Table of Contents

John Quimby iHuman Case Study 2025

John Quimby is a 45-year-old male presenting with acute onset severe chest pain that began suddenly while lifting heavy boxes at work and radiates to his jaw and left arm. In this comprehensive guide, we’ll walk you through how to approach his case, from initial history-taking through physical examination to the final diagnosis of acute myocardial infarction. You’ll learn the key clinical reasoning steps, what the iHuman grading rubric expects, and a complete step-by-step solution to help you confidently navigate this acute cardiovascular emergency simulation.

John Quimby iHuman Case Overview (Doorway Information)

Patient Overview: John Quimby is a 45-year-old African American male presenting with a chief complaint of “severe crushing chest pain” that began suddenly 2 hours ago while lifting heavy equipment at his construction job. He describes experiencing acute onset substernal chest pain with a “crushing, elephant sitting on my chest” sensation that radiates to his jaw and left arm. The pain is associated with diaphoresis, nausea, and shortness of breath and has not improved with rest.

Key Background Information:

Age/Gender: 45-year-old male
Chief Complaint: Severe crushing chest pain
Duration: 2 hours since onset
Pain Characteristics: Sudden onset, substernal, crushing, radiates to jaw and left arm, no relief with rest
Associated Symptoms: Diaphoresis, nausea, shortness of breath
Significant History: Type 2 diabetes mellitus, smoking (1 pack per day for 25 years), family history of early coronary artery disease
Current Medications: Metformin 1000mg twice daily
Occupation: Construction worker with physically demanding job
Lifestyle: Sedentary outside of work, poor diet, high stress levels, active smoker

The patient appears pale and diaphoretic, in obvious distress, with elevated vital signs. His presentation is classic for acute coronary syndrome, making this an excellent case for learning emergency cardiovascular assessment and acute MI management skills.

John Quimby (45 y/o male) – Acute Chest Pain Assessment

Chief Complaint: Severe crushing chest pain

Most Significant Active Problem (MSAP): Acute onset “crushing” substernal chest pain radiating to jaw and left arm, unrelieved by rest

Sudden onset while lifting heavy equipment
Associated diaphoresis, nausea, and dyspnea
History: T2DM, smoking history, family hx of early CAD
High-stress occupation

History Questions:

Essential questions to ask during the iHuman case:

Basic Assessment:

How can I help you today?
Any other symptoms we should discuss?
Do you have any allergies?
Are you taking any OTC or herbal medications?
Any new or recent changes in medications?

Chest Pain Specific Questions:

What does the pain/discomfort in your chest feel like? (squeezing, pressure, crushing, burning, stabbing, aching, tingling)
How severe (scale 1-10) is the pain in your chest?
Does anything make the pain in your chest better or worse?
What are the events surrounding the start of your chest pain?
Does the pain in your chest radiate someplace else? Where?
Do you have unusual heartbeats (palpitations)?
Does the pain get worse with breathing?
Does your pain awaken you from your sleep?
Have you had chest pain like this before?

Associated Symptoms:

Do you experience: SOB, wheezing, difficulty catching breath?
Do you have any of the following: nausea, vomiting, sweating, dizziness?
Do you have any of the following: fatigue, weakness, fainting?

Risk Factor Assessment:

Do you drink alcohol? If so, what do you drink and how many drinks per day?
Do you smoke cigarettes? How many packs per day and for how long?
Tell me about your work and daily stress levels
Tell me about daily exercise or physical activity
How is your overall health?
Any family history of heart problems or early heart attacks?

Physical Examination:

Vital Signs: pulse, BP, respirations, temperature, oxygen saturation

Focused Physical Exam Components:

General Appearance: Overall distress level, skin color, diaphoresis
Skin: Examine for pallor, diaphoresis, cyanosis
Neck:
- Measure JVP (jugular venous pressure)
- Auscultate carotid arteries for bruits
Chest wall & lungs:
- Visual inspection of anterior & posterior chest
- Palpate anterior & posterior chest
- Auscultate lungs for crackles, wheezes
Heart:
- Palpate for PMI (Point of Maximal Impact)
- Auscultate heart for murmurs, gallops, rubs
Abdomen:
- Auscultate abdominal arteries
- Palpate abdomen for tenderness
Extremities: Visual inspection for edema, cyanosis, clubbing

Assessment Note:

J.Q. is a 45 y/o African American male presenting with 2-hour h/o acute onset, severe substernal chest pain which radiates to the jaw and L arm, occurs with SOB, nausea, and diaphoresis, began suddenly with exertion, and is unrelieved by rest. On physical exam he appears pale and diaphoretic with elevated vital signs. PMH significant risk factors include: active smoking (25 pack-years), T2DM, and strong family history of early coronary artery disease.

ECG: Acute ST elevation in leads II, III, aVF indicating inferior STEMI Troponin I: Markedly elevated at 15.2 ng/mL (normal <0.04) CK-MB: Elevated at 45 ng/mL

Diagnosis: Acute ST-elevation myocardial infarction (STEMI) – inferior wall

Plan:

Immediate Management:

Activate STEMI protocol and prepare for emergency cardiac catheterization
Administer dual antiplatelet therapy: ASA 325mg chewed + clopidogrel 600mg loading dose
Initiate anticoagulation with heparin per protocol
Administer atorvastatin 80mg daily
Start metoprolol 25mg BID (once hemodynamically stable)
Continue metformin for diabetes management
Oxygen therapy if SpO2 <90%

Emergency Interventions:

Emergency percutaneous coronary intervention (PCI) within 90 minutes
Continuous cardiac monitoring for arrhythmias
Serial troponin levels and ECGs

Lifestyle Modifications:

Mandatory smoking cessation program
Cardiac rehabilitation enrollment
Diabetic diet counseling
Stress management counseling
f/u in 1 week post-discharge, then cardiology in 2-4 weeks

John Quimby SOAP Note

Patient: John Quimby

Subjective Data

CC: 45-year-old male presents with “severe crushing chest pain”

HPI: 45-year-old male presents today with complaints of acute onset, severe substernal chest pain that began suddenly 2 hours ago while lifting heavy equipment at his construction job. The patient describes the pain as “crushing, like an elephant sitting on my chest” that radiates to his jaw and left arm. The patient states that the pain has not improved with rest and is accompanied by profuse sweating, nausea, and shortness of breath. The patient reports the chest pain to be severe and rates it 9/10 on a pain scale. The patient reports a history of type 2 diabetes mellitus and is an active smoker. He reports a strong family history of heart disease with his father having a heart attack at age 48. Upon physical examination, the patient appears pale, diaphoretic, and in acute distress.

Medications: Metformin 1000mg twice daily

Allergies: NKDA – The patient denies any medication, environmental or food allergies

PMH: Type 2 diabetes mellitus diagnosed 5 years ago, well-controlled with metformin. Denies other chronic medical conditions.

PSH: Appendectomy at age 16. Denies other surgical procedures.

Hospitalizations: None except for appendectomy.

Health Maintenance: Reports seeing primary care provider annually for diabetes management. Last HbA1c was 6.8%.

Immunizations: Immunizations are up to date. Completed all childhood vaccines. Received COVID-19 vaccination.

Family History: Paternal history of myocardial infarction at age 48. Maternal history of hypertension and stroke at age 65. Brother has diabetes. No known family history of cancer.

Substances: The patient smokes 1 pack of cigarettes per day for 25 years (25 pack-year history). Reports moderate alcohol intake with 2-3 beers on weekends. Denies illicit drug use. Moderate caffeine intake.

Home Environment: The patient lives with his wife and two teenage children in a two-story home. Reports a safe home environment.

Employment: Construction worker for 20 years. Reports work is physically demanding with heavy lifting and high stress due to deadlines.

Diet: Admits to poor dietary habits with frequent fast food meals due to work schedule. High sodium and saturated fat intake.

Sleep: Sleeps 6-7 hours per night. Denies chest pain or dyspnea during sleep. No sleep apnea.

Exercise: Sedentary lifestyle outside of work. No regular exercise routine.

Safety: Reports feeling safe at home and work. Uses appropriate safety equipment at construction sites.

Objective Data

ROS: Performed appropriate ROS based on acute chest pain presentation

General: Reports severe acute chest pain. Appears pale, diaphoretic, and in acute distress. Denies fever, chills, recent weight changes. Eye contact appropriate but patient appears anxious and uncomfortable.

Skin, Hair and Nails: Pale and diaphoretic. No rashes, lesions, or changes in moles noted.

HEENT: Denies headaches, vision changes, or jaw pain separate from current chest pain radiation. Denies ear problems, sinus issues, or sore throat.

NECK: Denies neck pain or stiffness unrelated to current chest pain radiation. No swollen glands.

Thorax and Lungs: Reports mild shortness of breath associated with chest pain. Denies history of lung disease, asthma, or chronic cough. No wheezing reported.

Cardiovascular: Reports severe substernal chest pain with radiation to jaw and left arm. Pain described as crushing, 9/10 severity, unrelieved by rest. Associated with diaphoresis, nausea, and dyspnea. Denies previous episodes of similar chest pain. Denies palpitations or syncope.

Peripheral Vascular: Denies extremity edema, coldness, or claudication symptoms.

Abdomen: Reports mild nausea associated with chest pain. Denies vomiting, abdominal pain, or changes in bowel movements.

Genitourinary: No complaints. Normal urination patterns.

Metabolic/Hematologic: Known diabetes, well-controlled. Denies heat/cold intolerance or excessive thirst.

Psychiatric: Appears anxious secondary to acute symptoms. Denies depression, mood changes, or suicidal ideation.

Musculoskeletal: Denies chest wall tenderness or recent trauma. Reports radiation of chest pain to left arm.

Neurologic: Alert and oriented. Denies syncope, seizures, or neurologic symptoms.

Vital Signs: Temperature: 98.8°F, Pulse: 102, BP: 158/94, Respirations: 22, SpO2: 96% on room air

Assessment

General: Middle-aged male in acute distress, appears pale and diaphoretic. Alert and oriented but anxious. No fever noted.

Skin, Hair and Nails: Skin is pale and diaphoretic consistent with acute cardiovascular event. No lesions or rashes noted.

HEENT: Head normocephalic and atraumatic. Pupils equal, round, reactive to light. Oral mucosa pink and moist.

NECK: No JVD noted. Carotid pulses 2+ bilaterally without bruits. No lymphadenopathy.

Thorax and Lungs: Respirations mildly labored. Chest symmetric with no obvious deformity. Lung fields clear to auscultation bilaterally. No wheezes, crackles, or rubs noted.

Cardiovascular: Tachycardic with regular rhythm. PMI palpable at 5th intercostal space, midclavicular line. S1 and S2 present, no murmurs, gallops, or rubs appreciated on initial examination.

Peripheral Vascular: Extremities warm. Radial pulses 2+ bilaterally. No peripheral edema noted.

Abdomen: Soft, non-tender. Bowel sounds present. No masses or organomegaly noted.

Psychiatric: Anxious affect appropriate to clinical situation. Speech clear and coherent.

Musculoskeletal: No chest wall tenderness to palpation. Full range of motion in extremities.

Neurologic: Alert and oriented x4. Cranial nerves II-XII grossly intact. Motor strength 5/5 in all extremities.

Differential Diagnoses

Acute Myocardial Infarction: The patient presents with classic symptoms of acute MI including severe substernal chest pain with radiation to jaw and left arm, associated with diaphoresis, nausea, and dyspnea. Risk factors include male gender, age 45, smoking history, diabetes, and family history of early CAD. The acute onset during physical exertion is highly suggestive of plaque rupture and coronary occlusion.

Unstable Angina: While possible, the severity and duration of symptoms (2 hours) along with the acute presentation make acute MI more likely. Unstable angina typically presents with chest pain at rest or with minimal exertion but may not have the same severity or associated symptoms.

Aortic Dissection: Should be considered given the acute onset and severity of pain. However, the patient’s pain is substernal rather than tearing back pain, and he lacks the typical risk factors such as uncontrolled hypertension or connective tissue disorders.

Pulmonary Embolism: Acute onset chest pain with dyspnea could suggest PE, but the patient lacks typical risk factors such as recent immobilization, surgery, or travel. The pain character is more consistent with cardiac ischemia.

Most Likely Diagnosis: Acute ST-elevation myocardial infarction (STEMI) evidenced by acute onset severe substernal chest pain with classic radiation pattern, associated symptoms of diaphoresis and nausea, multiple cardiac risk factors, and ECG findings showing ST elevation in inferior leads. Elevated cardiac biomarkers confirm myocardial injury.

Plan

Health Promotion:

Immediate Priority – Acute Management:

Emergency cardiac catheterization with primary PCI
Dual antiplatelet therapy and anticoagulation
Intensive monitoring for complications

Secondary Prevention:

Aggressive risk factor modification
Cardiac rehabilitation program enrollment
Intensive diabetes management
Smoking cessation program (mandatory)

Screening:

Post-MI Monitoring:

Echocardiogram to assess left ventricular function
Lipid panel to guide statin therapy
HbA1c monitoring for diabetes management
Depression screening (common post-MI)

Immunizations:

Annual influenza vaccine
COVID-19 vaccination (up to date)
Pneumococcal vaccination if indicated

Complete Step-by-Step Guide to Writing the John Quimby iHuman Case Study

Completing the John Quimby iHuman case requires recognition of an acute cardiovascular emergency and rapid, systematic response. This comprehensive guide will walk you through each section of the simulation, providing specific strategies and key points to ensure you achieve the required 70% score.

Step 1: Pre-Case Preparation and Initial Approach

Before diving into the case, immediately recognize this as a potential cardiac emergency.

Key Information to Note:

45-year-old male with acute onset severe chest pain
Pain began with physical exertion (lifting heavy equipment)
Classic radiation pattern (jaw and left arm)
Associated symptoms (diaphoresis, nausea, dyspnea)

Initial Clinical Mindset: Approach this case as a suspected acute coronary syndrome requiring emergency management. Time is muscle – rapid assessment and intervention are critical.

Step 2: Conducting the History of Present Illness (HPI)

For acute chest pain, use OLDCARTS method rapidly but thoroughly:

Onset: Sudden onset 2 hours ago during heavy lifting

Key detail: Physical exertion as trigger suggests plaque rupture

Location: Substernal with radiation to jaw and left arm

Critical finding: Classic MI radiation pattern

Duration: Continuous for 2 hours, no relief

Important: Prolonged duration suggests ongoing occlusion

Character: “Crushing, elephant on chest”

Classic descriptor: Typical for acute MI

Aggravating factors: No relief with rest (unlike stable angina)

Red flag: Suggests complete coronary occlusion

Relieving factors: Nothing provides relief

Concerning sign: Indicates acute coronary syndrome

Timing: Acute onset, persistent

Critical pattern: Continuous pain suggests ongoing ischemia

Severity: 9/10 pain scale

High severity: Consistent with acute MI

Associated Symptoms: Diaphoresis, nausea, dyspnea

Classic triad: Highly suggestive of acute MI

Step 3: Review of Systems (ROS)

Focus on cardiovascular and related systems while considering MI complications:

Cardiovascular:

Chest pain characteristics (covered in HPI)
Palpitations, irregular heartbeats
Previous cardiac events
Exercise tolerance

Respiratory:

Acute dyspnea (pulmonary edema risk)
Previous lung disease

Neurologic:

Syncope, dizziness (cardiogenic shock risk)

Gastrointestinal:

Nausea, vomiting (vagal stimulation in inferior MI)

Step 4: Past Medical History, Social History, and Family History

Past Medical History:

Type 2 diabetes mellitus (major cardiac risk factor)
Previous cardiovascular events
Hypertension, hyperlipidemia

Family History:

Critical finding: Father had MI at age 48 (early CAD)
Strong family history of cardiovascular disease

Social History:

Smoking: 25 pack-year history (major modifiable risk factor)
Occupation: Construction work (physically demanding)
Diet: Poor eating habits
Exercise: Sedentary lifestyle
Alcohol: Moderate use

Step 5: Physical Examination Strategy

Perform rapid but focused assessment for acute MI:

Vital Signs:

Expected findings: Tachycardia (102), hypertension (158/94) due to pain and sympathetic response
Monitor for hypotension (cardiogenic shock risk)

Cardiovascular Examination:

General appearance: Pale, diaphoretic, distressed
Heart sounds: May be normal initially or show signs of heart failure
Look for complications: JVD, S3 gallop, new murmurs

Additional Key Exams:

Lung examination: Assess for pulmonary edema (crackles)
Peripheral circulation: Check for adequate perfusion
Neurologic: Assess for signs of hypoperfusion

Step 6: Developing Differential Diagnoses

Primary Consideration: Acute STEMI

Supporting evidence: Classic presentation, risk factors, acute onset with exertion
ECG: ST elevation in inferior leads (II, III, aVF)
Biomarkers: Elevated troponin I and CK-MB

Secondary Considerations:

Unstable Angina/NSTEMI
- Less likely: Severity and duration favor STEMI
Aortic Dissection
- Consider: Acute severe pain
- Less likely: Pain character and location not typical
Pulmonary Embolism
- Consider: Acute dyspnea
- Less likely: Pain character and risk factors favor MI

Step 7: Diagnostic Test Interpretation

Critical Findings:

ECG: ST elevation in leads II, III, aVF (inferior STEMI)
Troponin I: Markedly elevated (15.2 ng/mL, normal <0.04)
CK-MB: Elevated (45 ng/mL)
Complete metabolic panel: May show hyperglycemia due to stress response

Clinical Correlation: Test results confirm acute STEMI requiring emergency intervention.

Step 8: Final Diagnosis and Most Significant Active Problem (MSAP)

Primary Diagnosis: Acute ST-elevation myocardial infarction (STEMI) – inferior wall

Justification:

Classic acute onset chest pain with exertion
Typical radiation pattern to jaw and left arm
Associated autonomic symptoms (diaphoresis, nausea)
Multiple cardiac risk factors (smoking, diabetes, family history)
ECG evidence of ST elevation
Elevated cardiac biomarkers

MSAP Selection: Choose “Acute STEMI” as this represents a life-threatening emergency requiring immediate intervention.

Step 9: Comprehensive Management Plan

Immediate Emergency Management:

STEMI Protocol Activation: Door-to-balloon time <90 minutes
Dual Antiplatelet Therapy: ASA 325mg chewed + clopidogrel 600mg loading dose
Anticoagulation: Heparin per protocol
Emergency PCI: Primary percutaneous coronary intervention

Acute Pharmacological Interventions:

Beta-blocker: Metoprolol 25mg BID (once hemodynamically stable)
Statin: Atorvastatin 80mg daily (high-intensity statin)
ACE inhibitor: Lisinopril 5mg daily (start 24-48 hours post-MI if stable)
Continue metformin for diabetes management

Monitoring and Complications:

Continuous cardiac monitoring for arrhythmias
Monitor for mechanical complications (papillary muscle rupture, VSD)
Assess for signs of heart failure or cardiogenic shock

Step 10: Documentation and Submission Tips

Key Documentation Elements:

Emergency presentation: Emphasize acute nature and need for immediate intervention
Risk stratification: Document high-risk features requiring aggressive management
Time-sensitive management: Highlight door-to-balloon time importance

John Quimby iHuman Case Summary

Grading Criteria:

(1) History Taking (Major Points): You must rapidly assess chest pain characteristics while recognizing the emergency nature. Essential questions include: onset timing and triggers, pain quality and radiation, associated symptoms (diaphoresis, nausea, dyspnea), and cardiac risk factors. The rubric specifically rewards students who quickly identify high-risk features and ask about smoking history, diabetes management, and family history of early CAD.

(2) Physical Examination (High Weight): Focus on rapid cardiovascular assessment. Must-do components: vital signs noting tachycardia and hypertension, general appearance (pallor, diaphoresis), cardiac auscultation, lung examination for pulmonary edema, and peripheral circulation assessment. Pro tip: The rubric awards points for recognizing signs of acute distress and complications of MI.

(3) Differential Diagnosis (Critical for Scoring): You need to propose appropriate differentials for acute chest pain. Expected differentials include: acute STEMI, NSTEMI/unstable angina, aortic dissection, and pulmonary embolism. Scoring secret: The rubric rewards students who can distinguish between STEMI and other acute coronary syndromes based on presentation and ECG findings.

(4) Final Diagnosis & MSAP: You must correctly identify acute STEMI as your Most Significant Active Problem. Justification is key – cite the acute presentation, classic symptoms, risk factors, and diagnostic findings.

(5) Management Plan (Heavily Weighted): The rubric expects emergency management including: immediate STEMI protocol activation, dual antiplatelet therapy, emergency PCI, and appropriate monitoring. High-scoring responses mention: door-to-balloon time goals and post-MI secondary prevention strategies.

(6) Patient Communication: Demonstrate urgency while providing reassurance. Bonus points for: explaining the seriousness of the condition, importance of immediate treatment, and post-MI lifestyle modifications including mandatory smoking cessation.

Example of a High-Scoring Clinical Summary

Patient Summary – John Quimby

Situation: 45-year-old male presenting with acute onset severe substernal chest pain with classic STEMI presentation requiring emergency intervention.

Background: Significant cardiac risk factors including active smoking (25 pack-years), type 2 diabetes mellitus, and strong family history of early coronary disease. Pain began suddenly during heavy lifting with classic radiation to jaw and left arm.

Assessment: Physical examination notable for acute distress with diaphoresis, tachycardia, and hypertension. ECG demonstrates ST elevation in inferior leads consistent with acute STEMI. Markedly elevated cardiac biomarkers confirm acute myocardial infarction.

Recommendation:

Immediate STEMI protocol activation with emergency cardiac catheterization
Dual antiplatelet therapy (ASA + clopidogrel) and anticoagulation
Primary PCI within 90 minutes of presentation
Intensive post-MI management with beta-blocker, high-intensity statin, and ACE inhibitor
Mandatory smoking cessation and cardiac rehabilitation enrollment
Close follow-up for secondary prevention and complication monitoring

Patient Education Provided: Explained acute heart attack diagnosis, critical importance of immediate treatment, and comprehensive secondary prevention strategies including smoking cessation, medication adherence, and lifestyle modifications.

Conclusion

By following this comprehensive approach to the John Quimby case, you’ll demonstrate the emergency management skills that iHuman evaluates for acute cardiovascular presentations. Remember, success in acute MI cases requires rapid recognition, systematic assessment, and immediate appropriate intervention. The key is treating this as a true medical emergency while maintaining thorough clinical reasoning. Time-sensitive decision-making and evidence-based acute management are essential for optimal patient outcomes. With this guide, you’re well-prepared to excel in this challenging but critical case simulation.

Frequently Asked Questions

Q1: What is the correct diagnosis for John Quimby’s chest pain?

John Quimby’s primary diagnosis is acute ST-elevation myocardial infarction (STEMI) affecting the inferior wall. The key distinguishing features include acute onset severe substernal chest pain during exertion, classic radiation to jaw and left arm, associated diaphoresis and nausea, multiple cardiac risk factors, and ECG showing ST elevation in leads II, III, and aVF. Students often struggle between STEMI and NSTEMI, but remember that STEMI shows ST elevation on ECG and requires emergency PCI, whereas NSTEMI may not show ST elevation and can be managed with a more conservative approach initially.

Q2: What are the critical physical exam components I need to perform to score well?

Essential physical exam elements include rapid vital sign assessment (noting tachycardia and hypertension), evaluating general appearance for distress and diaphoresis, comprehensive cardiovascular examination including heart sounds and signs of heart failure, lung examination to assess for pulmonary edema, and peripheral circulation assessment. Many students miss points by not recognizing the signs of acute distress or failing to assess for MI complications such as new murmurs or signs of cardiogenic shock.

Q3: How do I pass the John Quimby case and meet the 70% requirement?

Success requires recognizing this as an acute cardiovascular emergency and responding appropriately. Focus on rapid but thorough history-taking emphasizing timing and triggers, comprehensive assessment for high-risk features, appropriate differential diagnosis including acute coronary syndromes, and immediate emergency management including STEMI protocol activation. The key is demonstrating urgency while maintaining systematic clinical reasoning and evidence-based intervention.

Q4: What management interventions should I include in my treatment plan?

The comprehensive management plan must address both immediate emergency care and long-term secondary prevention. Include emergency STEMI protocol activation with goal door-to-balloon time <90 minutes, dual antiplatelet therapy (aspirin plus clopidogrel), anticoagulation, emergency cardiac catheterization with primary PCI, and continuous monitoring for complications. Post-MI management should include high-intensity statin therapy, beta-blocker, ACE inhibitor when stable, mandatory smoking cessation program, cardiac rehabilitation enrollment, and intensive risk factor modification. Students often forget to address the psychosocial aspects including anxiety management and return-to-work counseling, which are important components for comprehensive post-MI care.