Advanced DDx Outpatient Simulation: Margaret Wilson
Shortness of Breath Case | History, Physical Exam, Diagnostics,
and Final Diagnosis
Comprehensive Clinical Case Study (Case 6)
1. Patient Demographics & Identifying Data
Patient Initials: M.W.
Patient Name: Margaret Wilson
Age: 60 years
Gender: Female
Ethnicity: Native American
Height: 5'4" (163 cm)
,Weight: 183 lb (83 kg)
BMI: 31.4 kg/m² (Obesity Class I)
Occupation: Retired Librarian
Living Situation: Lives with her spouse in a rural community and
performs all activities of daily living independently.
Source of Information: Patient; reliable historian.
2. Chief Complaint (CC)
"I've been getting more short of breath, especially when I lie
down at night."
3. History of Present Illness (HPI) – OLD CARTS
Onset
The patient reports gradually worsening shortness of breath
over the past two weeks.
Location
No localized pain. Reports chest heaviness without radiation.
Duration
Shortness of breath is present daily and has progressively
worsened.
, Characteristics
Describes difficulty breathing with activity and while lying flat.
Reports waking up at night gasping for air and needing multiple
pillows to sleep comfortably.
Aggravating Factors
• Walking more than one block
• Climbing stairs
• Lying flat
• Physical exertion
Relieving Factors
• Sitting upright
• Rest
• Sleeping in a recliner
Treatment
Patient increased use of an over-the-counter herbal diuretic
without improvement and has been limiting fluid intake.
Severity
• Shortness of breath: 8/10
• Chest heaviness: 3/10
Associated symptoms include:
Shortness of Breath Case | History, Physical Exam, Diagnostics,
and Final Diagnosis
Comprehensive Clinical Case Study (Case 6)
1. Patient Demographics & Identifying Data
Patient Initials: M.W.
Patient Name: Margaret Wilson
Age: 60 years
Gender: Female
Ethnicity: Native American
Height: 5'4" (163 cm)
,Weight: 183 lb (83 kg)
BMI: 31.4 kg/m² (Obesity Class I)
Occupation: Retired Librarian
Living Situation: Lives with her spouse in a rural community and
performs all activities of daily living independently.
Source of Information: Patient; reliable historian.
2. Chief Complaint (CC)
"I've been getting more short of breath, especially when I lie
down at night."
3. History of Present Illness (HPI) – OLD CARTS
Onset
The patient reports gradually worsening shortness of breath
over the past two weeks.
Location
No localized pain. Reports chest heaviness without radiation.
Duration
Shortness of breath is present daily and has progressively
worsened.
, Characteristics
Describes difficulty breathing with activity and while lying flat.
Reports waking up at night gasping for air and needing multiple
pillows to sleep comfortably.
Aggravating Factors
• Walking more than one block
• Climbing stairs
• Lying flat
• Physical exertion
Relieving Factors
• Sitting upright
• Rest
• Sleeping in a recliner
Treatment
Patient increased use of an over-the-counter herbal diuretic
without improvement and has been limiting fluid intake.
Severity
• Shortness of breath: 8/10
• Chest heaviness: 3/10
Associated symptoms include:
