IHUMAN CASE STUDY 2026/2027: 60-YEAR-OLD FEMALE
WITH SHORTNESS OF BREATH DUE TO CONGESTIVE
HEART FAILURE EXACERBATION
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Mrs. A.M
Age 60 years old
Gender Female
Race/Ethincity [Will be specified]
Date of Birth [Will be specified]
Date of Visit [Current date]
Source Patient (self) and spouse (provides collateral history)
Cooperative, but mildly anxious due to breathing difficulty; able
Reliability
to provide clear history with occasional prompting
Allergies No Known Drug Allergies (NKDA) - Confirm in history
Code Status Full Code
, PART 2: PAST MEDICAL HISTORY (PMH)
Chronic Conditions
ICD-
Condition Duration Notes
10
Diagnosed at age 45; on
Hypertension I10 15 years
medication
Diagnosed at age 52; diet
Type 2 Diabetes
E11.9 8 years and medication
Mellitus
controlled
Hyperlipidemia E78.5 10 years On statin therapy
Obesity E66.9 Chronic BMI >30
Bilateral knees; managed
Osteoarthritis M17.9 5 years
with PRN analgesics
Prior Cardiovascular History
Previous MI? Denies
Previous CHF? Unknown (possible first presentation)
Previous Arrhythmias? Denies
Previous Echocardiogram? Unknown
, Other History
Prior Hospitalizations: None recent
Childhood Illnesses: Immunizations up to date
Infectious Diseases: Denies history of tuberculosis, hepatitis
PART 3: PAST SURGICAL HISTORY (PSH)
Surgery Year Complications
Cholecystectomy 2005 Uncomplicated
Tonsillectomy Childhood Uncomplicated
No cardiac surgeries N/A N/A
PART 4: MEDICATIONS
Current Medications
Medication Dose Frequency Prescriber Purpose
20
Lisinopril Once daily PCP Hypertension
mg
500 Twice Type 2
Metformin PCP
mg daily Diabetes
, Medication Dose Frequency Prescriber Purpose
20
Atorvastatin Once daily PCP Hyperlipidemia
mg
200 PRN (1- Self-
Ibuprofen Knee pain
mg 2x/week) prescribed
1 Self-
Multivitamin Once daily General health
tablet prescribed
Medication Adherence
Reports taking medications as prescribed most days
Occasionally misses doses on weekends
OTC/Herbal Supplements
Denies herbal supplements
Uses ibuprofen occasionally for arthritis pain
PART 5: FAMILY HISTORY
Relative Age/Status Medical Conditions
Mother Deceased (age 78) Hypertension, Diabetes, Heart Failure
Father Deceased (age 72) Myocardial infarction (age 70), Hypertensi
Brother Age 65, living Hypertension, Diabetes
WITH SHORTNESS OF BREATH DUE TO CONGESTIVE
HEART FAILURE EXACERBATION
PART 1: PATIENT BIO DATA & INITIAL DATA GATHERING
Category Details
Name Mrs. A.M
Age 60 years old
Gender Female
Race/Ethincity [Will be specified]
Date of Birth [Will be specified]
Date of Visit [Current date]
Source Patient (self) and spouse (provides collateral history)
Cooperative, but mildly anxious due to breathing difficulty; able
Reliability
to provide clear history with occasional prompting
Allergies No Known Drug Allergies (NKDA) - Confirm in history
Code Status Full Code
, PART 2: PAST MEDICAL HISTORY (PMH)
Chronic Conditions
ICD-
Condition Duration Notes
10
Diagnosed at age 45; on
Hypertension I10 15 years
medication
Diagnosed at age 52; diet
Type 2 Diabetes
E11.9 8 years and medication
Mellitus
controlled
Hyperlipidemia E78.5 10 years On statin therapy
Obesity E66.9 Chronic BMI >30
Bilateral knees; managed
Osteoarthritis M17.9 5 years
with PRN analgesics
Prior Cardiovascular History
Previous MI? Denies
Previous CHF? Unknown (possible first presentation)
Previous Arrhythmias? Denies
Previous Echocardiogram? Unknown
, Other History
Prior Hospitalizations: None recent
Childhood Illnesses: Immunizations up to date
Infectious Diseases: Denies history of tuberculosis, hepatitis
PART 3: PAST SURGICAL HISTORY (PSH)
Surgery Year Complications
Cholecystectomy 2005 Uncomplicated
Tonsillectomy Childhood Uncomplicated
No cardiac surgeries N/A N/A
PART 4: MEDICATIONS
Current Medications
Medication Dose Frequency Prescriber Purpose
20
Lisinopril Once daily PCP Hypertension
mg
500 Twice Type 2
Metformin PCP
mg daily Diabetes
, Medication Dose Frequency Prescriber Purpose
20
Atorvastatin Once daily PCP Hyperlipidemia
mg
200 PRN (1- Self-
Ibuprofen Knee pain
mg 2x/week) prescribed
1 Self-
Multivitamin Once daily General health
tablet prescribed
Medication Adherence
Reports taking medications as prescribed most days
Occasionally misses doses on weekends
OTC/Herbal Supplements
Denies herbal supplements
Uses ibuprofen occasionally for arthritis pain
PART 5: FAMILY HISTORY
Relative Age/Status Medical Conditions
Mother Deceased (age 78) Hypertension, Diabetes, Heart Failure
Father Deceased (age 72) Myocardial infarction (age 70), Hypertensi
Brother Age 65, living Hypertension, Diabetes
