,Here is a comprehensive HISTORY section for your i-Human
Week #7 Case Study of the 60-Year-Old Female Patient
presenting with Shortness of Breath (SOB) in Class 6531:
HISTORY OF PRESENT ILLNESS (HPI):
Patient: 60-year-old African American female
Chief Complaint: “I’ve been feeling short of breath for the past
few days.”
Onset: Began gradually about 4–5 days ago
Duration: Persistent, getting worse with activity
Character: Described as a feeling of “tightness” in the chest
and difficulty taking deep breaths
Aggravating Factors: Physical exertion, lying flat at night
(orthopnea)
Relieving Factors: Sitting upright, resting
Associated Symptoms:
• Mild chest discomfort (non-radiating)
• Swelling in the legs/ankles (bilateral pedal edema)
• Fatigue and reduced exercise tolerance
• Occasional dry cough (worsens at night)
• Reports waking up at night short of breath (paroxysmal
nocturnal dyspnea – PND)
Severity: 6/10 in terms of discomfort, limits her ability to walk
across a room
, REVIEW OF SYSTEMS (ROS):
General: Fatigue, no weight loss or fever
HEENT: No sore throat, sinus congestion, or headache
Cardiovascular: Chest tightness, occasional palpitations, leg
swelling
Respiratory: Dyspnea on exertion, orthopnea, dry cough, no
wheezing or hemoptysis
GI: Denies nausea, vomiting, abdominal pain
GU: No dysuria, frequency, or hematuria
Musculoskeletal: Reports heaviness in legs, no joint pain
Neurological: No dizziness, fainting, or confusion
Skin: No rashes
Psych: No anxiety or depression reported
PAST MEDICAL HISTORY (PMH):
• Hypertension (diagnosed 10 years ago)
• Type 2 Diabetes Mellitus (controlled on oral meds)
• Hyperlipidemia
• Possible history of heart failure (undiagnosed or borderline)
• No known history of asthma or COPD
MEDICATIONS:
• Lisinopril 10 mg daily
• Metformin 500 mg BID
Week #7 Case Study of the 60-Year-Old Female Patient
presenting with Shortness of Breath (SOB) in Class 6531:
HISTORY OF PRESENT ILLNESS (HPI):
Patient: 60-year-old African American female
Chief Complaint: “I’ve been feeling short of breath for the past
few days.”
Onset: Began gradually about 4–5 days ago
Duration: Persistent, getting worse with activity
Character: Described as a feeling of “tightness” in the chest
and difficulty taking deep breaths
Aggravating Factors: Physical exertion, lying flat at night
(orthopnea)
Relieving Factors: Sitting upright, resting
Associated Symptoms:
• Mild chest discomfort (non-radiating)
• Swelling in the legs/ankles (bilateral pedal edema)
• Fatigue and reduced exercise tolerance
• Occasional dry cough (worsens at night)
• Reports waking up at night short of breath (paroxysmal
nocturnal dyspnea – PND)
Severity: 6/10 in terms of discomfort, limits her ability to walk
across a room
, REVIEW OF SYSTEMS (ROS):
General: Fatigue, no weight loss or fever
HEENT: No sore throat, sinus congestion, or headache
Cardiovascular: Chest tightness, occasional palpitations, leg
swelling
Respiratory: Dyspnea on exertion, orthopnea, dry cough, no
wheezing or hemoptysis
GI: Denies nausea, vomiting, abdominal pain
GU: No dysuria, frequency, or hematuria
Musculoskeletal: Reports heaviness in legs, no joint pain
Neurological: No dizziness, fainting, or confusion
Skin: No rashes
Psych: No anxiety or depression reported
PAST MEDICAL HISTORY (PMH):
• Hypertension (diagnosed 10 years ago)
• Type 2 Diabetes Mellitus (controlled on oral meds)
• Hyperlipidemia
• Possible history of heart failure (undiagnosed or borderline)
• No known history of asthma or COPD
MEDICATIONS:
• Lisinopril 10 mg daily
• Metformin 500 mg BID
