IHUMAN CASE ANALYSIS WEEK 3:
SHORTNESS OF BREATH IN A 60-
YEAR-OLD FEMALE
Part 1: Patient Bio Data & Initial Data
Gathering
Name: Mrs. L.M
Age: 60 years
Gender: Female
Date of Birth: 1965 (approximate)
Marital Status: Married
Occupation: Retired office administrator
Ethnicity: Not specified
Source of History: Patient (reliable historian)
Date of Encounter: Week 3 iHuman Case
Mode of Arrival: Walk-inReliability: Reliable,
oriented, and able to provide a clear history, though
slightly anxious due to breathing difficulty.
, Allergies: No Known Drug Allergies (NKDA) (Confirm in
history)
Medications: (This is critical to identify early. Common
possibilities for a 60-year-old include:)
o Lisinopril (for hypertension) - Important: Can cause cough!
o Metformin (for type 2 diabetes)
o Atorvastatin (for hyperlipidemia)
o Albuterol Inhaler (if known asthmatic)
o Ibuprofen or Naproxen (for arthritis/pain)
o OTC medications: Antacids, allergy medications
Past Medical History (PMH):
o Hypertension
o Hyperlipidemia
o Key Question: Does she have a history of Asthma, COPD,
Heart Failure, Diabetes, GERD, or Anxiety/Panic Attacks?
o Past Surgical History (PSH): Cholecystectomy?
Hysterectomy? (Common for age)
Family History:
o Mother: Deceased (Breast Cancer or MI)
o Father: Deceased (Lung Cancer? COPD? - Heavy smoking
history?)
o Siblings: Living, with hypertension/diabetes.
, o Key Question: Family history of heart disease, lung
disease, or blood clots (DVT/PE)?
Social History:
o Occupation: (e.g., Administrative assistant, teacher,
retired)
o Living Situation: Lives with spouse.
o Substance Use:
Tobacco: THIS IS THE MOST CRITICAL
QUESTION. "Have you ever smoked?" If yes: "How many
packs per day for how many years?" (Calculate pack-
years). A 60-year-old with dyspnea and a smoking history
immediately raises suspicion for COPD.
Alcohol: Occasional use.
Illicit Drugs: Denies.
Part 2: History of Present Illness (HPI) & Review of
Systems (ROS)
HPI (Use OLDCARTS format):
"Mrs. [Patient Name] is a 60-year-old female with a PMH
of [e.g., HTN] who presents to the clinic with a chief
complaint of shortness of breath for the past 3-4 days."
SHORTNESS OF BREATH IN A 60-
YEAR-OLD FEMALE
Part 1: Patient Bio Data & Initial Data
Gathering
Name: Mrs. L.M
Age: 60 years
Gender: Female
Date of Birth: 1965 (approximate)
Marital Status: Married
Occupation: Retired office administrator
Ethnicity: Not specified
Source of History: Patient (reliable historian)
Date of Encounter: Week 3 iHuman Case
Mode of Arrival: Walk-inReliability: Reliable,
oriented, and able to provide a clear history, though
slightly anxious due to breathing difficulty.
, Allergies: No Known Drug Allergies (NKDA) (Confirm in
history)
Medications: (This is critical to identify early. Common
possibilities for a 60-year-old include:)
o Lisinopril (for hypertension) - Important: Can cause cough!
o Metformin (for type 2 diabetes)
o Atorvastatin (for hyperlipidemia)
o Albuterol Inhaler (if known asthmatic)
o Ibuprofen or Naproxen (for arthritis/pain)
o OTC medications: Antacids, allergy medications
Past Medical History (PMH):
o Hypertension
o Hyperlipidemia
o Key Question: Does she have a history of Asthma, COPD,
Heart Failure, Diabetes, GERD, or Anxiety/Panic Attacks?
o Past Surgical History (PSH): Cholecystectomy?
Hysterectomy? (Common for age)
Family History:
o Mother: Deceased (Breast Cancer or MI)
o Father: Deceased (Lung Cancer? COPD? - Heavy smoking
history?)
o Siblings: Living, with hypertension/diabetes.
, o Key Question: Family history of heart disease, lung
disease, or blood clots (DVT/PE)?
Social History:
o Occupation: (e.g., Administrative assistant, teacher,
retired)
o Living Situation: Lives with spouse.
o Substance Use:
Tobacco: THIS IS THE MOST CRITICAL
QUESTION. "Have you ever smoked?" If yes: "How many
packs per day for how many years?" (Calculate pack-
years). A 60-year-old with dyspnea and a smoking history
immediately raises suspicion for COPD.
Alcohol: Occasional use.
Illicit Drugs: Denies.
Part 2: History of Present Illness (HPI) & Review of
Systems (ROS)
HPI (Use OLDCARTS format):
"Mrs. [Patient Name] is a 60-year-old female with a PMH
of [e.g., HTN] who presents to the clinic with a chief
complaint of shortness of breath for the past 3-4 days."
