Advanced Differential Diagnosis Case Play: Margaret Wilson
with Dyspnea | Complete Patient Assessment and
Management
Comprehensive Clinical Case Study
1. Patient Demographics & Identifying Data
Patient Initials: M.W.
Name: Margaret Wilson
Age: 60 years
Gender: Female
Ethnicity: Caucasian
Height: 5'4" (163 cm)
,Weight: 183 lb (83.2 kg)
BMI: 31.4 kg/m² (Obesity Class I)
Occupation: Administrative Assistant at a local insurance
company
Living Situation: Lives alone in a one-story apartment.
Independent in activities of daily living.
Source of Information: Patient; reliable historian.
2. Chief Complaint (CC)
"I've been getting more short of breath over the past week,
especially when I walk."
3. History of Present Illness (HPI) – OLD CARTS
Onset
Symptoms began approximately one week ago after recovering
from what she describes as a "bad cold."
Location
Generalized chest tightness without localized pain.
Duration
, Shortness of breath occurs with exertion and lasts several
minutes after stopping activity.
Characteristics
Describes the sensation as "not getting enough air." Reports
occasional wheezing and productive cough with yellow sputum.
Aggravating Factors
• Walking uphill
• Climbing stairs
• Cold air exposure
• Household chores
Relieving Factors
• Sitting upright
• Rest
• Rescue inhaler provides temporary improvement
Treatment
Patient has been using her albuterol inhaler every 4 hours over
the last three days with only partial relief.
Severity
Rates shortness of breath 8/10 during activity and 3/10 while
resting.
with Dyspnea | Complete Patient Assessment and
Management
Comprehensive Clinical Case Study
1. Patient Demographics & Identifying Data
Patient Initials: M.W.
Name: Margaret Wilson
Age: 60 years
Gender: Female
Ethnicity: Caucasian
Height: 5'4" (163 cm)
,Weight: 183 lb (83.2 kg)
BMI: 31.4 kg/m² (Obesity Class I)
Occupation: Administrative Assistant at a local insurance
company
Living Situation: Lives alone in a one-story apartment.
Independent in activities of daily living.
Source of Information: Patient; reliable historian.
2. Chief Complaint (CC)
"I've been getting more short of breath over the past week,
especially when I walk."
3. History of Present Illness (HPI) – OLD CARTS
Onset
Symptoms began approximately one week ago after recovering
from what she describes as a "bad cold."
Location
Generalized chest tightness without localized pain.
Duration
, Shortness of breath occurs with exertion and lasts several
minutes after stopping activity.
Characteristics
Describes the sensation as "not getting enough air." Reports
occasional wheezing and productive cough with yellow sputum.
Aggravating Factors
• Walking uphill
• Climbing stairs
• Cold air exposure
• Household chores
Relieving Factors
• Sitting upright
• Rest
• Rescue inhaler provides temporary improvement
Treatment
Patient has been using her albuterol inhaler every 4 hours over
the last three days with only partial relief.
Severity
Rates shortness of breath 8/10 during activity and 3/10 while
resting.
