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I-HUMAN WEEK 9 ADVANCED CASE STUDY | 50-
YEAR-OLD FEMALE WITH FATIGUE &
SHORTNESS OF BREATH | COMPLETE CASE
ANALYSIS & 50+ Q&A | HIGH-YIELD
## Case Overview
**Patient:** 50-year-old female
**Chief Complaint:** "I have been feeling tired and short of breath for
the past 2 months. It's getting worse."
**Setting:** Outpatient primary care clinic
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---
# Part 1: Case Summary & Key Data
## History of Present Illness (HPI)
- **Onset:** Gradual onset 2 months ago; progressive worsening over
the past 2 weeks
- **Fatigue:** Describes as "feeling exhausted even after a full night's
sleep"; worsens by afternoon; unable to perform usual daily activities
(cooking, cleaning, walking one block)
- **Shortness of breath:** Occurs with minimal exertion (walking 50
feet, climbing 5 stairs); also notes dyspnea when lying flat (orthopnea) –
uses 2 pillows; no paroxysmal nocturnal dyspnea
- **Other symptoms:** Palpitations (feeling of heart racing) occasional;
mild dizziness upon standing; no chest pain, no cough, no hemoptysis,
no fever, no night sweats, no lower extremity edema
- **Severity:** Fatigue 7/10; dyspnea 6/10 (on exertion)
- **Timing:** Constant fatigue; dyspnea occurs with activity and when
lying flat
- **Aggravating factors:** Physical activity, lying flat, stress
- **Relieving factors:** Rest, sitting upright, sleeping with head
elevated
- **Review of systems – positive:** Cold intolerance, dry skin, hair
thinning, constipation, weight gain of 10 lbs over 6 months despite no
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change in appetite; irregular menses (skip periods for 2–3 months at a
time) – perimenopausal; denies heat intolerance, palpitations (except
occasional), tremors, or anxiety
## Past Medical History (PMH)
- **Hypertension** (diagnosed 5 years ago) – controlled on lisinopril 10
mg daily
- **Hyperlipidemia** (diagnosed 3 years ago) – on atorvastatin 20 mg
daily
- **Hypothyroidism** (diagnosed 8 years ago) – on levothyroxine 75
mcg daily (takes inconsistently, "sometimes forgets")
- **Gastroesophageal reflux disease (GERD)** – on omeprazole 20 mg
daily
- **No history of asthma, COPD, heart failure, or anemia**
## Past Surgical History (PSH)
- **Tubal ligation** (age 35)
- **No other surgeries**
## Medications
- Lisinopril 10 mg daily
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- Atorvastatin 20 mg daily
- Levothyroxine 75 mcg daily (takes 3–4 times per week, not daily)
- Omeprazole 20 mg daily
- Ibuprofen 400 mg PRN for headaches (rarely)
## Allergies
- **Sulfa** (rash) – avoid sulfonamides
## Social History
- **Occupation:** Administrative assistant (sedentary office job)
- **Smoking:** Never
- **Alcohol:** 1–2 glasses of wine per week
- **Illicit drugs:** Denies
- **Activity:** Sedentary; no regular exercise
## Family History
- Mother: Hypertension, hypothyroidism, coronary artery disease (age
65)
- Father: Type 2 diabetes, died of MI at age 68
I-HUMAN WEEK 9 ADVANCED CASE STUDY | 50-
YEAR-OLD FEMALE WITH FATIGUE &
SHORTNESS OF BREATH | COMPLETE CASE
ANALYSIS & 50+ Q&A | HIGH-YIELD
## Case Overview
**Patient:** 50-year-old female
**Chief Complaint:** "I have been feeling tired and short of breath for
the past 2 months. It's getting worse."
**Setting:** Outpatient primary care clinic
,2|Page
---
# Part 1: Case Summary & Key Data
## History of Present Illness (HPI)
- **Onset:** Gradual onset 2 months ago; progressive worsening over
the past 2 weeks
- **Fatigue:** Describes as "feeling exhausted even after a full night's
sleep"; worsens by afternoon; unable to perform usual daily activities
(cooking, cleaning, walking one block)
- **Shortness of breath:** Occurs with minimal exertion (walking 50
feet, climbing 5 stairs); also notes dyspnea when lying flat (orthopnea) –
uses 2 pillows; no paroxysmal nocturnal dyspnea
- **Other symptoms:** Palpitations (feeling of heart racing) occasional;
mild dizziness upon standing; no chest pain, no cough, no hemoptysis,
no fever, no night sweats, no lower extremity edema
- **Severity:** Fatigue 7/10; dyspnea 6/10 (on exertion)
- **Timing:** Constant fatigue; dyspnea occurs with activity and when
lying flat
- **Aggravating factors:** Physical activity, lying flat, stress
- **Relieving factors:** Rest, sitting upright, sleeping with head
elevated
- **Review of systems – positive:** Cold intolerance, dry skin, hair
thinning, constipation, weight gain of 10 lbs over 6 months despite no
,3|Page
change in appetite; irregular menses (skip periods for 2–3 months at a
time) – perimenopausal; denies heat intolerance, palpitations (except
occasional), tremors, or anxiety
## Past Medical History (PMH)
- **Hypertension** (diagnosed 5 years ago) – controlled on lisinopril 10
mg daily
- **Hyperlipidemia** (diagnosed 3 years ago) – on atorvastatin 20 mg
daily
- **Hypothyroidism** (diagnosed 8 years ago) – on levothyroxine 75
mcg daily (takes inconsistently, "sometimes forgets")
- **Gastroesophageal reflux disease (GERD)** – on omeprazole 20 mg
daily
- **No history of asthma, COPD, heart failure, or anemia**
## Past Surgical History (PSH)
- **Tubal ligation** (age 35)
- **No other surgeries**
## Medications
- Lisinopril 10 mg daily
, 4|Page
- Atorvastatin 20 mg daily
- Levothyroxine 75 mcg daily (takes 3–4 times per week, not daily)
- Omeprazole 20 mg daily
- Ibuprofen 400 mg PRN for headaches (rarely)
## Allergies
- **Sulfa** (rash) – avoid sulfonamides
## Social History
- **Occupation:** Administrative assistant (sedentary office job)
- **Smoking:** Never
- **Alcohol:** 1–2 glasses of wine per week
- **Illicit drugs:** Denies
- **Activity:** Sedentary; no regular exercise
## Family History
- Mother: Hypertension, hypothyroidism, coronary artery disease (age
65)
- Father: Type 2 diabetes, died of MI at age 68
