Advanced DDx Case Study: Margaret Wilson – 60-Year-Old
Female with Shortness of Breath | Comprehensive Clinical
Reasoning Guide
Comprehensive Clinical Case Study
1. Patient Demographics & Identifying Data
Patient Initials: M.W. (Margaret Wilson)
Age: 60 years
Gender: Female
Ethnicity: African American (fictional for educational purposes)
Height: 5'4" (163 cm)
Weight: 183 lb (83.2 kg)
,BMI: 31.4 kg/m² (Obese Class I)
Occupation: Retired elementary school teacher
Living Situation: Lives with her husband in a single-family
home. Independent with activities of daily living.
Source of Information: Patient; considered reliable and able to
provide a complete history.
2. Chief Complaint (CC)
"I've been feeling short of breath for the past several days."
3. History of Present Illness (HPI) – OLD CARTS
Onset
Shortness of breath began approximately five days ago and has
progressively worsened.
Location
No localized pain. Sensation of chest tightness with difficulty
catching her breath.
Duration
Symptoms occur throughout the day and worsen with physical
activity.
, Characteristics
Describes breathing as "hard work." Associated with mild
wheezing, dry cough, and fatigue.
Aggravating Factors
• Walking upstairs
• Carrying groceries
• Lying flat at night
• Cold weather
Relieving Factors
• Sitting upright
• Rest
• Using husband's rescue inhaler once (minimal
improvement)
Treatment Attempted
• OTC cough suppressant
• Increased fluid intake
• One puff of albuterol borrowed from spouse
Minimal symptom relief.
Severity
Shortness of breath rated 7/10.
Female with Shortness of Breath | Comprehensive Clinical
Reasoning Guide
Comprehensive Clinical Case Study
1. Patient Demographics & Identifying Data
Patient Initials: M.W. (Margaret Wilson)
Age: 60 years
Gender: Female
Ethnicity: African American (fictional for educational purposes)
Height: 5'4" (163 cm)
Weight: 183 lb (83.2 kg)
,BMI: 31.4 kg/m² (Obese Class I)
Occupation: Retired elementary school teacher
Living Situation: Lives with her husband in a single-family
home. Independent with activities of daily living.
Source of Information: Patient; considered reliable and able to
provide a complete history.
2. Chief Complaint (CC)
"I've been feeling short of breath for the past several days."
3. History of Present Illness (HPI) – OLD CARTS
Onset
Shortness of breath began approximately five days ago and has
progressively worsened.
Location
No localized pain. Sensation of chest tightness with difficulty
catching her breath.
Duration
Symptoms occur throughout the day and worsen with physical
activity.
, Characteristics
Describes breathing as "hard work." Associated with mild
wheezing, dry cough, and fatigue.
Aggravating Factors
• Walking upstairs
• Carrying groceries
• Lying flat at night
• Cold weather
Relieving Factors
• Sitting upright
• Rest
• Using husband's rescue inhaler once (minimal
improvement)
Treatment Attempted
• OTC cough suppressant
• Increased fluid intake
• One puff of albuterol borrowed from spouse
Minimal symptom relief.
Severity
Shortness of breath rated 7/10.
