I HUMAN WEEK #7ACTUAL
SCREENSHOTS Case Study: Evaluation
and Management of Dyspnea in a 60-
Year-Old Female with Acute
Exacerbation of Congestive Heart Failure
and Chronic Obstructive Pulmonary
Disease (COPD)
,📝 HISTORY (Subjective Data)
Patient Name: JOWNSWANE)
Age: 60 years
Sex: Female
Date of Visit: [Insert date]
Chief Complaint (CC):
"I’ve been having shortness of breath for the last few days."
History of Present Illness (HPI):
The patient is a 60-year-old female presenting with complaints of progressive shortness of
breath for the past [X] days. The dyspnea is described as [e.g., constant, intermittent,
worsening with exertion or at rest]. She reports associated symptoms such as:
[Yes/No] Cough
[Yes/No] Sputum production (if yes, describe color/consistency)
[Yes/No] Fever/chills
[Yes/No] Chest pain or pressure
[Yes/No] Orthopnea or paroxysmal nocturnal dyspnea (PND)
[Yes/No] Lower extremity swelling
[Yes/No] Fatigue or weight gain/loss
[Yes/No] Palpitations
Onset: [e.g., gradual vs. sudden]
Severity: [e.g., mild, moderate, severe; impact on daily activities]
Aggravating/Relieving Factors: [e.g., worse with exertion, relieved with rest]
Treatment tried: [e.g., inhalers, OTC meds, rest]
Past Medical History (PMH):
, Hypertension: Yes/No
Diabetes Mellitus: Yes/No
Hyperlipidemia: Yes/No
Chronic Obstructive Pulmonary Disease (COPD): Yes/No
Asthma: Yes/No
Heart Failure: Yes/No
Coronary Artery Disease / MI: Yes/No
Anemia: Yes/No
Pulmonary Embolism: Yes/No
Other chronic illnesses: [e.g., renal disease, thyroid disorders]
Surgical History:
List prior surgeries (especially cardiac or pulmonary).
Medications:
Include prescribed, OTC, and supplements.
Allergies:
Include medication, food, environmental allergies (and reaction type).
Family History (FH):
Any history of:
Heart disease
COPD
Asthma
Cancer
Clotting disorders
Social History (SH):
Tobacco Use: [e.g., 1 pack/day for 30 years; current/former smoker]
SCREENSHOTS Case Study: Evaluation
and Management of Dyspnea in a 60-
Year-Old Female with Acute
Exacerbation of Congestive Heart Failure
and Chronic Obstructive Pulmonary
Disease (COPD)
,📝 HISTORY (Subjective Data)
Patient Name: JOWNSWANE)
Age: 60 years
Sex: Female
Date of Visit: [Insert date]
Chief Complaint (CC):
"I’ve been having shortness of breath for the last few days."
History of Present Illness (HPI):
The patient is a 60-year-old female presenting with complaints of progressive shortness of
breath for the past [X] days. The dyspnea is described as [e.g., constant, intermittent,
worsening with exertion or at rest]. She reports associated symptoms such as:
[Yes/No] Cough
[Yes/No] Sputum production (if yes, describe color/consistency)
[Yes/No] Fever/chills
[Yes/No] Chest pain or pressure
[Yes/No] Orthopnea or paroxysmal nocturnal dyspnea (PND)
[Yes/No] Lower extremity swelling
[Yes/No] Fatigue or weight gain/loss
[Yes/No] Palpitations
Onset: [e.g., gradual vs. sudden]
Severity: [e.g., mild, moderate, severe; impact on daily activities]
Aggravating/Relieving Factors: [e.g., worse with exertion, relieved with rest]
Treatment tried: [e.g., inhalers, OTC meds, rest]
Past Medical History (PMH):
, Hypertension: Yes/No
Diabetes Mellitus: Yes/No
Hyperlipidemia: Yes/No
Chronic Obstructive Pulmonary Disease (COPD): Yes/No
Asthma: Yes/No
Heart Failure: Yes/No
Coronary Artery Disease / MI: Yes/No
Anemia: Yes/No
Pulmonary Embolism: Yes/No
Other chronic illnesses: [e.g., renal disease, thyroid disorders]
Surgical History:
List prior surgeries (especially cardiac or pulmonary).
Medications:
Include prescribed, OTC, and supplements.
Allergies:
Include medication, food, environmental allergies (and reaction type).
Family History (FH):
Any history of:
Heart disease
COPD
Asthma
Cancer
Clotting disorders
Social History (SH):
Tobacco Use: [e.g., 1 pack/day for 30 years; current/former smoker]
