Advanced Clinical Case Study: Evaluation of Dyspnea in a 60-
Year-Old Female | Margaret Wilson Case Analysis
Comprehensive Clinical Case Study
1. Patient Demographics & Identifying Data
Patient Initials: M.W.
Patient Name: Margaret Wilson
Age: 60 years
Gender: Female
Ethnicity: White
Height: 5'4" (163 cm)
,Weight: 183 lb (83 kg)
BMI: 31.4 kg/m² (Obesity Class I)
Occupation: Retired Bank Teller
Living Situation: Lives independently with her husband in a
suburban home.
Source of Information: Patient; reliable historian.
2. Chief Complaint (CC)
"I've had increasing shortness of breath and pain when I take a
deep breath."
3. History of Present Illness (HPI) – OLD CARTS
Onset
The patient reports sudden onset of shortness of breath
approximately 24 hours ago while watching television.
Symptoms worsened after walking to the mailbox.
Location
Sharp pain localized to the right lower chest that worsens with
deep inspiration.
Duration
, Symptoms have been continuous for the past 24 hours.
Characteristics
Describes the pain as sharp and stabbing with associated
shortness of breath. She also reports mild dry cough and
anxiety because of difficulty breathing.
Aggravating Factors
• Deep breathing
• Walking
• Climbing stairs
• Coughing
Relieving Factors
• Sitting still
• Shallow breathing
Treatment
Patient took acetaminophen without relief and attempted to
rest at home.
Severity
Shortness of breath: 8/10
Chest pain: 7/10
Associated symptoms include:
Year-Old Female | Margaret Wilson Case Analysis
Comprehensive Clinical Case Study
1. Patient Demographics & Identifying Data
Patient Initials: M.W.
Patient Name: Margaret Wilson
Age: 60 years
Gender: Female
Ethnicity: White
Height: 5'4" (163 cm)
,Weight: 183 lb (83 kg)
BMI: 31.4 kg/m² (Obesity Class I)
Occupation: Retired Bank Teller
Living Situation: Lives independently with her husband in a
suburban home.
Source of Information: Patient; reliable historian.
2. Chief Complaint (CC)
"I've had increasing shortness of breath and pain when I take a
deep breath."
3. History of Present Illness (HPI) – OLD CARTS
Onset
The patient reports sudden onset of shortness of breath
approximately 24 hours ago while watching television.
Symptoms worsened after walking to the mailbox.
Location
Sharp pain localized to the right lower chest that worsens with
deep inspiration.
Duration
, Symptoms have been continuous for the past 24 hours.
Characteristics
Describes the pain as sharp and stabbing with associated
shortness of breath. She also reports mild dry cough and
anxiety because of difficulty breathing.
Aggravating Factors
• Deep breathing
• Walking
• Climbing stairs
• Coughing
Relieving Factors
• Sitting still
• Shallow breathing
Treatment
Patient took acetaminophen without relief and attempted to
rest at home.
Severity
Shortness of breath: 8/10
Chest pain: 7/10
Associated symptoms include:
