I-Human Advanced DDX Case Study: Margaret Wilson –
,I-Human Advanced DDX Case Study: Margaret Wilson –
Advanced Clinical Case Study (Original
Educational Simulation)
Patient Name
Margaret Wilson (Original Fictional Educational Case)
Age: 60 Years
Gender: Female
Chief Complaint: Shortness of breath and chest tightness for three days.
Page 1 – Patient History & Initial Assessment
Chief Complaint
Margaret Wilson is a 60-year-old female who presents to the emergency department complaining
of worsening shortness of breath that began three days ago. She reports that the symptoms
initially occurred only while climbing stairs but have gradually worsened to the point where she
now experiences dyspnea while performing routine household activities. She also reports mild
chest tightness, fatigue, and difficulty sleeping because she becomes short of breath when lying
flat.
She denies fever, productive cough, hemoptysis, nausea, vomiting, recent surgery, prolonged
travel, or leg pain.
History of Present Illness
• Onset: Three days ago
• Duration: Constant with worsening severity
• Quality: Difficulty catching breath with chest pressure
• Severity: 7/10
• Aggravating Factors:
o Walking
, I-Human Advanced DDX Case Study: Margaret Wilson –
o Climbing stairs
o Lying flat
• Relieving Factors:
o Sitting upright
o Rest
Past Medical History
• Hypertension
• Type 2 Diabetes Mellitus
• Hyperlipidemia
• Obesity
• Gastroesophageal Reflux Disease (GERD)
Surgical History
• Cholecystectomy
• Hysterectomy
Current Medications
• Lisinopril 20 mg daily
• Metformin 1000 mg twice daily
• Atorvastatin 40 mg nightly
• Aspirin 81 mg daily
• Omeprazole 20 mg daily
Allergies
No known drug allergies.
Family History
• Father died from myocardial infarction at age 62.
• Mother had congestive heart failure.
• Brother has coronary artery disease.
Social History
• Former smoker (20 pack-years; quit 8 years ago)
• Drinks wine socially
• Denies illicit drug use
• Lives with husband
• Independent with activities of daily living
,I-Human Advanced DDX Case Study: Margaret Wilson –
Advanced Clinical Case Study (Original
Educational Simulation)
Patient Name
Margaret Wilson (Original Fictional Educational Case)
Age: 60 Years
Gender: Female
Chief Complaint: Shortness of breath and chest tightness for three days.
Page 1 – Patient History & Initial Assessment
Chief Complaint
Margaret Wilson is a 60-year-old female who presents to the emergency department complaining
of worsening shortness of breath that began three days ago. She reports that the symptoms
initially occurred only while climbing stairs but have gradually worsened to the point where she
now experiences dyspnea while performing routine household activities. She also reports mild
chest tightness, fatigue, and difficulty sleeping because she becomes short of breath when lying
flat.
She denies fever, productive cough, hemoptysis, nausea, vomiting, recent surgery, prolonged
travel, or leg pain.
History of Present Illness
• Onset: Three days ago
• Duration: Constant with worsening severity
• Quality: Difficulty catching breath with chest pressure
• Severity: 7/10
• Aggravating Factors:
o Walking
, I-Human Advanced DDX Case Study: Margaret Wilson –
o Climbing stairs
o Lying flat
• Relieving Factors:
o Sitting upright
o Rest
Past Medical History
• Hypertension
• Type 2 Diabetes Mellitus
• Hyperlipidemia
• Obesity
• Gastroesophageal Reflux Disease (GERD)
Surgical History
• Cholecystectomy
• Hysterectomy
Current Medications
• Lisinopril 20 mg daily
• Metformin 1000 mg twice daily
• Atorvastatin 40 mg nightly
• Aspirin 81 mg daily
• Omeprazole 20 mg daily
Allergies
No known drug allergies.
Family History
• Father died from myocardial infarction at age 62.
• Mother had congestive heart failure.
• Brother has coronary artery disease.
Social History
• Former smoker (20 pack-years; quit 8 years ago)
• Drinks wine socially
• Denies illicit drug use
• Lives with husband
• Independent with activities of daily living
