iHUMAN Case Study – 60-Year-Old Female
with Shortness of Breath (CHF
Exacerbation) | 2026/2027
SOAP NOTE: 60-Year-Old Female with
Shortness of Breath (CHF Exacerbation)
,
,
Age: 60 years old
Gender: Female
Encounter Date: [Current Date]
Setting: Emergency Department / Urgent Care Clinic / Primary Care
(based on acuity)
Chief Complaint: "I can't catch my breath, and my legs are swollen."
SUBJECTIVE (S)
History of Present Illness (HPI):
The patient is a 60-year-old female who presents with a chief
complaint of progressive shortness of breath over the past 3-4 days.
She reports that the shortness of breath initially occurred only with
exertion (walking up stairs, carrying groceries) but has progressively
worsened. She now becomes short of breath walking from her
bedroom to the bathroom. She endorses orthopnea, stating she needs
"3 pillows" to sleep at night to avoid feeling like she is suffocating. She
reports waking up suddenly at night gasping for air (Paroxysmal
Nocturnal Dyspnea) on two occasions over the past week.
She reports bilateral lower extremity swelling that has progressively
worsened, noting that her shoes no longer fit by the end of the day.
She endorses a 5-6 pound weight gain over the past week despite a
decreased appetite. She reports a dry, non-productive cough,
especially when lying flat. She denies chest pain, pressure, or
palpitations. Denies fever, chills, or sick contacts.
, She reports increased fatigue and generalized weakness, making it
difficult to complete her daily activities.
Review of Systems (ROS):
● General: Fatigue, weakness, subjective weight gain (fluid).
● Cardiovascular: Dyspnea on exertion (DOE), orthopnea, PND,
bilateral lower extremity edema. Denies chest pain, palpitations,
syncope.
● Respiratory: Shortness of breath, dry cough when supine. Denies
wheezing, hemoptysis, sputum production.
● Gastrointestinal: Decreased appetite, early satiety. Denies
nausea, vomiting, diarrhea, abdominal pain.
● Genitourinary: Reports decreased urine output over past 2 days.
No dysuria.
● Musculoskeletal: Generalized weakness.
● Neurological: Denies dizziness, headaches, focal deficits.
● Psychiatric: Anxiety related to breathing difficulty.
Past Medical History (PMH):
● Heart Failure with reduced Ejection Fraction (HFrEF) - diagnosed
5 years ago
● Hypertension (HTN) - 15 years
● Type 2 Diabetes Mellitus (T2DM) - 10 years
● Hyperlipidemia (HLD) - 10 years
● Chronic Kidney Disease (CKD) Stage 3
Past Surgical History (PSH):
● None reported
Medications:
with Shortness of Breath (CHF
Exacerbation) | 2026/2027
SOAP NOTE: 60-Year-Old Female with
Shortness of Breath (CHF Exacerbation)
,
,
Age: 60 years old
Gender: Female
Encounter Date: [Current Date]
Setting: Emergency Department / Urgent Care Clinic / Primary Care
(based on acuity)
Chief Complaint: "I can't catch my breath, and my legs are swollen."
SUBJECTIVE (S)
History of Present Illness (HPI):
The patient is a 60-year-old female who presents with a chief
complaint of progressive shortness of breath over the past 3-4 days.
She reports that the shortness of breath initially occurred only with
exertion (walking up stairs, carrying groceries) but has progressively
worsened. She now becomes short of breath walking from her
bedroom to the bathroom. She endorses orthopnea, stating she needs
"3 pillows" to sleep at night to avoid feeling like she is suffocating. She
reports waking up suddenly at night gasping for air (Paroxysmal
Nocturnal Dyspnea) on two occasions over the past week.
She reports bilateral lower extremity swelling that has progressively
worsened, noting that her shoes no longer fit by the end of the day.
She endorses a 5-6 pound weight gain over the past week despite a
decreased appetite. She reports a dry, non-productive cough,
especially when lying flat. She denies chest pain, pressure, or
palpitations. Denies fever, chills, or sick contacts.
, She reports increased fatigue and generalized weakness, making it
difficult to complete her daily activities.
Review of Systems (ROS):
● General: Fatigue, weakness, subjective weight gain (fluid).
● Cardiovascular: Dyspnea on exertion (DOE), orthopnea, PND,
bilateral lower extremity edema. Denies chest pain, palpitations,
syncope.
● Respiratory: Shortness of breath, dry cough when supine. Denies
wheezing, hemoptysis, sputum production.
● Gastrointestinal: Decreased appetite, early satiety. Denies
nausea, vomiting, diarrhea, abdominal pain.
● Genitourinary: Reports decreased urine output over past 2 days.
No dysuria.
● Musculoskeletal: Generalized weakness.
● Neurological: Denies dizziness, headaches, focal deficits.
● Psychiatric: Anxiety related to breathing difficulty.
Past Medical History (PMH):
● Heart Failure with reduced Ejection Fraction (HFrEF) - diagnosed
5 years ago
● Hypertension (HTN) - 15 years
● Type 2 Diabetes Mellitus (T2DM) - 10 years
● Hyperlipidemia (HLD) - 10 years
● Chronic Kidney Disease (CKD) Stage 3
Past Surgical History (PSH):
● None reported
Medications:
