies chest pain but notes fatigue and mild fever. He reports no recent travel, but has had an
upper respiratory infection approximately one week ago.
Aggravating factors: exertion, lying flat.
Relieving factors: sitting upright, resting.
No history of trauma.
Past Medical History (PMH)
• Hypertension
• Hyperlipidemia
• (Add COPD/asthma if part of your specific case – some NR509 versions include this)
• No known drug allergies (update per your scenario)
Social History (SH)
• Former smoker (quit 10 years ago)
• Lives with spouse, retired
REASON FOR ENCOUNTER; DIFFICULTY
BREATHING. LATEST CASE (Chamberlain
University) NR 509
, NR 509 – Patient Encounter Summary
Patient: Lawrence Lee
Age: 70 years
Reason for Encounter: Difficulty breathing
Chief Complaint (CC)
“I'm having trouble breathing.”
History of Present Illness (HPI)
Mr. Lawrence Lee is a 70-year-old male who presents with increasing difficulty breathing for
the past 2 days. He reports wheezing, chest tightness, and a productive cough producing
yellow-white sputum. Symptoms are worse at night, waking him due to shortness of breath. He
denies chest pain but notes fatigue and mild fever. He reports no recent travel, but has had an
upper respiratory infection approximately one week ago.
Aggravating factors: exertion, lying flat.
Relieving factors: sitting upright, resting.
No history of trauma.
Past Medical History (PMH)
• Hypertension
• Hyperlipidemia
• (Add COPD/asthma if part of your specific case – some NR509 versions include this)
• No known drug allergies (update per your scenario)
Social History (SH)
• Former smoker (quit 10 years ago)
• Lives with spouse, retired
