2
1
,2
1.2 Reason for Encounter
Margaret Wilson, a 60-year-old female, presents to the outpatient clinic with
a chief complaint of shortness of breath. The symptom has been
progressively worsening over the past several weeks, significantly impacting
her activities of daily living. The patient reports that she initially attributed
her breathlessness to deconditioning and age-related changes, but the
severity has escalated to the point where she now experiences dyspnea with
minimal exertion, including walking short distances and performing routine
household tasks.
1.3 Case Significance and Learning Objectives
This case presents a classic yet complex clinical scenario involving a middle-
aged female with dyspnea—a symptom that ranks among the most common
presenting complaints in both outpatient and emergency settings. Dyspnea
affects millions worldwide and may serve as the primary manifestation of
respiratory, cardiac, neuromuscular, systemic, or psychogenic disorders . For
a 60-year-old female with obesity, the differential diagnosis is particularly
broad, encompassing both pulmonary and cardiac etiologies, as well as the
possibility of multifactorial causes.
Key Learning Objectives:
1. Develop a systematic approach to evaluating dyspnea in an older adult
2. Recognize the importance of a comprehensive history and physical
examination
3. Formulate an evidence-based differential diagnosis
4. Select appropriate diagnostic tests based on clinical suspicion
5. Develop a management plan addressing both acute symptoms and
underlying etiology
SECTION 2: COMPREHENSIVE HISTORY OF
PRESENT ILLNESS
2
,2
2.1 Symptom Characterization
The history of present illness is the cornerstone of evaluating dyspnea. For
Ms. Wilson, a detailed symptom characterization using the OLDCARTS
(Onset, Location, Duration, Characteristics, Aggravating factors, Relieving
factors, Timing, Severity) mnemonic is essential .
Onset
The patient reports that her shortness of breath began approximately 3-4
weeks ago. She describes the onset as "gradual" rather than sudden, which
is an important distinguishing feature. Acute onset dyspnea suggests
conditions such as pulmonary embolism, pneumothorax, or acute myocardial
ischemia, whereas chronic or progressive dyspnea is more often due to
COPD, interstitial lung disease, heart failure, or deconditioning .
Location and Radiation
The sensation of breathlessness is primarily felt in the chest and throat. She
does not report any chest pain, pressure, or radiation to the arms, neck, or
jaw. The absence of chest pain reduces but does not eliminate the possibility
of cardiac ischemia, as atypical presentations are common in women and
older adults .
Duration
The dyspnea has been present for 3-4 weeks, placing it in the subacute to
chronic category. Chronic dyspnea is defined as breathlessness persisting for
more than 4 weeks . This duration suggests the possibility of an ongoing
pathological process rather than an acute self-limiting condition.
Characteristics
The patient describes her breathlessness as:
"A feeling of not getting enough air"
"Difficulty taking a deep breath"
"Heaviness in the chest when I try to breathe deeply"
She denies wheezing, stridor, or audible respiratory sounds that would
suggest upper airway obstruction or bronchospasm. The sensation of
3
, 2
"inability to take a deep breath" may be associated with restrictive lung
disease, diaphragm dysfunction, or deconditioning .
Aggravating Factors
The dyspnea is significantly worsened by:
Physical exertion (walking more than 50-100 feet)
Climbing stairs (even a single flight)
Bending over or performing household tasks
Lying flat (orthopnea)
Emotional stress or anxiety
Relieving Factors
The patient reports some relief with:
Sitting upright
Resting
Using her "breathing techniques" (taking slow, deep breaths)
Cool air or a fan directed at her face—a non-pharmacological strategy that
has shown benefit for dyspnea in COPD and cancer patients
Timing
Dyspnea is present most of the day but worsens with activity
No significant diurnal variation
Paroxysmal nocturnal dyspnea (PND): The patient reports waking up at night
with a feeling of breathlessness, requiring her to sit up in bed. This occurred
3-4 times in the past two weeks. PND is a classic symptom of left-sided heart
failure .
Severity
Functional Impact: Unable to walk more than one block without stopping
to catch her breath
Activities of Daily Living: Difficulty performing routine tasks such as
cooking, cleaning, and showering
Modified Medical Research Council (mMRC) Dyspnea Scale: Grade 3
("Stops for breath after walking about 100 yards or after a few minutes on
4
1
,2
1.2 Reason for Encounter
Margaret Wilson, a 60-year-old female, presents to the outpatient clinic with
a chief complaint of shortness of breath. The symptom has been
progressively worsening over the past several weeks, significantly impacting
her activities of daily living. The patient reports that she initially attributed
her breathlessness to deconditioning and age-related changes, but the
severity has escalated to the point where she now experiences dyspnea with
minimal exertion, including walking short distances and performing routine
household tasks.
1.3 Case Significance and Learning Objectives
This case presents a classic yet complex clinical scenario involving a middle-
aged female with dyspnea—a symptom that ranks among the most common
presenting complaints in both outpatient and emergency settings. Dyspnea
affects millions worldwide and may serve as the primary manifestation of
respiratory, cardiac, neuromuscular, systemic, or psychogenic disorders . For
a 60-year-old female with obesity, the differential diagnosis is particularly
broad, encompassing both pulmonary and cardiac etiologies, as well as the
possibility of multifactorial causes.
Key Learning Objectives:
1. Develop a systematic approach to evaluating dyspnea in an older adult
2. Recognize the importance of a comprehensive history and physical
examination
3. Formulate an evidence-based differential diagnosis
4. Select appropriate diagnostic tests based on clinical suspicion
5. Develop a management plan addressing both acute symptoms and
underlying etiology
SECTION 2: COMPREHENSIVE HISTORY OF
PRESENT ILLNESS
2
,2
2.1 Symptom Characterization
The history of present illness is the cornerstone of evaluating dyspnea. For
Ms. Wilson, a detailed symptom characterization using the OLDCARTS
(Onset, Location, Duration, Characteristics, Aggravating factors, Relieving
factors, Timing, Severity) mnemonic is essential .
Onset
The patient reports that her shortness of breath began approximately 3-4
weeks ago. She describes the onset as "gradual" rather than sudden, which
is an important distinguishing feature. Acute onset dyspnea suggests
conditions such as pulmonary embolism, pneumothorax, or acute myocardial
ischemia, whereas chronic or progressive dyspnea is more often due to
COPD, interstitial lung disease, heart failure, or deconditioning .
Location and Radiation
The sensation of breathlessness is primarily felt in the chest and throat. She
does not report any chest pain, pressure, or radiation to the arms, neck, or
jaw. The absence of chest pain reduces but does not eliminate the possibility
of cardiac ischemia, as atypical presentations are common in women and
older adults .
Duration
The dyspnea has been present for 3-4 weeks, placing it in the subacute to
chronic category. Chronic dyspnea is defined as breathlessness persisting for
more than 4 weeks . This duration suggests the possibility of an ongoing
pathological process rather than an acute self-limiting condition.
Characteristics
The patient describes her breathlessness as:
"A feeling of not getting enough air"
"Difficulty taking a deep breath"
"Heaviness in the chest when I try to breathe deeply"
She denies wheezing, stridor, or audible respiratory sounds that would
suggest upper airway obstruction or bronchospasm. The sensation of
3
, 2
"inability to take a deep breath" may be associated with restrictive lung
disease, diaphragm dysfunction, or deconditioning .
Aggravating Factors
The dyspnea is significantly worsened by:
Physical exertion (walking more than 50-100 feet)
Climbing stairs (even a single flight)
Bending over or performing household tasks
Lying flat (orthopnea)
Emotional stress or anxiety
Relieving Factors
The patient reports some relief with:
Sitting upright
Resting
Using her "breathing techniques" (taking slow, deep breaths)
Cool air or a fan directed at her face—a non-pharmacological strategy that
has shown benefit for dyspnea in COPD and cancer patients
Timing
Dyspnea is present most of the day but worsens with activity
No significant diurnal variation
Paroxysmal nocturnal dyspnea (PND): The patient reports waking up at night
with a feeling of breathlessness, requiring her to sit up in bed. This occurred
3-4 times in the past two weeks. PND is a classic symptom of left-sided heart
failure .
Severity
Functional Impact: Unable to walk more than one block without stopping
to catch her breath
Activities of Daily Living: Difficulty performing routine tasks such as
cooking, cleaning, and showering
Modified Medical Research Council (mMRC) Dyspnea Scale: Grade 3
("Stops for breath after walking about 100 yards or after a few minutes on
4
