i-Human Case Week #4 15-year-old male(15y/o,5’10”(178cm)170.0lb(77.3kgs)
Reason for Encounter: Shortness of breath Location: Emergency department
with full imaging and laboratory capabilities latest 2025
Here's a structured clinical summary for a 15-year-old male, 178 cm tall, 77.3 kg,
presenting to the Emergency Department with shortness of breath, assuming
full imaging and lab capabilities are available:
,Reason for Encounter
Shortness of breath (dyspnea)
Patient Information
• Age: 15 years
• Sex: Male
• Height: 178 cm
• Weight: 77.3 kg
• BMI: ~24.4 (within normal range)
History of Present Illness
• Onset: Sudden or gradual?
• Duration: How long has SOB persisted?
• Character: Constant or intermittent?
• Associated symptoms:
o Chest pain?
o Cough (productive or dry)? o Wheezing? o Fever? o Palpitations? o
Leg swelling or pain (suggestive of DVT)?
o Recent upper respiratory infection or allergy exposure?
• Aggravating/relieving factors: Worse with exertion or lying down?
• Past medical history: Asthma, recent infections, heart disease,
allergies?
• Family history: Cardiac or respiratory conditions?
• Medications: Inhalers, allergy meds, others?
, • Social history: Smoking/vaping, substance use, exposure to
allergens?
Physical Examination
Vital Signs:
• Temperature
• Heart Rate
• Respiratory Rate
• Blood Pressure
• Oxygen Saturation (SpO₂) General Appearance:
• Distress level, alertness
Respiratory:
• Work of breathing, use of accessory muscles
• Auscultation: wheezing, crackles, diminished breath sounds
• Percussion and chest expansion Cardiovascular:
• Heart sounds, murmurs, rhythm
• Jugular venous pressure Other:
• Skin: cyanosis, rash
• Extremities: edema, clubbing
Initial Investigations (Labs and Imaging)
Given ED has full capabilities, request:
Laboratory Tests
• CBC with differential (look for infection/anemia)
• Electrolytes, BUN, Creatinine
, • BNP (if cardiac cause suspected)
• D-dimer (if PE suspected)
• ABG (for hypoxia or acidosis)
• Troponin (if cardiac ischemia suspected)
• COVID-19/Influenza/RSV PCR
• Sputum culture if productive cough
Imaging
• Chest X-ray – first-line (look for pneumonia, pneumothorax,
cardiomegaly)
• ECG – rule out arrhythmias or myocarditis
• Echocardiogram – if murmur, chest pain, or heart failure suspected
• CT Pulmonary Angiogram – if pulmonary embolism suspected
• Spirometry/PFTs – if stable and asthma suspected (not in acute
distress)
Differential Diagnoses
1. Asthma exacerbation
2. Pneumonia or lower respiratory tract infection
3. Pneumothorax (spontaneous)
4. Pulmonary embolism (less common but possible)
5. Anemia
6. Cardiac cause – myocarditis, congenital heart disease, pericardial
effusion
7. Upper airway obstruction
8. Psychogenic/Anxiety-related SOB
Reason for Encounter: Shortness of breath Location: Emergency department
with full imaging and laboratory capabilities latest 2025
Here's a structured clinical summary for a 15-year-old male, 178 cm tall, 77.3 kg,
presenting to the Emergency Department with shortness of breath, assuming
full imaging and lab capabilities are available:
,Reason for Encounter
Shortness of breath (dyspnea)
Patient Information
• Age: 15 years
• Sex: Male
• Height: 178 cm
• Weight: 77.3 kg
• BMI: ~24.4 (within normal range)
History of Present Illness
• Onset: Sudden or gradual?
• Duration: How long has SOB persisted?
• Character: Constant or intermittent?
• Associated symptoms:
o Chest pain?
o Cough (productive or dry)? o Wheezing? o Fever? o Palpitations? o
Leg swelling or pain (suggestive of DVT)?
o Recent upper respiratory infection or allergy exposure?
• Aggravating/relieving factors: Worse with exertion or lying down?
• Past medical history: Asthma, recent infections, heart disease,
allergies?
• Family history: Cardiac or respiratory conditions?
• Medications: Inhalers, allergy meds, others?
, • Social history: Smoking/vaping, substance use, exposure to
allergens?
Physical Examination
Vital Signs:
• Temperature
• Heart Rate
• Respiratory Rate
• Blood Pressure
• Oxygen Saturation (SpO₂) General Appearance:
• Distress level, alertness
Respiratory:
• Work of breathing, use of accessory muscles
• Auscultation: wheezing, crackles, diminished breath sounds
• Percussion and chest expansion Cardiovascular:
• Heart sounds, murmurs, rhythm
• Jugular venous pressure Other:
• Skin: cyanosis, rash
• Extremities: edema, clubbing
Initial Investigations (Labs and Imaging)
Given ED has full capabilities, request:
Laboratory Tests
• CBC with differential (look for infection/anemia)
• Electrolytes, BUN, Creatinine
, • BNP (if cardiac cause suspected)
• D-dimer (if PE suspected)
• ABG (for hypoxia or acidosis)
• Troponin (if cardiac ischemia suspected)
• COVID-19/Influenza/RSV PCR
• Sputum culture if productive cough
Imaging
• Chest X-ray – first-line (look for pneumonia, pneumothorax,
cardiomegaly)
• ECG – rule out arrhythmias or myocarditis
• Echocardiogram – if murmur, chest pain, or heart failure suspected
• CT Pulmonary Angiogram – if pulmonary embolism suspected
• Spirometry/PFTs – if stable and asthma suspected (not in acute
distress)
Differential Diagnoses
1. Asthma exacerbation
2. Pneumonia or lower respiratory tract infection
3. Pneumothorax (spontaneous)
4. Pulmonary embolism (less common but possible)
5. Anemia
6. Cardiac cause – myocarditis, congenital heart disease, pericardial
effusion
7. Upper airway obstruction
8. Psychogenic/Anxiety-related SOB
