,Patient Information
Age: 50 years
Gender: Female
Height: 5’4” (162.6 cm)
Weight: 165 lb (75 kg, BMI 28.3 kg/m², classified as overweight)
Reason for Encounter: Fatigue and shortness of breath for 3
months, presenting to a primary care clinic in 2024.
History of Present Illness
A 50-year-old female presents to the primary care clinic with a 3-month
history of progressive fatigue and shortness of breath. She describes
the fatigue as a pervasive lack of energy that significantly impacts her
ability to perform daily activities, such as climbing a single flight of
stairs, walking briskly, or completing household chores. These activities,
which she previously managed without difficulty, now leave her feeling
exhausted. The shortness of breath (dyspnea) occurs primarily during
exertion (e.g., walking moderate distances or climbing stairs) and
resolves with rest. She denies shortness of breath while at rest,
difficulty breathing when lying flat (orthopnea), or waking up at night
gasping for air (paroxysmal nocturnal dyspnea). The patient also reports
intermittent palpitations, described as a “fluttering” or rapid heartbeat,
,occurring 2-3 times per week and lasting only a few seconds before
resolving spontaneously. She denies chest pain, fainting, or swelling in
her legs or feet. Additional symptoms include an unintentional weight
gain of approximately 10 pounds over the past 6 months, despite no
significant changes in diet or physical activity. She attributes this to
increased snacking on processed foods due to work-related stress. She
also notes increased irritability, difficulty falling asleep, and frequent
awakenings, which she believes are related to her demanding job as an
office manager. The patient has not sought medical care for these
symptoms previously, hoping they would improve on their own, but
their persistence prompted this visit. Medical History
Past Medical History:
Hypertension: Diagnosed 5 years ago, well-controlled with
lisinopril 10 mg daily.
Hypothyroidism: Diagnosed 3 years ago, managed with
levothyroxine 75 mcg daily. The patient reports compliance
with the medication.
No history of heart disease, lung disease, diabetes, or
autoimmune conditions.
Surgical History: Appendectomy at age 25, uncomplicated.
, Allergies: No known allergies to medications, foods, or
environmental triggers.
Medications:
Lisinopril 10 mg daily (for hypertension).
Levothyroxine 75 mcg daily (for hypothyroidism).
Occasional acetaminophen for headaches or minor pain.
Immunizations: Up to date, including annual influenza vaccine and
COVID-19 boosters (last received in 2024).
Family History:
Mother: Diagnosed with type 2 diabetes mellitus; died at
age 70 from a myocardial infarction.
Father: Hypertension, alive at age 78.
No known family history of pulmonary disease, thyroid
disorders, or blood disorders.
Social History:
Occupation: Office manager, reports high stress due to
recent workplace restructuring and increased
responsibilities.
Smoking: Never smoked, no exposure to secondhand smoke.
Age: 50 years
Gender: Female
Height: 5’4” (162.6 cm)
Weight: 165 lb (75 kg, BMI 28.3 kg/m², classified as overweight)
Reason for Encounter: Fatigue and shortness of breath for 3
months, presenting to a primary care clinic in 2024.
History of Present Illness
A 50-year-old female presents to the primary care clinic with a 3-month
history of progressive fatigue and shortness of breath. She describes
the fatigue as a pervasive lack of energy that significantly impacts her
ability to perform daily activities, such as climbing a single flight of
stairs, walking briskly, or completing household chores. These activities,
which she previously managed without difficulty, now leave her feeling
exhausted. The shortness of breath (dyspnea) occurs primarily during
exertion (e.g., walking moderate distances or climbing stairs) and
resolves with rest. She denies shortness of breath while at rest,
difficulty breathing when lying flat (orthopnea), or waking up at night
gasping for air (paroxysmal nocturnal dyspnea). The patient also reports
intermittent palpitations, described as a “fluttering” or rapid heartbeat,
,occurring 2-3 times per week and lasting only a few seconds before
resolving spontaneously. She denies chest pain, fainting, or swelling in
her legs or feet. Additional symptoms include an unintentional weight
gain of approximately 10 pounds over the past 6 months, despite no
significant changes in diet or physical activity. She attributes this to
increased snacking on processed foods due to work-related stress. She
also notes increased irritability, difficulty falling asleep, and frequent
awakenings, which she believes are related to her demanding job as an
office manager. The patient has not sought medical care for these
symptoms previously, hoping they would improve on their own, but
their persistence prompted this visit. Medical History
Past Medical History:
Hypertension: Diagnosed 5 years ago, well-controlled with
lisinopril 10 mg daily.
Hypothyroidism: Diagnosed 3 years ago, managed with
levothyroxine 75 mcg daily. The patient reports compliance
with the medication.
No history of heart disease, lung disease, diabetes, or
autoimmune conditions.
Surgical History: Appendectomy at age 25, uncomplicated.
, Allergies: No known allergies to medications, foods, or
environmental triggers.
Medications:
Lisinopril 10 mg daily (for hypertension).
Levothyroxine 75 mcg daily (for hypothyroidism).
Occasional acetaminophen for headaches or minor pain.
Immunizations: Up to date, including annual influenza vaccine and
COVID-19 boosters (last received in 2024).
Family History:
Mother: Diagnosed with type 2 diabetes mellitus; died at
age 70 from a myocardial infarction.
Father: Hypertension, alive at age 78.
No known family history of pulmonary disease, thyroid
disorders, or blood disorders.
Social History:
Occupation: Office manager, reports high stress due to
recent workplace restructuring and increased
responsibilities.
Smoking: Never smoked, no exposure to secondhand smoke.
