, iHuman Week 9: Complete Advanced Clinical Case
Study 50-Year-Old Female with Fatigue and Shortness
of Breath
PATIENT DEMOGRAPHICS
Field Information
Name Maria Garcia
Age 50 years
Sex Female
Race/Ethnicity Hispanic / Latina
Date of Birth 04/15/1976
Occupation Elementary school teacher (2nd grade)
Marital Status Married (22 years)
Children Two (daughter 16, son 14)
Insurance Private PPO
Primary Language English (bilingual Spanish)
Code Status Full code
PCP Dr. Johnson (seen for 5 years)
, CHIEF COMPLAINT
"I've been feeling really tired for the last three months, and I get winded doing things that
never used to bother me."
HISTORY OF PRESENT ILLNESS (HPI)
Onset: Gradual, approximately 12 weeks ago.
Course: The patient initially noticed mild fatigue after teaching, which she attributed to
stress and lack of sleep. Over the past 6–8 weeks, she developed progressive exertional
dyspnea.
Specific limitations:
3 months ago: Able to walk 3 blocks without stopping; climbed stairs normally
2 months ago: Short of breath after 2 flights of stairs
1 month ago: Short of breath after 1 flight of stairs
Now: Short of breath after walking 1 block on flat ground; must rest before continuing
Associated symptoms:
Fatigue: "I come home from school and collapse on the couch. I used to cook dinner
every night."
Palpitations: Occasional "heart racing" when climbing stairs – lasts 5–10 seconds,
resolves with rest
Headaches: Mild, frontal, occasional – worse at end of day
Cold intolerance: "I feel cold even when the classroom is warm"
Pica: Admits to craving ice chips for the past 2 months ("I chew ice all day long")
Denies:
Chest pain, pressure, or tightness
Paroxysmal nocturnal dyspnea (PND)
Orthopnea (sleeps with one pillow)
Lower extremity edema
Syncope or near-syncope
Cough, sputum production, hemoptysis, wheezing
Study 50-Year-Old Female with Fatigue and Shortness
of Breath
PATIENT DEMOGRAPHICS
Field Information
Name Maria Garcia
Age 50 years
Sex Female
Race/Ethnicity Hispanic / Latina
Date of Birth 04/15/1976
Occupation Elementary school teacher (2nd grade)
Marital Status Married (22 years)
Children Two (daughter 16, son 14)
Insurance Private PPO
Primary Language English (bilingual Spanish)
Code Status Full code
PCP Dr. Johnson (seen for 5 years)
, CHIEF COMPLAINT
"I've been feeling really tired for the last three months, and I get winded doing things that
never used to bother me."
HISTORY OF PRESENT ILLNESS (HPI)
Onset: Gradual, approximately 12 weeks ago.
Course: The patient initially noticed mild fatigue after teaching, which she attributed to
stress and lack of sleep. Over the past 6–8 weeks, she developed progressive exertional
dyspnea.
Specific limitations:
3 months ago: Able to walk 3 blocks without stopping; climbed stairs normally
2 months ago: Short of breath after 2 flights of stairs
1 month ago: Short of breath after 1 flight of stairs
Now: Short of breath after walking 1 block on flat ground; must rest before continuing
Associated symptoms:
Fatigue: "I come home from school and collapse on the couch. I used to cook dinner
every night."
Palpitations: Occasional "heart racing" when climbing stairs – lasts 5–10 seconds,
resolves with rest
Headaches: Mild, frontal, occasional – worse at end of day
Cold intolerance: "I feel cold even when the classroom is warm"
Pica: Admits to craving ice chips for the past 2 months ("I chew ice all day long")
Denies:
Chest pain, pressure, or tightness
Paroxysmal nocturnal dyspnea (PND)
Orthopnea (sleeps with one pillow)
Lower extremity edema
Syncope or near-syncope
Cough, sputum production, hemoptysis, wheezing
