i-Human Case Week #3: 67-Year-Old Male with Acute Shortness of Breath

i-Human Case Week #3: 67-Year-Old Male
with Acute Shortness of Breath
****week #3 2025**********

Case Study: 67-Year-Old with Shortness of Breath –
Diagnosis and Management of HFrEF

,
, Got it — here’s the History (HPI + PMH + Social/Family) in bullet form for your 67-
year-old patient with SOB.




History (Bullet Form)
Chief Complaint (CC):

• Shortness of breath (progressive, worsening over 2 weeks)



History of Present Illness (HPI):

• Progressive dyspnea → initially on exertion, now at rest
• Orthopnea (needs 2 pillows at night)
• Paroxysmal nocturnal dyspnea (PND) – wakes up gasping
• Fatigue and reduced exercise tolerance
• Ankle swelling (bilateral, worsening)
• Dry cough (especially at night)
• No chest pain, palpitations, fever, or hemoptysis



Past Medical History (PMH):

• Hypertension (long-standing, suboptimally controlled)
• Type 2 diabetes mellitus
• Hyperlipidemia
• Overweight (BMI ~28)
• No history of COPD, asthma, or recent infection



Medications:

• Lisinopril (ACE inhibitor)
• Metformin (diabetes)
• Atorvastatin (hyperlipidemia)
• Occasional OTC meds (denies NSAID overuse)