, I-Human Case Study: 55-Year-Old Female with Acute Confusion (Week 8)
Case Overview
A 55-year-old female presents to the emergency department with an acute change in mental
status. Family members report that the patient has become increasingly confused over the past
day and is unable to respond appropriately to simple questions.
History of Present Illness (HPI)
The patient is a 55-year-old female brought in by her family due to sudden onset confusion that
began approximately 24 hours prior to presentation. According to her daughter, the patient
was in her usual state of health until yesterday when she began forgetting recent events and
appeared disoriented even in familiar settings.
The patient describes feeling mentally “foggy” and has difficulty maintaining focus. She reports
intermittent dizziness, particularly when standing up quickly, and generalized weakness. The
confusion has gradually worsened, especially during the evening hours.
She denies any recent head injury, seizure activity, or loss of consciousness. There is no prior
history of similar symptoms.
Key HPI Questions and Responses
When asked about onset, the patient states the symptoms began yesterday. She reports no
previous episodes. She admits to dizziness on standing but denies pain. Symptoms fluctuate
and worsen in the evening.
Review of Systems (ROS)
General: Fatigue present, no chills
Neurological: Confusion, decreased concentration, dizziness
Cardiovascular: No chest pain or palpitations
Respiratory: No shortness of breath
Gastrointestinal: Decreased appetite, no nausea or vomiting
Genitourinary: Reports mild dysuria
Endocrine: History of diabetes
Psychiatric: No history of anxiety or depression
Past Medical History
Type 2 Diabetes Mellitus
Hypertension
Current Medications
Metformin
Amlodipine
Social History
Case Overview
A 55-year-old female presents to the emergency department with an acute change in mental
status. Family members report that the patient has become increasingly confused over the past
day and is unable to respond appropriately to simple questions.
History of Present Illness (HPI)
The patient is a 55-year-old female brought in by her family due to sudden onset confusion that
began approximately 24 hours prior to presentation. According to her daughter, the patient
was in her usual state of health until yesterday when she began forgetting recent events and
appeared disoriented even in familiar settings.
The patient describes feeling mentally “foggy” and has difficulty maintaining focus. She reports
intermittent dizziness, particularly when standing up quickly, and generalized weakness. The
confusion has gradually worsened, especially during the evening hours.
She denies any recent head injury, seizure activity, or loss of consciousness. There is no prior
history of similar symptoms.
Key HPI Questions and Responses
When asked about onset, the patient states the symptoms began yesterday. She reports no
previous episodes. She admits to dizziness on standing but denies pain. Symptoms fluctuate
and worsen in the evening.
Review of Systems (ROS)
General: Fatigue present, no chills
Neurological: Confusion, decreased concentration, dizziness
Cardiovascular: No chest pain or palpitations
Respiratory: No shortness of breath
Gastrointestinal: Decreased appetite, no nausea or vomiting
Genitourinary: Reports mild dysuria
Endocrine: History of diabetes
Psychiatric: No history of anxiety or depression
Past Medical History
Type 2 Diabetes Mellitus
Hypertension
Current Medications
Metformin
Amlodipine
Social History
