i-Human Case Study: Paisley Ward – Cough & Shortness of
Breath Clinical Evaluation of Acute Asthma Exacerbation
|Real Exam 2025 nov
Patient Information
Name: Paisley Ward
Age: 16 years old
Sex: Female
Height: 5'5" (165 cm)
Weight: 150 lbs (68.2 kg)
Ethnicity: Not specified
Accompanied by: Mother
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
, Chief Complaint
“I’ve been coughing a lot and it’s hard to catch my breath sometimes.”
History of Present Illness (HPI)
Paisley Ward is a 16-year-old adolescent female who presents to the outpatient
clinic with a two-week history of persistent cough and shortness of breath. She
reports that her symptoms began gradually after what she described as a “bad
cold.” Initially, the cough was dry and intermittent, but it has become more
frequent and occasionally produces small amounts of clear sputum.
Paisley notes that her shortness of breath worsens with physical activity,
particularly when climbing stairs or playing soccer. She denies chest pain,
palpitations, wheezing at rest, or orthopnea. She has not experienced fevers, chills,
or night sweats.
Her symptoms have been affecting her sleep due to nighttime coughing, which
occasionally wakes her up. She denies exposure to new pets, molds, or
environmental irritants. No recent travel or contact with individuals known to be
sick.
Paisley has a history of childhood asthma, which was considered mild and well
controlled; however, she admits that she has not used her inhaler for over a year.
She takes no regular medications.
Past Medical History
Mild intermittent asthma diagnosed at age 8
Seasonal allergies
No prior hospitalizations or emergency visits for asthma in the past
three years
No history of pneumonia, bronchitis, or tuberculosis
No chronic conditions such as diabetes or hypertension
Breath Clinical Evaluation of Acute Asthma Exacerbation
|Real Exam 2025 nov
Patient Information
Name: Paisley Ward
Age: 16 years old
Sex: Female
Height: 5'5" (165 cm)
Weight: 150 lbs (68.2 kg)
Ethnicity: Not specified
Accompanied by: Mother
Setting: Outpatient clinic with X-ray, ECG, and laboratory capabilities
, Chief Complaint
“I’ve been coughing a lot and it’s hard to catch my breath sometimes.”
History of Present Illness (HPI)
Paisley Ward is a 16-year-old adolescent female who presents to the outpatient
clinic with a two-week history of persistent cough and shortness of breath. She
reports that her symptoms began gradually after what she described as a “bad
cold.” Initially, the cough was dry and intermittent, but it has become more
frequent and occasionally produces small amounts of clear sputum.
Paisley notes that her shortness of breath worsens with physical activity,
particularly when climbing stairs or playing soccer. She denies chest pain,
palpitations, wheezing at rest, or orthopnea. She has not experienced fevers, chills,
or night sweats.
Her symptoms have been affecting her sleep due to nighttime coughing, which
occasionally wakes her up. She denies exposure to new pets, molds, or
environmental irritants. No recent travel or contact with individuals known to be
sick.
Paisley has a history of childhood asthma, which was considered mild and well
controlled; however, she admits that she has not used her inhaler for over a year.
She takes no regular medications.
Past Medical History
Mild intermittent asthma diagnosed at age 8
Seasonal allergies
No prior hospitalizations or emergency visits for asthma in the past
three years
No history of pneumonia, bronchitis, or tuberculosis
No chronic conditions such as diabetes or hypertension
