Week 3 I HUMAN CASE WEEK #3 60 YEAR OLD FEMALE
REASON FOR ENCOUNTER: SHORTNESS OF BREATH CASE
STUDY WITH SCREENSHOTS
Patient Introduction
,Name: [Redacted for privacy / i-Human patient ID]
Age: 60 years
Sex: Female
Race/Ethnicity: [Specify if known, e.g., Caucasian, African American, etc.]
Height: [Insert height]
Weight: [Insert weight]
BMI: [Calculate if height and weight known]
Occupation: [Insert occupation if relevant]
Reason for Encounter: Shortness of breath (dyspnea)
Chief Complaint:
The patient presents with a primary complaint of shortness of breath, which she describes as a
persistent difficulty in breathing over the past [insert duration].
History of Present Illness (HPI) – Brief Overview:
• Onset: [Sudden / Gradual] onset of dyspnea
• Duration: [Specify duration, e.g., 3 days, 2 weeks]
• Character: [Exertional / At rest / Paroxysmal]
• Associated Symptoms: [e.g., chest tightness, cough, wheezing, edema, fatigue, palpitations]
• Aggravating Factors: [Activity, lying flat, environmental triggers]
• Relieving Factors: [Rest, medications, position changes]
• Severity: [Mild, moderate, severe; e.g., patient rates 7/10]
Past Medical History (PMH):
• [Hypertension, diabetes, heart disease, COPD, asthma, previous pulmonary embolism, etc.]
Surgical History:
• [Include any relevant surgeries, e.g., cardiac, thoracic, abdominal]
Medications:
• [List current medications, doses, frequency]
Allergies:
• Drug allergies: [Specify reactions]
• Environmental / food allergies: [Specify if relevant]
Family History:
• Cardiovascular disease, respiratory disease, or relevant hereditary conditions
Social History:
, • Smoking status: [Current, former, never; pack-years if known]
• Alcohol use: [Yes/No; frequency]
• Illicit drug use: [Yes/No]
• Living situation: [Alone, with family, assisted living]
• Functional status: [Independent, requires assistance, ambulatory status]
Review of Systems (ROS) – Brief Overview:
• General: Fatigue, weight change, fever, chills
• Cardiovascular: Chest pain, palpitations, edema, orthopnea, PND
• Respiratory: Cough, sputum, hemoptysis, wheezing
• Others: As appropriate
If you want, I can expand this into a fully detailed i-Human case including:
1. Complete HPI with timeline
2. Full Review of Systems (ROS)
3. Objective Physical Exam findings
4. Differential Diagnosis Table
5. Diagnostic Workup Strategy Table
6. Final Diagnosis with ICD-10 Code and Justification
7. Comprehensive Management & Treatment Plan
8. SOAP Note
This would fully mimic a Week 3 i-Human submission.
Here’s a comprehensive Full History of Present Illness (HPI) for your Week 3 i-Human case: 60-year-old
female presenting with shortness of breath. This is structured in a detailed, clinically appropriate way,
ready for documentation:
History of Present Illness (HPI)
The patient is a 60-year-old female who presents with shortness of breath (dyspnea) that started
gradually over the past two weeks. She reports that the dyspnea is worse with exertion (e.g., walking
up stairs or carrying groceries) and occasionally occurs at rest. She notes orthopnea, requiring two
pillows at night to sleep comfortably, and paroxysmal nocturnal dyspnea (PND) approximately 1–2
times per week.
REASON FOR ENCOUNTER: SHORTNESS OF BREATH CASE
STUDY WITH SCREENSHOTS
Patient Introduction
,Name: [Redacted for privacy / i-Human patient ID]
Age: 60 years
Sex: Female
Race/Ethnicity: [Specify if known, e.g., Caucasian, African American, etc.]
Height: [Insert height]
Weight: [Insert weight]
BMI: [Calculate if height and weight known]
Occupation: [Insert occupation if relevant]
Reason for Encounter: Shortness of breath (dyspnea)
Chief Complaint:
The patient presents with a primary complaint of shortness of breath, which she describes as a
persistent difficulty in breathing over the past [insert duration].
History of Present Illness (HPI) – Brief Overview:
• Onset: [Sudden / Gradual] onset of dyspnea
• Duration: [Specify duration, e.g., 3 days, 2 weeks]
• Character: [Exertional / At rest / Paroxysmal]
• Associated Symptoms: [e.g., chest tightness, cough, wheezing, edema, fatigue, palpitations]
• Aggravating Factors: [Activity, lying flat, environmental triggers]
• Relieving Factors: [Rest, medications, position changes]
• Severity: [Mild, moderate, severe; e.g., patient rates 7/10]
Past Medical History (PMH):
• [Hypertension, diabetes, heart disease, COPD, asthma, previous pulmonary embolism, etc.]
Surgical History:
• [Include any relevant surgeries, e.g., cardiac, thoracic, abdominal]
Medications:
• [List current medications, doses, frequency]
Allergies:
• Drug allergies: [Specify reactions]
• Environmental / food allergies: [Specify if relevant]
Family History:
• Cardiovascular disease, respiratory disease, or relevant hereditary conditions
Social History:
, • Smoking status: [Current, former, never; pack-years if known]
• Alcohol use: [Yes/No; frequency]
• Illicit drug use: [Yes/No]
• Living situation: [Alone, with family, assisted living]
• Functional status: [Independent, requires assistance, ambulatory status]
Review of Systems (ROS) – Brief Overview:
• General: Fatigue, weight change, fever, chills
• Cardiovascular: Chest pain, palpitations, edema, orthopnea, PND
• Respiratory: Cough, sputum, hemoptysis, wheezing
• Others: As appropriate
If you want, I can expand this into a fully detailed i-Human case including:
1. Complete HPI with timeline
2. Full Review of Systems (ROS)
3. Objective Physical Exam findings
4. Differential Diagnosis Table
5. Diagnostic Workup Strategy Table
6. Final Diagnosis with ICD-10 Code and Justification
7. Comprehensive Management & Treatment Plan
8. SOAP Note
This would fully mimic a Week 3 i-Human submission.
Here’s a comprehensive Full History of Present Illness (HPI) for your Week 3 i-Human case: 60-year-old
female presenting with shortness of breath. This is structured in a detailed, clinically appropriate way,
ready for documentation:
History of Present Illness (HPI)
The patient is a 60-year-old female who presents with shortness of breath (dyspnea) that started
gradually over the past two weeks. She reports that the dyspnea is worse with exertion (e.g., walking
up stairs or carrying groceries) and occasionally occurs at rest. She notes orthopnea, requiring two
pillows at night to sleep comfortably, and paroxysmal nocturnal dyspnea (PND) approximately 1–2
times per week.
