Shortness of Breath | Complete Case Analysis & Correct Diagnosis
(100% Score) 2026
,1. PATIENT BIODATA & REASON FOR ENCOUNTER
Data Category Clinical Information
Full Name Jamie Lynn Feldman
Date of Birth June 15, 1956
Age 67 years
Biological Sex Female
Height 5'6" (168 cm)
Weight 174.0 lb (79.1 kg)
BMI 28.1 kg/m² (Overweight)
Race/Ethnicity Caucasian
Reason for Encounter Shortness of breath – progressively worsening over past 2-4 weeks, now
impairing activities of daily living
Source:
2. CASE INTRODUCTION
Jamie Feldman is a 67-year-old female who presents to an outpatient clinic with laboratory and imaging
capabilities, reporting progressively worsening shortness of breath. The symptom began approximately
2-4 weeks ago with mild exertional dyspnea and has rapidly progressed to the point where she
experiences breathlessness with minimal activity such as dressing and preparing meals. The patient has
a history of hypertension diagnosed at age 56 and hyperlipidemia, with no prior cardiopulmonary
diagnoses. She has been independent in all activities of daily living until the recent onset of symptoms.
This case presents a common but potentially serious geriatric complaint requiring systematic
assessment to distinguish between cardiac, pulmonary, and other systemic causes of acute dyspnea. The
patient expresses significant anxiety about her symptoms and their impact on her independence.
3. CHIEF COMPLAINT (CC)
Verbatim Patient Statement:
"Doctor, I just can't catch my breath anymore. It started about two weeks ago when I noticed getting
winded walking up the stairs to my apartment. Now I'm breathless just getting dressed or making
breakfast. Yesterday, I had to sit down halfway through cooking because I felt like I couldn't get enough
air."
Clinician Interpretation:
,Primary symptom: Progressive exertional dyspnea
Onset: Approximately 14 days prior to visit
Progression: Rapid worsening over past 72 hours
Current functional limitation: Activities of daily living now impaired
Associated concern: Patient expressing anxiety about symptom severity
4. QUESTIONS AND ANSWERS DURING FULL HISTORY
RESPIRATORY HISTORY INQUIRY
Q: "Can you describe what the shortness of breath feels like?"
A: "It's like I can't take a deep enough breath. My chest feels tight, and I have to work harder to
breathe."
Q: "What makes it better or worse?"
A: "Worse when I walk or do anything physical. Better when I sit completely still. Propping up on extra
pillows at night helps a little."
Q: "Do you wake up at night short of breath?"
A: "The last three nights, I've woken up around 2 AM feeling like I'm suffocating. I have to sit up on the
edge of the bed to breathe."
Q: "Have you noticed any cough?"
A: "A dry cough started a few days ago, mostly when I'm lying down. No phlegm or anything."
Q: "Is the shortness of breath constant or does it come and go?"
, A: "It's there all the time now, but much worse with any movement."
CARDIOVASCULAR HISTORY INQUIRY
Q: "Have you noticed any chest pain or discomfort?"
A: "Not really pain, but sometimes a heaviness in my chest when the breathing is bad."
Q: "Any swelling in your feet or ankles?"
A: "My shoes have felt tighter the last few days, and I can see indentations from my socks."
Q: "Do you have any palpitations or feeling like your heart is racing?"
A: "Sometimes my heart feels like it's pounding, especially when I try to walk."
Q: "Have you noticed needing to urinate more at night?"
A: "I've been getting up twice a night lately, which is new for me."
FUNCTIONAL ASSESSMENT
Q: "How has this affected your daily activities?"
A: "I can't do my grocery shopping anymore. My neighbor had to get my prescriptions yesterday. I'm
afraid to shower alone."
Q: "What were you able to do before this started?"
A: "I used to walk 30 minutes every day. Now I can barely walk from my bedroom to the kitchen."
Q: "Have you noticed any changes in your weight or appetite?"
A: "I'm not as hungry. I think I've lost a couple of pounds, but I feel bloated."
Q: "Have you had any fever, chills, or night sweats?"
A: "No fever that I've noticed. I haven't had any chills or sweats either."