COMPLETE AND Actual i-Human Advanced DDx Case
Study: Margaret Wilson (60-Year-Old Female With
Shortness Of Breath) | Complete Clinical Case Solution
Featuring Full Patient Interview, Comprehensive HPI,
PMH, ROS, Physical Examination Findings, Diagnostic
Testing
,I. PATIENT IDENTIFICATION
Field Information
Name Margaret Wilson
Age 60 years
Sex Female
Height 5'4" (163 cm)
Weight 183.0 lb (83.2 kg)
BMI 31.3 (Obese Class I)
Race/Ethnicity African American
Reason for Encounter Shortness of breath
Location Outpatient clinic with x-ray, ECG, and laboratory capabilities
II. CHIEF COMPLAINT (CC)
"Shortness of breath that has been getting worse over the last week."
, III. HISTORY OF PRESENTING ILLNESS (HPI)
Onset and Duration
• Gradual onset of dyspnea over the past 2–3 months
• Significant worsening over the last week
• Symptoms have progressed to the point where she experiences dyspnea with minimal
exertion
Character and Quality
• Describes the sensation as "air hunger"
• Reports associated chest "tightness" (not sharp pain)
• Sensation is suffocating and distressing
• Dry cough when lying down in bed
Location
• Dyspnea is central to the presentation
• No radiation of symptoms
Severity
• 7/10 on a symptom severity scale
• Significantly limits her daily activities
• Becomes breathless with minimal exertion
Timing and Pattern
• Progressive worsening over 2–3 months
• Acute exacerbation over the past week
• Symptoms occur with decreasing levels of exertion
• Now experiences dyspnea with activities of daily living (walking short distances, getting
dressed, climbing as few as 10 stairs)
• Takes 10–15 minutes of rest to fully recover
Aggravating Factors
, • Exertion/physical activity
• Lying flat (orthopnea)
• Walking short distances
• Climbing stairs
• Getting dressed
Relieving Factors
• Rest
• Sitting upright
• Sleeping with multiple pillows
Associated Symptoms
Symptom Details
Orthopnea Now requires two pillows to sleep; new change
Paroxysmal Nocturnal Dyspnea (PND) Awakens gasping for air approximately 2–3 times per week
Bilateral Lower Extremity Edema New onset; worsening in the evenings
Fatigue Generalized weakness; difficulty completing daily activities
Weight Gain 8 lbs over the past 3 months
Dizziness Mild, sometimes when standing up
Pertinent Negatives (Denies)
• Fever or chills
• Productive cough
• Wheezing
• Hemoptysis
• Palpitations
• Syncope
• Pleuritic chest pain
• Nausea or vomiting
• Diaphoresis
Study: Margaret Wilson (60-Year-Old Female With
Shortness Of Breath) | Complete Clinical Case Solution
Featuring Full Patient Interview, Comprehensive HPI,
PMH, ROS, Physical Examination Findings, Diagnostic
Testing
,I. PATIENT IDENTIFICATION
Field Information
Name Margaret Wilson
Age 60 years
Sex Female
Height 5'4" (163 cm)
Weight 183.0 lb (83.2 kg)
BMI 31.3 (Obese Class I)
Race/Ethnicity African American
Reason for Encounter Shortness of breath
Location Outpatient clinic with x-ray, ECG, and laboratory capabilities
II. CHIEF COMPLAINT (CC)
"Shortness of breath that has been getting worse over the last week."
, III. HISTORY OF PRESENTING ILLNESS (HPI)
Onset and Duration
• Gradual onset of dyspnea over the past 2–3 months
• Significant worsening over the last week
• Symptoms have progressed to the point where she experiences dyspnea with minimal
exertion
Character and Quality
• Describes the sensation as "air hunger"
• Reports associated chest "tightness" (not sharp pain)
• Sensation is suffocating and distressing
• Dry cough when lying down in bed
Location
• Dyspnea is central to the presentation
• No radiation of symptoms
Severity
• 7/10 on a symptom severity scale
• Significantly limits her daily activities
• Becomes breathless with minimal exertion
Timing and Pattern
• Progressive worsening over 2–3 months
• Acute exacerbation over the past week
• Symptoms occur with decreasing levels of exertion
• Now experiences dyspnea with activities of daily living (walking short distances, getting
dressed, climbing as few as 10 stairs)
• Takes 10–15 minutes of rest to fully recover
Aggravating Factors
, • Exertion/physical activity
• Lying flat (orthopnea)
• Walking short distances
• Climbing stairs
• Getting dressed
Relieving Factors
• Rest
• Sitting upright
• Sleeping with multiple pillows
Associated Symptoms
Symptom Details
Orthopnea Now requires two pillows to sleep; new change
Paroxysmal Nocturnal Dyspnea (PND) Awakens gasping for air approximately 2–3 times per week
Bilateral Lower Extremity Edema New onset; worsening in the evenings
Fatigue Generalized weakness; difficulty completing daily activities
Weight Gain 8 lbs over the past 3 months
Dizziness Mild, sometimes when standing up
Pertinent Negatives (Denies)
• Fever or chills
• Productive cough
• Wheezing
• Hemoptysis
• Palpitations
• Syncope
• Pleuritic chest pain
• Nausea or vomiting
• Diaphoresis
