COMPREHENSIVE I-HUMAN CASE STUDY OF A 60-
YEAR-OLD FEMALE WITH PROGRESSIVE
DYSPNEA: DIAGNOSIS AND MANAGEMENT OF
CONGESTIVE HEART FAILURE (CLAS 6550)
• Age: 60 years
• Gender: Female
• Ethnicity: African
• Occupation: Retired teacher
• Height: 165 cm
• Weight: 78 kg
• BMI: 28.7 (Overweight)
,1. Case Overview & Problem Statement
This is a fictional, i-Human–style educational case study of a 60-year-old
female presenting with shortness of breath. The presentation is most
consistent with acute decompensated heart failure (ADHF) with pulmonary
congestion, likely triggered by poor blood pressure control and medication
nonadherence.
The central clinical problem is to determine whether the dyspnea is due to a
cardiac, pulmonary, thromboembolic, infectious, or metabolic cause, then
to stabilize the patient and identify the underlying diagnosis.
2. Patient Demographics & Vitals
Category Details
Name Mrs. M.K.
Age 60 years
Sex Female
Race/Ethnicity Not specified
Marital Status Married
Occupation Shopkeeper
Chief Complaint “I cannot breathe well, especially when I lie down.”
Triage Priority Urgent
, Initial Vital Signs
Vital Sign Value
Temperature 37.1°C
Heart Rate 108 beats/min
Respiratory Rate 26 breaths/min
Blood Pressure 168/96 mmHg
Oxygen Saturation 89% on room air
Pain Score 0/10
BMI 31 kg/m²
3. Chief Complaint & History of Present Illness
Chief Complaint:
“I have been getting short of breath for the last week.”
History of Present Illness
The patient is a 60-year-old woman who presents with progressively
worsening shortness of breath for 7 days. The dyspnea is initially present
with exertion but is now noticeable even at rest. She reports:
• Orthopnea: needs 3 pillows to sleep
• Paroxysmal nocturnal dyspnea: wakes up at night gasping for air
• Dry cough
• Fatigue
YEAR-OLD FEMALE WITH PROGRESSIVE
DYSPNEA: DIAGNOSIS AND MANAGEMENT OF
CONGESTIVE HEART FAILURE (CLAS 6550)
• Age: 60 years
• Gender: Female
• Ethnicity: African
• Occupation: Retired teacher
• Height: 165 cm
• Weight: 78 kg
• BMI: 28.7 (Overweight)
,1. Case Overview & Problem Statement
This is a fictional, i-Human–style educational case study of a 60-year-old
female presenting with shortness of breath. The presentation is most
consistent with acute decompensated heart failure (ADHF) with pulmonary
congestion, likely triggered by poor blood pressure control and medication
nonadherence.
The central clinical problem is to determine whether the dyspnea is due to a
cardiac, pulmonary, thromboembolic, infectious, or metabolic cause, then
to stabilize the patient and identify the underlying diagnosis.
2. Patient Demographics & Vitals
Category Details
Name Mrs. M.K.
Age 60 years
Sex Female
Race/Ethnicity Not specified
Marital Status Married
Occupation Shopkeeper
Chief Complaint “I cannot breathe well, especially when I lie down.”
Triage Priority Urgent
, Initial Vital Signs
Vital Sign Value
Temperature 37.1°C
Heart Rate 108 beats/min
Respiratory Rate 26 breaths/min
Blood Pressure 168/96 mmHg
Oxygen Saturation 89% on room air
Pain Score 0/10
BMI 31 kg/m²
3. Chief Complaint & History of Present Illness
Chief Complaint:
“I have been getting short of breath for the last week.”
History of Present Illness
The patient is a 60-year-old woman who presents with progressively
worsening shortness of breath for 7 days. The dyspnea is initially present
with exertion but is now noticeable even at rest. She reports:
• Orthopnea: needs 3 pillows to sleep
• Paroxysmal nocturnal dyspnea: wakes up at night gasping for air
• Dry cough
• Fatigue
