I-HUMAN ADVANCED DDX CASE STUDY - MARGARET WILSON (60-YEAR-OLD FEMALE WITH
SHORTNESS OF BREATH) | COMPLETE CLINICAL ASSESSMENT, COMPREHENSIVE HISTORY
TAKING (HPI), REVIEW OF SYSTEMS (ROS), PHYSICAL EXAMINATION, DIAGNOSTIC WORKUP,
DIFFERENTIAL DIAGNOSES, FINAL DIAGNOSIS, SOAP NOTE, EVIDENCE-BASED TREATMENT
PLAN, MEDICATIONS, PATIENT EDUCATION, FOLLOW-UP CARE & CLINICAL
DOCUMENTATION GUIDE
I-Human Advanced DDx Case Study: Margaret Wilson
60-Year-Old Female with Shortness of Breath
SECTION 1: PATIENT DEMOGRAPHICS & IDENTIFYING DATA
Item Details
Patient Initials M.W.
,Item Details
Age 60 years
Gender Female
Ethnicity African American
Height 5'4" (163 cm)
Weight 186.0 lb (84.2 kg)
BMI 31.7 kg/m² (Obese Class I)
Occupation Retired Primary School Teacher (retired 3 years ago)
Insurance Medicare
Living Situation Lives with husband in own home; stable environment
Source of Information Patient; reliable historian
SECTION 2: CHIEF COMPLAINT (CC)
Patient's Own Words:
"I've been getting short of breath, especially when I walk or climb stairs. I feel out of breath doing
things that never used to bother me, like walking across the parking lot or going up a few stairs."
Documentation Format:
Progressive shortness of breath for several weeks, worse with exertion.
SECTION 3: HISTORY OF PRESENTING ILLNESS (HPI) – OLD CARTS FORMAT
ONSET
• Gradual onset approximately 3–4 weeks ago
• Initially noticed mild breathlessness when walking longer distances
• No specific triggering event (trauma, surgery, acute illness)
, • Symptoms have become progressively more noticeable over time
LOCATION
• Patient describes sensation as difficulty getting enough air
• Feels chest tightness during episodes
• Symptoms localized to chest (not throat or nose)
• No localized chest pain
DURATION
• Breathlessness occurs daily
• Episodes last from a few minutes to 15–20 minutes, depending on activity
• Recovery usually occurs within several minutes of resting
CHARACTER
• Describes symptoms as: "Feeling winded" and "Like I can't catch my breath"
• Reports needing to stop and take deep breaths
• Denies sharp pleuritic pain
• Reports occasional mild chest heaviness during exertion
AGGRAVATING FACTORS
• Walking short distances
• Climbing stairs
• Carrying groceries or household items
• Bending over for prolonged periods
• Physical exertion in general
• Lying flat at night (orthopnea)
RELIEVING FACTORS
• Sitting down and resting
• Slowing pace
• Taking deep breaths
• Symptoms improve within several minutes of stopping activity
• Using extra pillows to sleep comfortably (orthopnea)
TIMING
• Worse with exertion
• More noticeable in afternoon/evening after being active
SHORTNESS OF BREATH) | COMPLETE CLINICAL ASSESSMENT, COMPREHENSIVE HISTORY
TAKING (HPI), REVIEW OF SYSTEMS (ROS), PHYSICAL EXAMINATION, DIAGNOSTIC WORKUP,
DIFFERENTIAL DIAGNOSES, FINAL DIAGNOSIS, SOAP NOTE, EVIDENCE-BASED TREATMENT
PLAN, MEDICATIONS, PATIENT EDUCATION, FOLLOW-UP CARE & CLINICAL
DOCUMENTATION GUIDE
I-Human Advanced DDx Case Study: Margaret Wilson
60-Year-Old Female with Shortness of Breath
SECTION 1: PATIENT DEMOGRAPHICS & IDENTIFYING DATA
Item Details
Patient Initials M.W.
,Item Details
Age 60 years
Gender Female
Ethnicity African American
Height 5'4" (163 cm)
Weight 186.0 lb (84.2 kg)
BMI 31.7 kg/m² (Obese Class I)
Occupation Retired Primary School Teacher (retired 3 years ago)
Insurance Medicare
Living Situation Lives with husband in own home; stable environment
Source of Information Patient; reliable historian
SECTION 2: CHIEF COMPLAINT (CC)
Patient's Own Words:
"I've been getting short of breath, especially when I walk or climb stairs. I feel out of breath doing
things that never used to bother me, like walking across the parking lot or going up a few stairs."
Documentation Format:
Progressive shortness of breath for several weeks, worse with exertion.
SECTION 3: HISTORY OF PRESENTING ILLNESS (HPI) – OLD CARTS FORMAT
ONSET
• Gradual onset approximately 3–4 weeks ago
• Initially noticed mild breathlessness when walking longer distances
• No specific triggering event (trauma, surgery, acute illness)
, • Symptoms have become progressively more noticeable over time
LOCATION
• Patient describes sensation as difficulty getting enough air
• Feels chest tightness during episodes
• Symptoms localized to chest (not throat or nose)
• No localized chest pain
DURATION
• Breathlessness occurs daily
• Episodes last from a few minutes to 15–20 minutes, depending on activity
• Recovery usually occurs within several minutes of resting
CHARACTER
• Describes symptoms as: "Feeling winded" and "Like I can't catch my breath"
• Reports needing to stop and take deep breaths
• Denies sharp pleuritic pain
• Reports occasional mild chest heaviness during exertion
AGGRAVATING FACTORS
• Walking short distances
• Climbing stairs
• Carrying groceries or household items
• Bending over for prolonged periods
• Physical exertion in general
• Lying flat at night (orthopnea)
RELIEVING FACTORS
• Sitting down and resting
• Slowing pace
• Taking deep breaths
• Symptoms improve within several minutes of stopping activity
• Using extra pillows to sleep comfortably (orthopnea)
TIMING
• Worse with exertion
• More noticeable in afternoon/evening after being active
