Advanced DDx Respiratory Case: 60-Year-Old Female
Presenting with Shortness of Breath | SOAP Note and
Differential Diagnosis
Comprehensive Clinical Case Study
1. Patient Demographics & Identifying Data
Patient Initials: M.W.
Patient Name: Margaret Wilson
Age: 60 years
Gender: Female
Ethnicity: African American
Height: 5'4" (163 cm)
,Weight: 183 lb (83 kg)
BMI: 31.4 kg/m² (Obesity Class I)
Occupation: Retired postal worker
Living Situation: Lives with her husband in a two-story home.
Independent with activities of daily living.
Source of Information: Patient; reliable historian.
2. Chief Complaint (CC)
"I've been short of breath and my heart has been racing for the
last two days."
3. History of Present Illness (HPI) – OLD CARTS
Onset
Symptoms began suddenly two days ago while walking from the
parking lot to work.
Location
No localized pain. Patient reports chest discomfort associated
with rapid heartbeat.
Duration
, Episodes occur several times daily and last between 20 and 45
minutes.
Characteristics
Patient describes a racing heartbeat accompanied by shortness
of breath, mild chest pressure, lightheadedness, and fatigue.
Aggravating Factors
• Walking
• Climbing stairs
• Emotional stress
• Physical activity
Relieving Factors
• Sitting quietly
• Deep breathing
• Rest
Treatment
Patient has not taken any medication for the episodes other
than her prescribed blood pressure medication.
Severity
Shortness of breath: 8/10
Chest discomfort: 4/10
Presenting with Shortness of Breath | SOAP Note and
Differential Diagnosis
Comprehensive Clinical Case Study
1. Patient Demographics & Identifying Data
Patient Initials: M.W.
Patient Name: Margaret Wilson
Age: 60 years
Gender: Female
Ethnicity: African American
Height: 5'4" (163 cm)
,Weight: 183 lb (83 kg)
BMI: 31.4 kg/m² (Obesity Class I)
Occupation: Retired postal worker
Living Situation: Lives with her husband in a two-story home.
Independent with activities of daily living.
Source of Information: Patient; reliable historian.
2. Chief Complaint (CC)
"I've been short of breath and my heart has been racing for the
last two days."
3. History of Present Illness (HPI) – OLD CARTS
Onset
Symptoms began suddenly two days ago while walking from the
parking lot to work.
Location
No localized pain. Patient reports chest discomfort associated
with rapid heartbeat.
Duration
, Episodes occur several times daily and last between 20 and 45
minutes.
Characteristics
Patient describes a racing heartbeat accompanied by shortness
of breath, mild chest pressure, lightheadedness, and fatigue.
Aggravating Factors
• Walking
• Climbing stairs
• Emotional stress
• Physical activity
Relieving Factors
• Sitting quietly
• Deep breathing
• Rest
Treatment
Patient has not taken any medication for the episodes other
than her prescribed blood pressure medication.
Severity
Shortness of breath: 8/10
Chest discomfort: 4/10
