Alvin Stafford - iHuman Case Study-Worsening shortness of breath

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iHuman Case Study - Alvin Stafford iHuman Case Study - Alvin Stafford A.S. - is a 63-year-old male Chief Complaint: Worsening shortness of breath Associated Sx/Sx Characteristics: When did y... ou start experiencing worsened shortness of breath? “Last week.” Do you experience pain in any area of your body? “Yes, around the chest region.” Does the difficulty in breathing become worse during the day or at night, or is it consistent the whole day? “It becomes worse at night. Sometimes it even becomes very hard to sleep.” Please describe how it makes you feel. “I feel like I cannot breathe properly, especially when going about my daily activities and I get tired most of the time. My chest is congested, and it hurts so much, especially when I cough.” Is the cough productive? “Yes, with white sputum.” Does your throat hurt? “No.” What makes the symptoms you have just describe worsen? “Cold weather and daily activities.” What about anything that makes the breathing difficulty and chest pain better? “It becomes better when am resting during the day in a warm weather.” Have you taken any drugs or tried any home remedies to relieve your chest pain and shortness of breath? “Yes, I have been using a budesonide inhaler every time I feel like am short of breath, and salbutamol, every night before I sleep. However, I was given these drugs the last time a visited the hospital and diagnosed with bronchial asthma. The drugs have not been of much help ever since my shortness of breath worsened. Ever since you started experiencing shortness of breath and chest pain, have you been able to go through your daily activities? “No, I have been resting most of the day.” Can you rate the severity of the pain on a scale of 0 to 10, with 0 being very mild and 10 the worst? “10, it really hurts.” Have you ever felt the same way before? “Yes, but not as worse as how I have been feeling in the past week.” Have you been taking all your medications as prescribed? “Yes, but sometimes I may forget and take the drugs 1 or 2 hours late, but I still maintain the dosage and frequency.” PMH According to your medical records, I can see that you were diagnosed with hypertension about 8 years ago. Is it correct? [Show More]

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