IHUMAN VIRTUAL PATIENT – DOROTHY JONES 54
YEARS OLD, CLINICAL ASSESSMENT – COMPLETE
HPI AND PHYSICAL EXAM DOCUMENTATION
I. CHIEF COMPLAINT
“I’ve been feeling tired and short of breath for the past few weeks, and yesterday
I felt some pressure in my chest.”
II. HISTORY OF PRESENT ILLNESS (HPI)
Dorothy Jones is a 54-year-old Caucasian female who presents with a 3-week
history of progressive fatigue, intermittent dyspnea on exertion, and new-onset
chest discomfort. She describes the chest sensation as a “heavy pressure” in the
substernal area, non-radiating, occurring twice in the past 24 hours, each lasting
5–10 minutes, provoked by walking up one flight of stairs and relieved by rest. No
diaphoresis, nausea, or palpitations. The dyspnea occurs with similar exertion and
also when lying flat for the past week (orthopnea, uses 2 pillows). She notes mild
ankle swelling in the evenings, improving with elevation. No cough, fever,
hemoptysis, or lower extremity pain. She denies any recent illness, trauma, or
travel.
III. REVIEW OF SYSTEMS (POSITIVE FINDINGS)
General: Fatigue, no fevers, chills, or weight changes.
, Cardiovascular: Substernal chest pressure on exertion, orthopnea,
paroxysmal nocturnal dyspnea (once last week), bilateral ankle edema.
Respiratory: Dyspnea on exertion, no wheeze or sputum.
GI: No nausea, vomiting, abdominal pain, or reflux.
Musculoskeletal: No leg pain or calf tenderness.
Neurological: No dizziness, syncope, or weakness.
Psychiatric: Mild anxiety about symptoms.
All other systems negative.
IV. PAST MEDICAL HISTORY
Hypertension (diagnosed 10 years ago)
Type 2 diabetes mellitus (diagnosed 5 years ago)
Hyperlipidemia
Obesity (BMI 32)
V. PAST SURGICAL HISTORY
Cholecystectomy (15 years ago)
No cardiac surgeries
VI. MEDICATIONS
Lisinopril 20 mg daily
Metformin 1000 mg BID
Atorvastatin 40 mg daily
Aspirin 81 mg daily
, Hydrochlorothiazide 12.5 mg daily
VII. ALLERGIES
Sulfa drugs (rash)
VIII. SOCIAL HISTORY
Married, lives with husband.
Works as an administrative assistant (sedentary job).
No smoking history.
Occasional alcohol (1–2 glasses of wine per week).
No illicit drug use.
Exercises minimally due to fatigue.
IX. FAMILY HISTORY
Father: Myocardial infarction at age 62
Mother: Type 2 diabetes, hypertension
No known cardiomyopathy or sudden death in family.
X. PHYSICAL EXAMINATION
Vitals:
BP 148/90 (right arm, sitting), HR 98 bpm and regular, RR 20/min, Temp 98.6°F
(37°C), SpO2 94% on room air.
General: Well-nourished, mild distress when supine.
HEENT: No JVD at 30 degrees.
Cardiovascular: PMI displaced laterally to 6th intercostal space anterior axillary
line; S1, S2 normal; S3 gallop heard at apex; no murmurs, rubs, or thrills.
Respiratory: Clear to auscultation bilaterally, no crackles or wheezes.
YEARS OLD, CLINICAL ASSESSMENT – COMPLETE
HPI AND PHYSICAL EXAM DOCUMENTATION
I. CHIEF COMPLAINT
“I’ve been feeling tired and short of breath for the past few weeks, and yesterday
I felt some pressure in my chest.”
II. HISTORY OF PRESENT ILLNESS (HPI)
Dorothy Jones is a 54-year-old Caucasian female who presents with a 3-week
history of progressive fatigue, intermittent dyspnea on exertion, and new-onset
chest discomfort. She describes the chest sensation as a “heavy pressure” in the
substernal area, non-radiating, occurring twice in the past 24 hours, each lasting
5–10 minutes, provoked by walking up one flight of stairs and relieved by rest. No
diaphoresis, nausea, or palpitations. The dyspnea occurs with similar exertion and
also when lying flat for the past week (orthopnea, uses 2 pillows). She notes mild
ankle swelling in the evenings, improving with elevation. No cough, fever,
hemoptysis, or lower extremity pain. She denies any recent illness, trauma, or
travel.
III. REVIEW OF SYSTEMS (POSITIVE FINDINGS)
General: Fatigue, no fevers, chills, or weight changes.
, Cardiovascular: Substernal chest pressure on exertion, orthopnea,
paroxysmal nocturnal dyspnea (once last week), bilateral ankle edema.
Respiratory: Dyspnea on exertion, no wheeze or sputum.
GI: No nausea, vomiting, abdominal pain, or reflux.
Musculoskeletal: No leg pain or calf tenderness.
Neurological: No dizziness, syncope, or weakness.
Psychiatric: Mild anxiety about symptoms.
All other systems negative.
IV. PAST MEDICAL HISTORY
Hypertension (diagnosed 10 years ago)
Type 2 diabetes mellitus (diagnosed 5 years ago)
Hyperlipidemia
Obesity (BMI 32)
V. PAST SURGICAL HISTORY
Cholecystectomy (15 years ago)
No cardiac surgeries
VI. MEDICATIONS
Lisinopril 20 mg daily
Metformin 1000 mg BID
Atorvastatin 40 mg daily
Aspirin 81 mg daily
, Hydrochlorothiazide 12.5 mg daily
VII. ALLERGIES
Sulfa drugs (rash)
VIII. SOCIAL HISTORY
Married, lives with husband.
Works as an administrative assistant (sedentary job).
No smoking history.
Occasional alcohol (1–2 glasses of wine per week).
No illicit drug use.
Exercises minimally due to fatigue.
IX. FAMILY HISTORY
Father: Myocardial infarction at age 62
Mother: Type 2 diabetes, hypertension
No known cardiomyopathy or sudden death in family.
X. PHYSICAL EXAMINATION
Vitals:
BP 148/90 (right arm, sitting), HR 98 bpm and regular, RR 20/min, Temp 98.6°F
(37°C), SpO2 94% on room air.
General: Well-nourished, mild distress when supine.
HEENT: No JVD at 30 degrees.
Cardiovascular: PMI displaced laterally to 6th intercostal space anterior axillary
line; S1, S2 normal; S3 gallop heard at apex; no murmurs, rubs, or thrills.
Respiratory: Clear to auscultation bilaterally, no crackles or wheezes.
