Best of Best Week #3 i-Human Case Study:Mild
Intermittent Asthma in a 16-Year-Old Female – A
Primary Care Approach. "Totur Secret Case"
, Patient Introduction – Kathleen Hamilton
• Name: Kathleen Hamilton
• Age: 16 years
• Gender: Female
• Ethnicity: Caucasian
• Date of Visit: July 19, 2025
• Source of History: Patient
• Reliability: Reliable historian
• Chief Complaint (CC):
"I've been coughing and feel short of breath, especially when I run."
• History of Present Illness (HPI) – Kathleen Hamilton
• Kathleen Hamilton is a 16-year-old female who presents with a 4-day history of dry,
intermittent cough and shortness of breath, especially with physical exertion.
Symptoms began after participating in a school track event. She reports no recent
fever, sore throat, or upper respiratory infection. Her symptoms are worse at night
and are partially relieved with her albuterol inhaler. She denies chest pain, wheezing
at rest, or sputum production. She rates her shortness of breath as 5/10 with activity
and 1–2/10 at rest.
Past Medical History (PMH) – Kathleen Hamilton
• Chronic Conditions:
o Diagnosed with mild intermittent asthma at age 12
• Past Illnesses:
o No history of pneumonia, bronchiolitis, or other significant illnesses
• Surgeries:
o None
• Hospitalizations:
o None
• Medications:
o Albuterol inhaler (as needed for symptoms and pre-exercise use)
• Allergies:
o No known drug allergies (NKDA)
• Immunizations:
o Up to date, including influenza and COVID-19 vaccines
Family and Social History – Kathleen Hamilton
Family History (FH):
, • Mother: 42 years old, healthy
• Father: 44 years old, history of seasonal allergies
• Siblings: One younger brother, age 12, healthy
• No family history of asthma, diabetes, heart disease, or cancer
Social History (SH):
• Education: 11th-grade student at a public high school
• Extracurriculars: Active in track and field, runs 3–4 times per week
• Living Situation: Lives with both parents and one sibling in a single-family home
• Tobacco/Alcohol/Drugs: Denies all use
• Sexual Activity: Denies
• Diet and Exercise: Well-balanced diet; exercises regularly
• Environmental Exposure: No pets indoors; home is smoke-free
• Safety: Always uses seatbelt; no known safety risks or abuse concerns
Review of Systems (ROS) – Kathleen Hamilton
General:
Denies fever, chills, fatigue, or weight loss.
HEENT:
Denies headache, nasal congestion, rhinorrhea, sore throat, or ear pain.
Respiratory:
Reports dry cough and mild shortness of breath with exertion. Denies chest tightness at rest,
hemoptysis, or wheezing unless exercising.
Cardiovascular:
Denies chest pain, palpitations, dizziness, or syncope.
Gastrointestinal:
Denies nausea, vomiting, abdominal pain, diarrhea, or constipation.
Genitourinary:
Denies dysuria, frequency, urgency, or hematuria.
Musculoskeletal:
Denies joint pain, muscle aches, or swelling.
Intermittent Asthma in a 16-Year-Old Female – A
Primary Care Approach. "Totur Secret Case"
, Patient Introduction – Kathleen Hamilton
• Name: Kathleen Hamilton
• Age: 16 years
• Gender: Female
• Ethnicity: Caucasian
• Date of Visit: July 19, 2025
• Source of History: Patient
• Reliability: Reliable historian
• Chief Complaint (CC):
"I've been coughing and feel short of breath, especially when I run."
• History of Present Illness (HPI) – Kathleen Hamilton
• Kathleen Hamilton is a 16-year-old female who presents with a 4-day history of dry,
intermittent cough and shortness of breath, especially with physical exertion.
Symptoms began after participating in a school track event. She reports no recent
fever, sore throat, or upper respiratory infection. Her symptoms are worse at night
and are partially relieved with her albuterol inhaler. She denies chest pain, wheezing
at rest, or sputum production. She rates her shortness of breath as 5/10 with activity
and 1–2/10 at rest.
Past Medical History (PMH) – Kathleen Hamilton
• Chronic Conditions:
o Diagnosed with mild intermittent asthma at age 12
• Past Illnesses:
o No history of pneumonia, bronchiolitis, or other significant illnesses
• Surgeries:
o None
• Hospitalizations:
o None
• Medications:
o Albuterol inhaler (as needed for symptoms and pre-exercise use)
• Allergies:
o No known drug allergies (NKDA)
• Immunizations:
o Up to date, including influenza and COVID-19 vaccines
Family and Social History – Kathleen Hamilton
Family History (FH):
, • Mother: 42 years old, healthy
• Father: 44 years old, history of seasonal allergies
• Siblings: One younger brother, age 12, healthy
• No family history of asthma, diabetes, heart disease, or cancer
Social History (SH):
• Education: 11th-grade student at a public high school
• Extracurriculars: Active in track and field, runs 3–4 times per week
• Living Situation: Lives with both parents and one sibling in a single-family home
• Tobacco/Alcohol/Drugs: Denies all use
• Sexual Activity: Denies
• Diet and Exercise: Well-balanced diet; exercises regularly
• Environmental Exposure: No pets indoors; home is smoke-free
• Safety: Always uses seatbelt; no known safety risks or abuse concerns
Review of Systems (ROS) – Kathleen Hamilton
General:
Denies fever, chills, fatigue, or weight loss.
HEENT:
Denies headache, nasal congestion, rhinorrhea, sore throat, or ear pain.
Respiratory:
Reports dry cough and mild shortness of breath with exertion. Denies chest tightness at rest,
hemoptysis, or wheezing unless exercising.
Cardiovascular:
Denies chest pain, palpitations, dizziness, or syncope.
Gastrointestinal:
Denies nausea, vomiting, abdominal pain, diarrhea, or constipation.
Genitourinary:
Denies dysuria, frequency, urgency, or hematuria.
Musculoskeletal:
Denies joint pain, muscle aches, or swelling.
