In-Depth i Human Case Study Week 3
Expert Analysis of a 60-Year-Old Female
with Shortness of Breath (Class 6550)
Age: 60 years
Gender: Female
Race/Ethnicity: [To be specified by learner during the case]
BMI: 39.1 (Obese Class II)
Context of Visit:
The patient presents for a scheduled follow-up appointment regarding her chronic
conditions, though she notes that her symptoms have worsened acutely over the last 48
hours, prompting her to seek immediate attention today. She reports that her
prescribed medications have been helping "okay" until recently, but she admits to
occasionally missing doses due to forgetfulness and cost.
,Appearance on Initial Observation:
The patient is alert but appears tired and uncomfortable at rest. She is sitting upright on
the exam table, which seems to ease her breathing. She is noticeably obese. Periorbital
puffiness is evident around both eyes. Her skin appears dry and pale. Speech is
interrupted by the need to take frequent breaths.
Identifier: 60-year-old female with a complex medical history including COPD, CAD,
and hypothyroidism.
Chief Complaint: "I can't catch my breath, and my shoes don't fit anymore because my
feet are so swollen."
Onset:
The patient reports that her current shortness of breath began acutely
approximately two days ago. She notes that she has had baseline dyspnea on exertion
for years due to her COPD and obesity, but this current episode is "different" and
"worse." The swelling in her legs was first noticed roughly three to four days ago and
has progressively worsened.
Location:
Dyspnea: Global; affects her ability to breathe comfortably at rest and with
minimal activity.
Edema: Bilateral, symmetric, involving both feet and ankles, extending up to the
mid-calf.
Duration:
The dyspnea is constant but worsens with exertion. The edema is persistent and does
not resolve with overnight elevation.
Characteristics:
, Dyspnea: Described as a "heaviness" and "tightness" in the chest. She feels she
cannot get a deep enough breath. She has an occasional, non-productive cough.
Edema: Described as a "tight," "heavy" feeling in the lower legs. Denies significant
pain or erythema in the legs.
Associated Symptoms: Reports feeling more tired than usual over the past week.
Notes some difficulty sleeping flat in bed, requiring two pillows to breathe
comfortably (orthopnea). Denies chest pain, but admits to a vague sense of chest
"discomfort." Denies fever, chills, or sputum production.
Aggravating Factors:
Symptoms are significantly worsened by any minimal exertion, such as walking from the
waiting room to the exam room. Lying flat exacerbates the breathlessness.
Relieving Factors:
Sitting upright (orthopneic position) provides partial relief. She has not used her home
BiPAP machine in the last two days because she "didn't think to use it for this."
Timing:
The symptoms have been progressively worsening over the 48 hours leading to this
visit. She reports one episode of similar, though less severe, swelling about six months
ago that resolved with increased diuretic use.
Severity:
She rates her shortness of breath as 7/10 at rest and 9/10 with minimal activity. She
states, "I just want to be able to breathe normally."
Context:
The patient lives with her husband in a two-story home. She has been largely
housebound for the past two days due to the symptoms. She admits to being non-
adherent with her medications for the past week, specifically missing doses of her
diuretic and levothyroxine because she "ran out and hadn't gotten to the pharmacy."
, FULL ANALYZED REVIEW OF SYSTEMS (ROS)
GENERAL / CONSTITUTIONAL
The patient reports profound fatigue and lethargy over the past week, which is out of
proportion to her usual baseline. This is a significant finding, as fatigue is a cardinal
symptom of both hypothyroidism, due to slowed metabolism, and heart failure, due to
decreased cardiac output. The severity here suggests progression toward a myxedema
state. She denies any fever, chills, or rigors. The absence of fever is clinically important;
while it does not entirely rule out infection, as elderly patients may present afebrile, it
makes a primary infectious process such as pneumonia or sepsis less likely as the sole
cause of her decompensation. In myxedema coma, hypothermia is actually more
common than fever. Regarding weight changes, she reports an unintentional gain of
approximately five to six pounds over the past one to two weeks despite having a poor
appetite. This pattern of weight gain with anorexia points to fluid retention rather than
increased caloric intake, supporting the hypothesis of heart failure exacerbation. In this
context, it is likely due to myxedema from decreased metabolic rate combined with fluid
retention from effusions. She also reports feeling cold when others are comfortable,
which is cold intolerance, a classic symptom of hypothyroidism resulting from decreased
thermogenesis. In a patient presenting with acute shortness of breath, this is a major
clue pointing toward the underlying endocrine disorder.
HEENT
The patient reports puffiness around the eyes, which is worse in the morning. This
periorbital edema is a critical finding. Periorbital edema in an adult is not typical for
heart failure, as heart failure usually spares the face unless the patient is recumbent
continuously. It is highly suggestive of hypothyroidism or myxedema due to deposition
of glycosaminoglycans in the skin. Her husband notes that her voice has become deeper
and more hoarse recently. This hoarseness is another classic myxedema sign caused by
myxedematous infiltration of the vocal cords and larynx, and it increases the risk of
upper airway obstruction, which is critical to recognize if sedation or intubation is
Expert Analysis of a 60-Year-Old Female
with Shortness of Breath (Class 6550)
Age: 60 years
Gender: Female
Race/Ethnicity: [To be specified by learner during the case]
BMI: 39.1 (Obese Class II)
Context of Visit:
The patient presents for a scheduled follow-up appointment regarding her chronic
conditions, though she notes that her symptoms have worsened acutely over the last 48
hours, prompting her to seek immediate attention today. She reports that her
prescribed medications have been helping "okay" until recently, but she admits to
occasionally missing doses due to forgetfulness and cost.
,Appearance on Initial Observation:
The patient is alert but appears tired and uncomfortable at rest. She is sitting upright on
the exam table, which seems to ease her breathing. She is noticeably obese. Periorbital
puffiness is evident around both eyes. Her skin appears dry and pale. Speech is
interrupted by the need to take frequent breaths.
Identifier: 60-year-old female with a complex medical history including COPD, CAD,
and hypothyroidism.
Chief Complaint: "I can't catch my breath, and my shoes don't fit anymore because my
feet are so swollen."
Onset:
The patient reports that her current shortness of breath began acutely
approximately two days ago. She notes that she has had baseline dyspnea on exertion
for years due to her COPD and obesity, but this current episode is "different" and
"worse." The swelling in her legs was first noticed roughly three to four days ago and
has progressively worsened.
Location:
Dyspnea: Global; affects her ability to breathe comfortably at rest and with
minimal activity.
Edema: Bilateral, symmetric, involving both feet and ankles, extending up to the
mid-calf.
Duration:
The dyspnea is constant but worsens with exertion. The edema is persistent and does
not resolve with overnight elevation.
Characteristics:
, Dyspnea: Described as a "heaviness" and "tightness" in the chest. She feels she
cannot get a deep enough breath. She has an occasional, non-productive cough.
Edema: Described as a "tight," "heavy" feeling in the lower legs. Denies significant
pain or erythema in the legs.
Associated Symptoms: Reports feeling more tired than usual over the past week.
Notes some difficulty sleeping flat in bed, requiring two pillows to breathe
comfortably (orthopnea). Denies chest pain, but admits to a vague sense of chest
"discomfort." Denies fever, chills, or sputum production.
Aggravating Factors:
Symptoms are significantly worsened by any minimal exertion, such as walking from the
waiting room to the exam room. Lying flat exacerbates the breathlessness.
Relieving Factors:
Sitting upright (orthopneic position) provides partial relief. She has not used her home
BiPAP machine in the last two days because she "didn't think to use it for this."
Timing:
The symptoms have been progressively worsening over the 48 hours leading to this
visit. She reports one episode of similar, though less severe, swelling about six months
ago that resolved with increased diuretic use.
Severity:
She rates her shortness of breath as 7/10 at rest and 9/10 with minimal activity. She
states, "I just want to be able to breathe normally."
Context:
The patient lives with her husband in a two-story home. She has been largely
housebound for the past two days due to the symptoms. She admits to being non-
adherent with her medications for the past week, specifically missing doses of her
diuretic and levothyroxine because she "ran out and hadn't gotten to the pharmacy."
, FULL ANALYZED REVIEW OF SYSTEMS (ROS)
GENERAL / CONSTITUTIONAL
The patient reports profound fatigue and lethargy over the past week, which is out of
proportion to her usual baseline. This is a significant finding, as fatigue is a cardinal
symptom of both hypothyroidism, due to slowed metabolism, and heart failure, due to
decreased cardiac output. The severity here suggests progression toward a myxedema
state. She denies any fever, chills, or rigors. The absence of fever is clinically important;
while it does not entirely rule out infection, as elderly patients may present afebrile, it
makes a primary infectious process such as pneumonia or sepsis less likely as the sole
cause of her decompensation. In myxedema coma, hypothermia is actually more
common than fever. Regarding weight changes, she reports an unintentional gain of
approximately five to six pounds over the past one to two weeks despite having a poor
appetite. This pattern of weight gain with anorexia points to fluid retention rather than
increased caloric intake, supporting the hypothesis of heart failure exacerbation. In this
context, it is likely due to myxedema from decreased metabolic rate combined with fluid
retention from effusions. She also reports feeling cold when others are comfortable,
which is cold intolerance, a classic symptom of hypothyroidism resulting from decreased
thermogenesis. In a patient presenting with acute shortness of breath, this is a major
clue pointing toward the underlying endocrine disorder.
HEENT
The patient reports puffiness around the eyes, which is worse in the morning. This
periorbital edema is a critical finding. Periorbital edema in an adult is not typical for
heart failure, as heart failure usually spares the face unless the patient is recumbent
continuously. It is highly suggestive of hypothyroidism or myxedema due to deposition
of glycosaminoglycans in the skin. Her husband notes that her voice has become deeper
and more hoarse recently. This hoarseness is another classic myxedema sign caused by
myxedematous infiltration of the vocal cords and larynx, and it increases the risk of
upper airway obstruction, which is critical to recognize if sedation or intubation is
