Wilson Smith: Comprehensive Clinical Case Study on Heart Failure
Patient presenting with orthopnea and respiratory distress.
Patient Profile
Name: Wilson Smith Age: 68 Gender: Male
Chief Complaint: "I can't catch my breath,
and my legs are huge."
History of Present Illness (HPI): Mr. Smith
presents with a 2-week history of
progressive dyspnea on exertion (DOE), now
occurring with minimal activity. He reports
significant orthopnea, requiring four pillows
to sleep at night, and frequent episodes of
Paroxysmal Nocturnal Dyspnea (PND) that
force him to sit upright to catch his breath.
He also notes worsening bilateral lower
extremity edema that has progressed to his
mid-shins.
Past Medical History (PMH) Vital Signs
• Hypertension (HTN) • Coronary Artery • HR: 108 bpm (Tachycardia) •
Disease (CAD) • Previous Myocardial BP: 152/94 mmHg (Hypertensive)
Infarction (5 years ago) • Hyperlipidemia • RR: 22 breaths/min
(Tachypnea) • SpO2: 91% on
Room Air (RA)
Physical Examination Findings
, System Clinical Findings
Neck/Vascular Jugular Venous Distention (JVD) measured at 8 cm above the sternal angle.
Cardiovascular Tachycardic; S1 and S2 present. An S3 gallop is clearly audible at the apex.
Pulmonary Increased work of breathing; fine crackles (rales) noted in bilateral lung bases.
Integumentary 2+ pitting edema noted bilaterally extending to the mid-shin level.
Pathophysiology: The S3 Gallop
The third heart sound (S3), or ventricular gallop, occurs early in diastole during the rapid ventricular
filling phase. It is caused by blood flowing from the atrium into a compliant, dilated, and often volume-
overloaded left ventricle. In older adults, this is a hallmark sign of systolic heart failure and indicates
elevated filling pressures.
Clinical Correlation: Based on Wilson Smith's vital signs and physical exam findings, identify the
primary physiological mechanism causing his bilateral lung crackles and low oxygen saturation. How
does his history of CAD and HTN contribute to this acute presentation?
Activity 2: SOAP Note & Differential Diagnosis
Using the clinical findings for Wilson Smith, review the pre-filled Subjective and Objective data.
Complete the Assessment and Plan sections to demonstrate clinical reasoning for this acute
presentation.
Component Clinical Documentation
Patient presenting with orthopnea and respiratory distress.
Patient Profile
Name: Wilson Smith Age: 68 Gender: Male
Chief Complaint: "I can't catch my breath,
and my legs are huge."
History of Present Illness (HPI): Mr. Smith
presents with a 2-week history of
progressive dyspnea on exertion (DOE), now
occurring with minimal activity. He reports
significant orthopnea, requiring four pillows
to sleep at night, and frequent episodes of
Paroxysmal Nocturnal Dyspnea (PND) that
force him to sit upright to catch his breath.
He also notes worsening bilateral lower
extremity edema that has progressed to his
mid-shins.
Past Medical History (PMH) Vital Signs
• Hypertension (HTN) • Coronary Artery • HR: 108 bpm (Tachycardia) •
Disease (CAD) • Previous Myocardial BP: 152/94 mmHg (Hypertensive)
Infarction (5 years ago) • Hyperlipidemia • RR: 22 breaths/min
(Tachypnea) • SpO2: 91% on
Room Air (RA)
Physical Examination Findings
, System Clinical Findings
Neck/Vascular Jugular Venous Distention (JVD) measured at 8 cm above the sternal angle.
Cardiovascular Tachycardic; S1 and S2 present. An S3 gallop is clearly audible at the apex.
Pulmonary Increased work of breathing; fine crackles (rales) noted in bilateral lung bases.
Integumentary 2+ pitting edema noted bilaterally extending to the mid-shin level.
Pathophysiology: The S3 Gallop
The third heart sound (S3), or ventricular gallop, occurs early in diastole during the rapid ventricular
filling phase. It is caused by blood flowing from the atrium into a compliant, dilated, and often volume-
overloaded left ventricle. In older adults, this is a hallmark sign of systolic heart failure and indicates
elevated filling pressures.
Clinical Correlation: Based on Wilson Smith's vital signs and physical exam findings, identify the
primary physiological mechanism causing his bilateral lung crackles and low oxygen saturation. How
does his history of CAD and HTN contribute to this acute presentation?
Activity 2: SOAP Note & Differential Diagnosis
Using the clinical findings for Wilson Smith, review the pre-filled Subjective and Objective data.
Complete the Assessment and Plan sections to demonstrate clinical reasoning for this acute
presentation.
Component Clinical Documentation
