Week #7 Comprehensive i-Human Case Study –
60-Year-Old Female with Shortness of Breath |
Outpatient Clinical Evaluation with Full
Diagnostics (X-ray, ECG, Labs) | Final CHF
Diagnosis + SOAP Note, Differential, Plan, Patient
Education & Reflection
, HPI & Chief Complaint (CC)
Chief Complaint (CC):
"I have been feeling short of breath for the last three days."
,History of Present Illness (HPI):
The patient is a 60-year-old female presenting to the outpatient clinic with a 3-day history of
worsening shortness of breath. Initially noticed during exertion (e.g., walking, going up stairs),
the dyspnea has progressed to being present even at rest. She describes the sensation as a
tightness in her chest without pain. She reports:
• Fatigue
• A dry, nonproductive cough
• No fevers, chills, or recent infections
• No orthopnea or paroxysmal nocturnal dyspnea (PND)
• Denies wheezing, chest pain, leg swelling, or hemoptysis
• No recent travel, sick contacts, or known exposures
The patient has a history of hypertension, diabetes, and hyperlipidemia and is concerned this
might be related to her heart or lungs.
Current & Surgical History
Current Medical Conditions:
• Hypertension (HTN) – diagnosed 12 years ago
• Type 2 Diabetes Mellitus – diagnosed 10 years ago
• Hyperlipidemia – on statin therapy
Past Surgical History:
• No prior surgeries reported
• No hospitalizations for respiratory or cardiac causes
Past Medical History (PMH)
• Hypertension
• Type 2 Diabetes Mellitus
• Hyperlipidemia
• No history of asthma, COPD, CHF, or MI
• No past blood clots or pulmonary embolism
, Family History (FH)
• Father: Died at age 68 of myocardial infarction
• Mother: Alive at 85, history of hypertension and type 2 diabetes
• Siblings: One brother with hypertension; no cancer, asthma, or autoimmune diseases
reported
• No known family history of heart failure or pulmonary conditions
Social History (SH)
• Smoking History: Smoked 1 pack/day for 30 years; quit 5 years ago
• Alcohol Use: Occasional – 1–2 glasses of wine per week
• Drug Use: Denies illicit drug use
• Living Situation: Lives alone; retired schoolteacher
• Exercise: Limited due to fatigue and recent weight gain
• Diet: High in carbohydrates; reports poor control of diabetes recently
Obstetric & Gynecologic History (OG)
• Menstrual History: Menopause at age 52
• Gravida 3, Para 3 – all full-term, vaginal deliveries
• Pap Smear: Up to date
• No history of gestational diabetes, preeclampsia, or post-menopausal bleeding
• Denies use of hormone replacement therapy
Review of Systems (ROS)
General:
• Positive for fatigue
• Denies weight loss, chills, or fever
Cardiovascular:
• Mild chest tightness
• No chest pain, palpitations, or edema
60-Year-Old Female with Shortness of Breath |
Outpatient Clinical Evaluation with Full
Diagnostics (X-ray, ECG, Labs) | Final CHF
Diagnosis + SOAP Note, Differential, Plan, Patient
Education & Reflection
, HPI & Chief Complaint (CC)
Chief Complaint (CC):
"I have been feeling short of breath for the last three days."
,History of Present Illness (HPI):
The patient is a 60-year-old female presenting to the outpatient clinic with a 3-day history of
worsening shortness of breath. Initially noticed during exertion (e.g., walking, going up stairs),
the dyspnea has progressed to being present even at rest. She describes the sensation as a
tightness in her chest without pain. She reports:
• Fatigue
• A dry, nonproductive cough
• No fevers, chills, or recent infections
• No orthopnea or paroxysmal nocturnal dyspnea (PND)
• Denies wheezing, chest pain, leg swelling, or hemoptysis
• No recent travel, sick contacts, or known exposures
The patient has a history of hypertension, diabetes, and hyperlipidemia and is concerned this
might be related to her heart or lungs.
Current & Surgical History
Current Medical Conditions:
• Hypertension (HTN) – diagnosed 12 years ago
• Type 2 Diabetes Mellitus – diagnosed 10 years ago
• Hyperlipidemia – on statin therapy
Past Surgical History:
• No prior surgeries reported
• No hospitalizations for respiratory or cardiac causes
Past Medical History (PMH)
• Hypertension
• Type 2 Diabetes Mellitus
• Hyperlipidemia
• No history of asthma, COPD, CHF, or MI
• No past blood clots or pulmonary embolism
, Family History (FH)
• Father: Died at age 68 of myocardial infarction
• Mother: Alive at 85, history of hypertension and type 2 diabetes
• Siblings: One brother with hypertension; no cancer, asthma, or autoimmune diseases
reported
• No known family history of heart failure or pulmonary conditions
Social History (SH)
• Smoking History: Smoked 1 pack/day for 30 years; quit 5 years ago
• Alcohol Use: Occasional – 1–2 glasses of wine per week
• Drug Use: Denies illicit drug use
• Living Situation: Lives alone; retired schoolteacher
• Exercise: Limited due to fatigue and recent weight gain
• Diet: High in carbohydrates; reports poor control of diabetes recently
Obstetric & Gynecologic History (OG)
• Menstrual History: Menopause at age 52
• Gravida 3, Para 3 – all full-term, vaginal deliveries
• Pap Smear: Up to date
• No history of gestational diabetes, preeclampsia, or post-menopausal bleeding
• Denies use of hormone replacement therapy
Review of Systems (ROS)
General:
• Positive for fatigue
• Denies weight loss, chills, or fever
Cardiovascular:
• Mild chest tightness
• No chest pain, palpitations, or edema
