Comprehensive Case Study: 60-Year-Old Female Patient with Shortness of Breath (Class 6531) | iHuman Case Analysis Week #4 for Walden University
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Course
Nursing
Institution
Nursing
Comprehensive Case Study: 60-Year-Old Female Patient with Shortness of Breath (Class 6531) | iHuman Case Analysis Week #4
This case study examines a 60-year-old female presenting with shortness of breath. The analysis involves investigating potential underlying causes, including cardiac conditio...
Comprehensive Case Study: 60-Year-Old Female Patient with Shortness Of
Breath (CLASS 6550) | iHuman Case Analysis Week #3 | Includes HPI, PE,
Differential Diagnosis, and Management Plan | Medical Case Review with
EXPERT FEEDBACK Latest Case Study!
Reason for Encounter
Primary Complaint: Shortness of breath
(SOB)
Onset: 2 days ago, progressively worsening
Previous Similar Episode: Yes, 1 year ago,
due to COPD exacerbation requiring
hospitalization
Patient Demographics
Age/Sex/Race: 60-year-old female
Weight/Height/BMI: 83.2 kg (183.0 lb), 163
cm
, HPI Questions
Patient Demographics & Chief Complaint
1. What brings you to the emergency department today?
"I’m having a hard time breathing. It started about two days ago and has just been
getting worse."
2. Have you had similar symptoms in the past?
"Yes, I had something like this about a year ago when I had a COPD flare-up and had to
be in the hospital."
3. Are you currently feeling short of breath?
"Yes, I feel short of breath even when I’m resting."
4. Are you experiencing any pain, pressure, or discomfort in your chest?
"No, I don’t have any chest pain or pressure."
Respiratory Symptoms
5. Are you coughing?
"No, I’m not coughing."
6. Have you noticed any wheezing or noisy breathing?
"Yes, I’ve noticed some wheezing."
7. Are you producing any phlegm or sputum? If so, what color is it?
"No, I’m not coughing anything up."
8. Do you use any breathing assistance devices at home?
"Yes, I use a BiPAP machine at night when I sleep."
Other Symptoms
9. Have you experienced any chills or fever?
"No, I haven’t had any fever or chills."
10. Do you feel fatigued or more tired than usual?
"Yes, I feel very weak and tired."
11. Are you feeling cold or needing extra blankets?
"Yes, I’ve been feeling chilled and needed extra blankets."
12. Have you experienced any swelling in your legs, feet, or anywhere else in your body?
"Yes, my legs have been swelling, and it’s getting worse."
13. Have you had any nausea, vomiting, diarrhea, or abdominal pain?
"No, I haven’t had any of those issues."
14. Have you noticed any changes in your ability to think clearly or concentrate?
"Yes, I feel a little forgetful lately."
15. Have you noticed any changes in your skin, like dryness, rashes, or discoloration?
"Yes, my skin has been really dry."
, Cardiovascular Symptoms
16. Have you had any episodes of your heart racing, fluttering, or feeling like it's
skipping beats?
"No, I haven’t noticed anything like that."
17. Do you have a history of heart problems, like heart attacks or heart disease?
"Yes, I have coronary artery disease, and I had a heart attack in the past."
18. Do you have any pain, numbness, or tingling in your arms or legs?
"No, I don’t have any of that."
19. Do you have a family history of heart disease or heart problems?
"Yes, my father had heart disease."
Lifestyle & Social History
20. Do you smoke, or have you ever smoked?
"Yes, I smoked for 30 years, but I quit 2 years ago."
21. Do you drink alcohol or use recreational drugs?
"No, I don’t drink alcohol or use any drugs."
22. Do you live with anyone who has been sick recently?
"No, no one at home is sick."
23. How often do you exercise or move around during the day?
"I haven’t been moving much lately because I’ve been feeling weak and short of breath."
Urinary Symptoms
24. Have you noticed any changes in how often you urinate or any issues with
urination?
"Yes, I’ve been going to the bathroom more often than usual."
25. Have you had any accidents or incontinence issues recently?
"Yes, I’ve had some accidents where I couldn’t make it to the bathroom."
Medical History & Medications
26. Do you have any medical conditions we should know about?
"Yes, I have COPD, coronary artery disease, diabetes, high blood pressure, high
cholesterol, thyroid problems, and peripheral vascular disease."
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