Comprehensive I-HUMAN ADVANCED DDX CASE STUDY:
MARGARET WILSON (60-YEAR OLD FEMALE WITH SHORTNESS OF
BREATH) | COMPLETE VIRTUAL PATIENT ASSESSMENT, FULL HPI,
PAST MEDICAL HISTORY (PMH), FAMILY & SOCIAL HISTORY,
REVIEW OF SYSTEMS (ROS),WITH COMPLETE SOLUTIONS.
,I. PATIENT IDENTIFICATION & DEMOGRAPHIC DATA
Field Information
Name Margaret Wilson
Age 60 years
Sex Female
Height 5'4" (163 cm)
Weight 180.0 lb (83.2 kg)
BMI 31.3 (Obese Class I)
Race/Ethnicity African American
Occupation Retired schoolteacher
Living Situation Lives alone in an apartment; daughter visits twice weekly
Setting Outpatient clinic (with X-ray, ECG, and laboratory capabilities on-site)
II. CHIEF COMPLAINT (CC)
"Shortness of breath that has been getting worse over the last week."
III. HISTORY OF PRESENTING ILLNESS (HPI) — OLD CARTS
Format
Onset: Gradual onset over the past 2–3 months, with significant worsening over the last
week.
, Location: Sensation of "air hunger" and chest "tightness" (not sharp pain). Dyspnea is
central to the presentation.
Duration: Progressive exertional dyspnea for 2–3 months. The patient notes she
becomes short of breath every time she walks even a short distance or climbs as few as
10 stairs. She must stop and rest to catch her breath. Over the past week, symptoms have
worsened to the point where she experiences dyspnea with activities of daily living, such
as walking short distances or getting dressed.
Characteristics: The patient describes the sensation as "air hunger" and chest
"tightness." She reports a dry cough when lying down in bed. She also reports orthopnea,
now requiring two pillows to sleep (new change), and paroxysmal nocturnal dyspnea
(PND), waking up gasping for air approximately 2–3 times per week.
Aggravating Factors: Exertion, lying flat (orthopnea), physical activity such as walking or
climbing stairs.
Relieving Factors: Rest (takes 10–15 minutes to fully resolve), sitting upright.
Timing: Symptoms have been progressive over 2–3 months, with acute exacerbation
over the past week. PND occurs approximately 2–3 times per week.
Severity: 7/10 on a symptom severity scale. The dyspnea significantly limits her daily
activities. She reports increased fatigue and generalized weakness, making it difficult to
complete her daily activities.
Associated Symptoms:
• New-onset bilateral lower extremity edema, worsening in the evenings
• Fatigue and generalized weakness
• Dry cough when lying down
• Recent weight gain (8 lbs over the past 3 months)
• Mild dizziness sometimes when standing up
Denies:
• Fever or chills
• Productive cough, wheezing, or hemoptysis
• Palpitations, syncope, or pleuritic chest pain
• Nausea, vomiting, or diaphoresis
IV. PAST MEDICAL HISTORY (PMH)
MARGARET WILSON (60-YEAR OLD FEMALE WITH SHORTNESS OF
BREATH) | COMPLETE VIRTUAL PATIENT ASSESSMENT, FULL HPI,
PAST MEDICAL HISTORY (PMH), FAMILY & SOCIAL HISTORY,
REVIEW OF SYSTEMS (ROS),WITH COMPLETE SOLUTIONS.
,I. PATIENT IDENTIFICATION & DEMOGRAPHIC DATA
Field Information
Name Margaret Wilson
Age 60 years
Sex Female
Height 5'4" (163 cm)
Weight 180.0 lb (83.2 kg)
BMI 31.3 (Obese Class I)
Race/Ethnicity African American
Occupation Retired schoolteacher
Living Situation Lives alone in an apartment; daughter visits twice weekly
Setting Outpatient clinic (with X-ray, ECG, and laboratory capabilities on-site)
II. CHIEF COMPLAINT (CC)
"Shortness of breath that has been getting worse over the last week."
III. HISTORY OF PRESENTING ILLNESS (HPI) — OLD CARTS
Format
Onset: Gradual onset over the past 2–3 months, with significant worsening over the last
week.
, Location: Sensation of "air hunger" and chest "tightness" (not sharp pain). Dyspnea is
central to the presentation.
Duration: Progressive exertional dyspnea for 2–3 months. The patient notes she
becomes short of breath every time she walks even a short distance or climbs as few as
10 stairs. She must stop and rest to catch her breath. Over the past week, symptoms have
worsened to the point where she experiences dyspnea with activities of daily living, such
as walking short distances or getting dressed.
Characteristics: The patient describes the sensation as "air hunger" and chest
"tightness." She reports a dry cough when lying down in bed. She also reports orthopnea,
now requiring two pillows to sleep (new change), and paroxysmal nocturnal dyspnea
(PND), waking up gasping for air approximately 2–3 times per week.
Aggravating Factors: Exertion, lying flat (orthopnea), physical activity such as walking or
climbing stairs.
Relieving Factors: Rest (takes 10–15 minutes to fully resolve), sitting upright.
Timing: Symptoms have been progressive over 2–3 months, with acute exacerbation
over the past week. PND occurs approximately 2–3 times per week.
Severity: 7/10 on a symptom severity scale. The dyspnea significantly limits her daily
activities. She reports increased fatigue and generalized weakness, making it difficult to
complete her daily activities.
Associated Symptoms:
• New-onset bilateral lower extremity edema, worsening in the evenings
• Fatigue and generalized weakness
• Dry cough when lying down
• Recent weight gain (8 lbs over the past 3 months)
• Mild dizziness sometimes when standing up
Denies:
• Fever or chills
• Productive cough, wheezing, or hemoptysis
• Palpitations, syncope, or pleuritic chest pain
• Nausea, vomiting, or diaphoresis
IV. PAST MEDICAL HISTORY (PMH)
