Mock patient scripts – Dyspnea

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Mock Patient Scripts – Dyspnea（呼吸困難）

“Why am I so out of breath just walking to the bathroom?”

Shortness of breath is a common symptom seen across various clinical settings—from benign hyperventilation to acute heart failure or pulmonary embolism. To respond effectively, you need strong English communication skills and structured clinical reasoning.

This article provides three realistic mock cases designed for practical training in:

  • English medical interviews for OSCE or OET
  • Differential diagnosis of dyspnea
  • SOAP note writing and case analysis

If you need to review clinical knowledge beforehand, please refer to our comprehensive guide on dyspnea linked below.

🧭 Review Before Practice: Symptom-based Approach to Dyspnea

🩺 Case 1 – “I can’t breathe when I lie down anymore…”

🚪 Doorway Information

  • Age / Gender: 78-year-old male
  • Chief Complaint: Shortness of breath, especially when lying down
  • Vital Signs: T 36.8°C, HR 102, BP 138/88, RR 22, SpO₂ 91% (room air)

🗣️ Opening

“I just can’t breathe when I lie down anymore.”

🌊 Shoreline

He began feeling more short of breath over the last few days and decided to visit after waking up breathless last night.

📋 Structured History

  • Onset & Course:
    “It started gradually about 3 days ago. I thought it was just because of the humid weather. But last night, I had to sleep sitting up.”
  • Associated Symptoms:
    “My legs have been swelling again. I also gained a couple of kilos recently. I feel more tired than usual.”
  • Mood / Function / Appetite / Sleep:
    “I can’t walk to the bathroom without stopping to catch my breath. I sleep poorly because of the breathing. Appetite is okay.”
  • Medical History / Medication:
    “I have high blood pressure and heart problems. I take some pills, including something called lisinopril, a water pill, and aspirin.”
  • Family & Social History (PAM HITS FOSS):
    • Previous Illnesses: Hypertension, chronic heart failure
    • Allergies: None known
    • Medication: Lisinopril, furosemide, aspirin
    • Hospitalizations: Admitted twice last year for “fluid in lungs”
    • Injuries / Trauma / Surgery: None significant
    • Family History: Father died of a heart attack in his 60s
    • OBGYN: N/A
    • Sexual History: Not sexually active
    • Social History: Lives alone, retired carpenter, no smoking, no alcohol
  • Concerns & Questions:
    “Is my heart getting worse again? I don’t want to go to the hospital again.”

🩺 Physical Examination

  • Positive Findings: Bilateral pitting edema to the knees, bibasilar crackles, jugular venous distension (JVD)
  • Negative Findings: No fever, no wheezing, heart sounds regular with no murmur
  • HEENT: No cyanosis
  • Chest: Crackles bilaterally at bases
  • Abdomen: Soft, non-tender, no hepatosplenomegaly
  • Neuro: Normal strength and reflexes

🩻 Differential Diagnosis (Top 3)

  1. Acute decompensated heart failure (ADCHF)
    • Supporting: Orthopnea, PND, weight gain, leg edema, crackles, JVD, known cardiac history
    • Contradictory: No chest pain or arrhythmia at present
  2. Pulmonary embolism
    • Supporting: Acute onset dyspnea, hypoxia
    • Contradictory: No chest pain, no DVT signs, subacute rather than sudden onset
  3. Pneumonia
    • Supporting: Dyspnea, crackles
    • Contradictory: No fever, no productive cough, normal WBC

💭 Clinical Reflection

This is a classic case of heart failure exacerbation with textbook symptoms. The patient’s concern about avoiding hospitalization is valid, but we need imaging and labs to decide the safest plan.

💡 Clinical Pearls

  • Orthopnea is one of the most specific symptoms of heart failure.
  • Always check for JVD and peripheral edema in dyspneic patients.
  • Don’t forget silent hypoxia—pulse oximetry matters even if the lungs sound “okay.”
  • Daily weight gain is an excellent marker for fluid retention.

❓ Challenging Questions

Q1: “Is my heart failing again?”
A: “It’s possible, but we’ll confirm it with a few tests like bloodwork and a chest X-ray. The symptoms you’re having are common when fluid builds up in the lungs. If we act early, we might manage this without needing to admit you.”

Q2: “Can I be treated at home?”
A: “It depends on how much fluid is built up and your oxygen levels. If things are stable, we might adjust your medication and monitor closely. But if we see signs of serious overload, a short hospital stay might be safer. We’ll decide together based on the test results.”

📝 SOAP Note

S: 78-year-old male presents with 3-day history of worsening dyspnea, especially at night. Reports orthopnea, paroxysmal nocturnal dyspnea, leg swelling, and 2kg weight gain. History of chronic heart failure and hypertension.

O: 
- T 36.8°C, HR 102, BP 138/88, RR 22, SpO₂ 91% (room air)
- Bibasilar crackles, bilateral pitting edema, JVD
- No murmur, no fever

A:
# Dyspnea with orthopnea and PND  
# Known heart failure  
# Signs of volume overload  

ddx): Acute decompensated heart failure, PE, pneumonia  
r/o): COPD (no wheeze, no chronic cough), asthma (no hx), infection (no fever)

→ Likely ADCHF given fluid signs, orthopnea, and known CHF. Needs further evaluation with CXR, BNP, renal function.

P:
- Order chest X-ray and BNP  
- Check renal function, electrolytes, CBC  
- Administer IV furosemide  
- Monitor oxygen and urine output  
- Consider cardiology consult if poor response

🩺 Case 2 – “I feel like I’m going to suffocate!”

🚪 Doorway Information

  • Age / Gender: 26-year-old female
  • Chief Complaint: Sudden shortness of breath during work
  • Vital Signs: T 36.7°C, HR 112, BP 124/76, RR 28, SpO₂ 98%

🗣️ Opening

“I felt like I was going to die—I couldn’t breathe all of a sudden!”

🌊 Shoreline

She was at her desk at work when she suddenly felt she couldn’t breathe and had to leave the office.

📋 Structured History

  • Onset & Course:
    “It came out of nowhere—I was just working and suddenly couldn’t get air in. It lasted maybe 10 or 15 minutes.”
  • Associated Symptoms:
    “My heart was racing, I felt dizzy, and my fingers were tingling. I thought I might faint.”
  • Mood / Function / Appetite / Sleep:
    “Lately I’ve been under a lot of stress at work. I haven’t been sleeping well and I skip meals sometimes.”
  • Medical History / Medication:
    “No real illnesses. I’m not on any meds except sometimes ibuprofen for cramps.”
  • Family & Social History (PAM HITS FOSS):
    • Previous Illnesses: None
    • Allergies: None
    • Medication: None regularly
    • Hospitalizations: Never
    • Injuries / Trauma / Surgery: None
    • Family History: Mother has anxiety disorder
    • OBGYN: Regular cycles, no pregnancies
    • Sexual History: In a relationship, sexually active, uses OCPs
    • Social History: Works as an office assistant, non-smoker, drinks socially
  • Concerns & Questions:
    “Am I having a heart attack? I honestly thought I was going to die.”

🩺 Physical Examination

  • Positive Findings: Mild tachycardia, fast breathing, anxious appearance
  • Negative Findings: Clear lungs, no wheeze, heart sounds normal, no edema, neurologically intact
  • HEENT: Normal
  • Chest: Clear bilaterally
  • Abdomen: Soft, non-tender
  • Neuro: No focal deficit, normal gait

🩻 Differential Diagnosis (Top 3)

  1. Panic attack
    • Supporting: Sudden onset, hyperventilation, tingling, stress, family history, normal SpO₂
    • Contradictory: None significant
  2. Pulmonary embolism
    • Supporting: OCP use, tachycardia, acute dyspnea
    • Contradictory: No chest pain, no hypoxia, no leg symptoms
  3. Asthma
    • Supporting: Dyspnea, hyperventilation
    • Contradictory: No wheezing, no history of asthma

💭 Clinical Reflection

This case reminds me how real panic attacks feel to patients. It’s easy to overlook if we don’t explore stress, sleep, and context carefully. Always rule out physical causes, but don’t ignore the psychological ones.

💡 Clinical Pearls

  • Panic attacks often mimic PE, MI, or asthma—be cautious but also confident.
  • SpO₂ is a valuable clue in functional dyspnea—it’s usually normal or elevated.
  • Use reassurance and structured breathing techniques during the attack.
  • Screen for triggers: life stress, trauma, family history, and caffeine use.

❓ Challenging Questions

Q1: “Was I having a heart attack?”
A: “It felt that way, I understand. But based on your exam and vital signs, it’s unlikely. These episodes are common in panic attacks, which can feel just as scary. We’ll do some basic tests to be sure and help you understand how to manage it.”

Q2: “Am I going crazy?”
A: “Absolutely not. Panic attacks are a real and treatable medical condition. Many people experience them under stress. You’re not alone, and we’ll work on strategies together to help you feel better.”

📝 SOAP Note

S: 26-year-old female presents with sudden dyspnea, palpitations, and dizziness. Episode occurred while working. Lasted ~15 minutes. No chest pain. History of stress and poor sleep. No medical history. Family history of anxiety.

O:
- T 36.7°C, HR 112, BP 124/76, RR 28, SpO₂ 98%
- Anxious appearance, no distress, lungs clear, neuro exam normal

A:
# Acute dyspnea with hyperventilation  
# No physical findings suggestive of PE, asthma, or MI  
# High stress and possible panic episode  

ddx): Panic attack, PE, asthma  
r/o): PE (no hypoxia, no DVT signs), asthma (no hx, no wheeze)

→ Likely panic attack triggered by stress and sleep deprivation. No alarming signs on physical exam.

P:
- Offer short-term breathing exercise training  
- Educate on panic attacks and coping strategies  
- Consider referral for mental health support  
- Rule out PE with D-dimer if clinically indicated  
- Reassure and arrange follow-up

🩺 Case 3 – “I’ve just been more short of breath these days…”

🚪 Doorway Information

  • Age / Gender: 42-year-old female
  • Chief Complaint: Gradual onset of shortness of breath for several days
  • Vital Signs: T 36.9°C, HR 96, BP 128/74, RR 20, SpO₂ 93% (room air)

🗣️ Opening

“I don’t know why, but I’ve been more out of breath than usual lately.”

🌊 Shoreline

She reports progressive shortness of breath over the past 4–5 days, especially when walking up stairs.

📋 Structured History

  • Onset & Course:
    “It started maybe 4 or 5 days ago. I just noticed I was more winded doing things I usually can handle.”
  • Associated Symptoms:
    “No cough or fever. But sometimes I get a tight feeling in my chest when I try to climb stairs.”
  • Mood / Function / Appetite / Sleep:
    “I’ve been feeling a bit tired but still working. Appetite and sleep are okay.”
  • Medical History / Medication:
    “I don’t have any major illnesses. I’m on birth control pills. No asthma or heart problems.”
  • Family & Social History (PAM HITS FOSS):
    • Previous Illnesses: Appendectomy at 25
    • Allergies: None
    • Medication: Oral contraceptives
    • Hospitalizations: Only for appendectomy
    • Injuries / Trauma / Surgery: None recent
    • Family History: Father had “a clot” in his leg in his 50s
    • OBGYN: Regular menses, no pregnancies
    • Sexual History: Monogamous relationship
    • Social History: Office worker, recently took a 14-hour flight, non-smoker, drinks occasionally
  • Concerns & Questions:
    “Could this be something with my lungs? Or maybe I’m just out of shape…”

🩺 Physical Examination

  • Positive Findings: Mild tachypnea, SpO₂ 93% at rest, mild right calf tenderness
  • Negative Findings: Clear lungs, no wheezing or crackles, normal heart sounds, no edema
  • HEENT: No cyanosis
  • Chest: Normal breath sounds
  • Abdomen: Soft, non-tender
  • Extremities: Mild tenderness in right calf, no swelling
  • Neuro: Intact

🩻 Differential Diagnosis (Top 3)

  1. Pulmonary embolism
    • Supporting: Gradual dyspnea, chest tightness, low SpO₂, OCP use, long flight, family history
    • Contradictory: No sudden onset, no pleuritic chest pain
  2. Deconditioning / Functional dyspnea
    • Supporting: Mild symptoms, no fever or wheeze, normal lung exam
    • Contradictory: Low SpO₂, calf tenderness, PE risk factors
  3. Anemia
    • Supporting: Fatigue and mild dyspnea on exertion
    • Contradictory: No bleeding history, normal appearance, no paleness

💭 Clinical Reflection

This case emphasizes the importance of subtle signs and risk factors. Her symptoms weren’t dramatic, but the prolonged flight, OCP use, and calf tenderness point strongly toward PE. A D-dimer or imaging is definitely warranted.

💡 Clinical Pearls

  • Always ask about recent travel and OCP use in unexplained dyspnea.
  • PE can present insidiously—no need for classic pleuritic pain to suspect it.
  • Calf tenderness without swelling may still suggest DVT.
  • Oxygen saturation is a crucial clue even when lungs sound normal.

❓ Challenging Questions

Q1: “But I didn’t collapse or have sharp chest pain—can it still be serious?”
A: “Yes, PE can sometimes come on slowly and quietly. It doesn’t always cause dramatic symptoms. But because you have some risk factors, we need to rule it out properly.”

Q2: “Will I need to stay in the hospital?”
A: “That depends on what the tests show. If we do find a clot, we may start treatment with blood thinners—some people can be treated as outpatients if they’re stable. Let’s first confirm the diagnosis together.”

📝 SOAP Note

S: 42-year-old woman with 4–5 days of gradually worsening shortness of breath on exertion. Reports chest tightness with stairs, no cough or fever. Risk factors include OCP use, recent long flight, and family history of DVT.

O:
- T 36.9°C, HR 96, BP 128/74, RR 20, SpO₂ 93%
- Lungs clear, heart normal, mild R calf tenderness, no swelling

A:
# Subacute exertional dyspnea  
# Risk factors for PE (OCP, flight, FHx, calf tenderness)  
# No signs of infection or asthma  

ddx): Pulmonary embolism, anemia, deconditioning  
r/o): Asthma (no wheeze), infection (no fever or cough)

→ PE is high on the list given risk profile. Needs D-dimer or CT-PA to confirm.

P:
- Order D-dimer and leg Doppler  
- Consider CTPA depending on results and Wells score  
- Monitor oxygen saturation  
- Begin anticoagulation if confirmed  
- Educate about PE risk and prevention

🧵 Summary & Take-Home Points

  • Dyspnea is a symptom, not a diagnosis—always think broadly and systematically.
  • Pay attention to red flags like orthopnea, low SpO₂, or pleuritic chest pain.
  • Don’t overlook psychological causes such as panic attacks, especially in young adults with normal exams.
  • Functional capacity (e.g., ability to walk or climb stairs) is often more informative than resting vitals.
  • Always assess for PE risk factors like immobility, OCPs, and personal/family history.

🔍 Differential Diagnosis List – VITAMIN CDE for Dyspnea

Use this mnemonic to structure your thinking when evaluating shortness of breath:

  • Vascular: Pulmonary embolism, pulmonary hypertension
  • Infectious / Inflammatory: Pneumonia, bronchitis, COVID-19, interstitial lung disease, sarcoidosis
  • Trauma: Rib fracture, pneumothorax, hemothorax
  • Autoimmune: Systemic sclerosis, lupus-related ILD
  • Metabolic / Endocrine: Severe anemia, acidosis, thyrotoxicosis
  • Idiopathic / Iatrogenic: Drug-induced lung disease, idiopathic pulmonary fibrosis, post-op atelectasis
  • Neoplastic: Lung cancer, pleural effusion due to malignancy, lymphangitic carcinomatosis
  • Congenital / Structural: Congenital heart disease, scoliosis with restrictive lung pattern
  • Degenerative / Drugs: Heart failure, COPD, asthma, medication side effects (e.g., amiodarone, methotrexate)
  • Endocrine / Emotional / Environmental: Panic attack, obesity hypoventilation, high altitude

📚 Related Articles

📖 References

  • BMJ Best Practice – Dyspnea (Accessed 2024)
  • UpToDate – Evaluation of dyspnea in adult
  • Mayo Clinic – Shortness of breath: Common causes
  • American Thoracic Society – Approach to the patient with dyspnea

📘 Recommended Resources

  • First Aid for the USMLE Step 2 CS – Patient note & differential diagnosis practice
  • 「ダ・ヴィンチのカルテ」– 日本語での臨床推論トレーニングに最適
  • OSCE Cases with Mark – Clinical reasoning and communication strategies
  • OET Speaking Guide – Roleplay-based English for healthcare professionals

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