Complete iHuman Case Study: 68-
Year-Old Male with Shortness of
Breath | Latest 2025/2026 Guide for
Guaranteed Exam Success
## iHuman Case Study: 68-Year-Old Male with Shortness of Breath – Complete SOAP Note &
Management Guide
### Case Overview
| Feature | Details |
,| :--- | :--- |
| **Patient** | James Whitaker / Robert Jenkins (68-Year-Old Male) |
| **Ethnicity** | African American or Caucasian |
| **Chief Complaint** | "I can't catch my breath." |
| **Setting** | Outpatient clinic with lab, ECG, and chest X-ray capability |
| **Course** | NURS 6550 / NUR 2026 – Advanced Practice Care of Adults |
| **Week** | 10 (2025/2026) |
| **Final Diagnosis** | **Acute Decompensated Systolic Heart Failure (HFrEF)** |
### Subjective Data (History Collection)
#### Chief Complaint in Patient's Own Words
> *"I can't catch my breath. It's been getting worse over the past few days."*
#### History of Present Illness (HPI) – OLDCARTS Format
| Feature | Finding |
| :--- | :--- |
| **Onset** | Gradual onset 5 days ago; progressive worsening |
| **Location** | Chest (no focal pain); sensation of "air hunger" |
| **Duration** | Persistent; worsens with exertion |
| **Character** | Describes as "tightness" and inability to draw full breath |
| **Aggravating Factors** | Walking short distances (20-30 feet), climbing stairs, lying flat |
, | **Relieving Factors** | Sitting upright, resting, elevating head of bed |
| **Timing** | Worse in evenings and at night; constant during day |
| **Severity** | 4/10 at rest, 7-8/10 with minimal exertion |
#### Associated Symptoms (Positive Findings)
| Symptom | Details | Clinical Significance |
| :--- | :--- | :--- |
| **Orthopnea** | Uses 3 pillows to sleep; cannot lie flat | Hallmark of heart failure |
| **Paroxysmal Nocturnal Dyspnea (PND)** | Wakes up 2x/week gasping, needs to sit at bedside 10-15
min | Classic for left heart failure |
| **Lower Extremity Edema** | Bilateral swelling worsening over 1 week | Right heart failure |
| **Weight Gain** | 6 lbs (2.7 kg) in 7 days | Fluid retention |
| **Fatigue** | Decreased exercise tolerance | Low cardiac output |
| **Dry Cough** | Mild, non-productive | Pulmonary congestion |
#### Critical Denials (Rule-Out Findings)
| Denied Symptom | Significance |
| :--- | :--- |
| Chest pain, pressure, or tightness | Rules out acute coronary syndrome as primary |
| Fever, chills, night sweats | Rules out infection/pneumonia |
| Hemoptysis | Rules out PE or malignancy |
| Wheezing | Rules against COPD exacerbation |
| Productive cough | Rules against pneumonia |
| Unilateral leg swelling | Rules against DVT/PE |
Year-Old Male with Shortness of
Breath | Latest 2025/2026 Guide for
Guaranteed Exam Success
## iHuman Case Study: 68-Year-Old Male with Shortness of Breath – Complete SOAP Note &
Management Guide
### Case Overview
| Feature | Details |
,| :--- | :--- |
| **Patient** | James Whitaker / Robert Jenkins (68-Year-Old Male) |
| **Ethnicity** | African American or Caucasian |
| **Chief Complaint** | "I can't catch my breath." |
| **Setting** | Outpatient clinic with lab, ECG, and chest X-ray capability |
| **Course** | NURS 6550 / NUR 2026 – Advanced Practice Care of Adults |
| **Week** | 10 (2025/2026) |
| **Final Diagnosis** | **Acute Decompensated Systolic Heart Failure (HFrEF)** |
### Subjective Data (History Collection)
#### Chief Complaint in Patient's Own Words
> *"I can't catch my breath. It's been getting worse over the past few days."*
#### History of Present Illness (HPI) – OLDCARTS Format
| Feature | Finding |
| :--- | :--- |
| **Onset** | Gradual onset 5 days ago; progressive worsening |
| **Location** | Chest (no focal pain); sensation of "air hunger" |
| **Duration** | Persistent; worsens with exertion |
| **Character** | Describes as "tightness" and inability to draw full breath |
| **Aggravating Factors** | Walking short distances (20-30 feet), climbing stairs, lying flat |
, | **Relieving Factors** | Sitting upright, resting, elevating head of bed |
| **Timing** | Worse in evenings and at night; constant during day |
| **Severity** | 4/10 at rest, 7-8/10 with minimal exertion |
#### Associated Symptoms (Positive Findings)
| Symptom | Details | Clinical Significance |
| :--- | :--- | :--- |
| **Orthopnea** | Uses 3 pillows to sleep; cannot lie flat | Hallmark of heart failure |
| **Paroxysmal Nocturnal Dyspnea (PND)** | Wakes up 2x/week gasping, needs to sit at bedside 10-15
min | Classic for left heart failure |
| **Lower Extremity Edema** | Bilateral swelling worsening over 1 week | Right heart failure |
| **Weight Gain** | 6 lbs (2.7 kg) in 7 days | Fluid retention |
| **Fatigue** | Decreased exercise tolerance | Low cardiac output |
| **Dry Cough** | Mild, non-productive | Pulmonary congestion |
#### Critical Denials (Rule-Out Findings)
| Denied Symptom | Significance |
| :--- | :--- |
| Chest pain, pressure, or tightness | Rules out acute coronary syndrome as primary |
| Fever, chills, night sweats | Rules out infection/pneumonia |
| Hemoptysis | Rules out PE or malignancy |
| Wheezing | Rules against COPD exacerbation |
| Productive cough | Rules against pneumonia |
| Unilateral leg swelling | Rules against DVT/PE |
