Description

Problem Statement – Version 1

C.A. is a 72 year old male presenting with progressive shortness of breath for the past two months accompanied by a cough, different than his chronic cough, white frothy sputum, occasional wheezing, bilateral lower extremity and abdominal edema. Medical history significant for hypertension, stent placement six months ago, hyperlipidemia and smoking cessation six months ago, after smoking a pack per day for fifty years. Assessment findings concerning for heart failure.

Problem Statement – Version 2

Mr. Alvarez, 72y.o male, presented with SOB for 2 months. Pertinent medical history includes HTN, CAD, recent cardiac stent 6 months ago, and HLD. Positive subjective findings of fatigue, leg/abdominal swelling, coughing, wheezing, and orthopnea.

Negative for chest pain/tightness. Physical exam positive for BLE 2-3+ pitting edema, S3/4 pan-systolic murmur, hepatomegaly with positive JVD and HJR, displaced PMI laterally 2cm, delayed cap refill, and hepatomegaly. Negative eye/mouth findings.

Problem Statement – Version 3

A 72 year old male, with PMH of hypertension, CAD, hyperlipidemia, coronary stent placement 6 months ago. Former smoker, quit 6 months ago. Patient presented with complaints of shortness of breath, worse with physical activity and when lying down, fatigue, edema in b/l LE and abdomen, cough with white frothy mucus. Patient denies abdominal pain, chest pain, GU or GI complaints.