Comprehensive Dyspnea Case Study: 72-Year-Old Male With Acut

COMPREHENSIVE DYSPNEA CASE STUDY: 72-YEAR-OLD MALE WITH ACUTE HEART FAILURE EXACERBATION EXPERT SOAP NOTE & EVIDENCE-BASED MANAGEMENT72-Year-Old Male with Acute Decompensated Heart Failure Expert SOAP Note Format with Complete Clinical Details I. CASE IDENTIFICATION & BACKGROUND A. Patient Demographics Age: 72 years Gender: Male Race/Ethnicity: African American Occupation: Retired postal worker Marital Status: Widowed (2 years) Living Situation: Lives alone in single-story home Religion: Baptist Primary Language: English Health Literacy: Fair (understands medications but not pathophysiology) B. Chief Complaint & Presenting Scenario Setting: Emergency Department, Friday evening, 8:45 PM Mode of Arrival: EMS via ambulance Chief Complaint: "I can't breathe and my legs are swollen" Duration: Symptoms worsening over 5 days, acute worsening today EMS Report: Called 911 after unable to walk to bathroom due to shortness of breath Found sitting on edge of bed, diaphoretic, using accessory muscles Initial vitals: BP 178/102, HR 118, RR 32, SpO 84% on room air Given 2 L/min O via nasal cannula en route, improved to 91% No medications given by EMS II. SUBJECTIVE (S) A. History of Present Illness A 72-year-old male with known systolic heart failure presents with progressive dyspnea and lower extremity edema over 5 days, with acute worsening today.