Susi Green iHuman Case Study and Best Guide 2025

Susi Green is a 63-year-old female presenting with sudden shortness of breath and severe difficulty breathing that occurred after getting off a plane. In this comprehensive guide, we’ll walk you through how to approach her case, from initial history-taking through physical examination to the final diagnosis of heart failure with possible pulmonary embolism. You’ll learn the key clinical reasoning steps, what the iHuman grading rubric expects, and a complete step-by-step solution to help you confidently navigate this complex cardiopulmonary case simulation.

Susi Green Ihuman Case Overview (Doorway Information)

Patient Overview: Susi Green is a 63-year-old female presenting with a chief complaint of “sudden shortness of breath and severe difficulty breathing” that occurred today as she was getting off a plane. She had to stop walking to catch her breath and reports difficulty with stairs, needing to stop walking every 10 or 20 yards. The patient denies shortness of breath at rest, cough, wheezing, bilateral lower extremity swelling, or fever.

Key Background Information:

• Age/Gender: 63-year-old female
• Chief Complaint: Sudden shortness of breath and severe difficulty breathing
• Duration: Acute onset today after plane flight
• Pain Characteristics: Exertional dyspnea, no chest pain
• Associated Symptoms: Severe breathing difficulty, exercise intolerance
• Significant History: Hypertension, COPD, anxiety, depression, smoking history (started at 19 years old for 17 years)
• Current Medications: Antihypertensive therapy
• Lifestyle: Recent air travel, former smoker
• Physical Presentation: Appears stressed/anxious, elevated BP 155/90, S4 gallop, respiratory rate 26 with labored breathing, oxygen saturation 70%

The patient appears distressed and anxious, currently experiencing significant respiratory compromise with markedly low oxygen saturation. Her presentation following air travel with acute dyspnea and low oxygen saturation raises concern for pulmonary embolism or acute heart failure exacerbation, making this an excellent case for learning systematic cardiopulmonary assessment and emergency diagnosis skills.

Susi Green (63 y/o female) – Dyspnea Assessment

• CC: Sudden shortness of breath and severe difficulty breathing
• MSAP: Acute onset exertional dyspnea following air travel, requiring frequent rest stops, severe breathing difficulty
• Exercise intolerance with need to stop every 10-20 yards
• History: HTN, COPD, anxiety, depression, significant smoking history
• Post-flight presentation with acute respiratory distress

History Questions:

• How can I help you today?
• When did your breathing difficulty start?
• Any other symptoms we should discuss?
• Do you have any allergies?
• Are you taking any OTC or herbal medications?
• Any new or recent changes in medications?
• What does your breathing difficulty feel like? (tight, heavy, suffocating, can’t catch breath)
• How severe (scale 1−10) is your breathing difficulty?
• Does anything make your breathing better or worse?
• What were you doing when your breathing difficulty started?
• Have you traveled recently? Any long flights or car rides?
• Do you have shortness of breath at rest or only with activity?
• Do you have any chest pain, pressure, or discomfort?
• Do you have unusual heartbeats (palpitations)?
• Do you have any swelling in your legs, ankles, or feet?
• Do you wake up at night short of breath?
• Do you need to sleep with extra pillows to breathe better?
• Do you have any cough or sputum production?
• Have you had any recent illness, surgery, or prolonged immobility?
• Do you drink alcohol? If so, what do you drink and how many drinks per day?
• Do you have any of the following problems: fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, night sweats?
• Do you experience: wheezing, chest tightness, difficulty catching breath?
• How long does your shortness of breath last?
• Do you have any of the following: dizziness, fainting, lightheadedness, weakness?
• Do you have problems with: nausea, vomiting, abdominal pain?
• How is your overall health?
• Tell me about your work and recent activities.
• Tell me about your smoking history.

Physical Exam:

• Vitals: pulse, BP, respirations, oxygen saturation
• Examine skin and general appearance
• Neck: measure JVP (jugular venous pressure)
• Neck: auscultate carotid arteries
• Chest wall & lungs:
  • Visual inspection of anterior & posterior chest
  • Palpate anterior & posterior chest
  • Percuss lung fields
  • Auscultate lungs
• Heart:
  • Palpate for PMI (Point of Maximal Impact)
  • Auscultate heart
• Abdomen:
  • Inspect for distention
  • Palpate abdomen
• Extremities: Visual inspection for edema, cyanosis, clubbing

Assessment note: S.G. is a 63-year-old female presenting with acute onset of severe dyspnea and breathing difficulty following air travel. Physical exam notable for respiratory distress with elevated respiratory rate (26), severely decreased oxygen saturation (70%), S4 gallop, and hypertension (155/90). Clear lung sounds with no wheezing or rales, no bilateral lower extremity edema noted. PMH significant for COPD, HTN, anxiety, depression, and 17-year smoking history.

Diagnostic Tests: Chest X-ray, ECG, ABG, D-dimer, BNP, CBC, Basic metabolic panel, PT/PTT

Diagnosis: Acute heart failure with possible pulmonary embolism

Plan:

• Immediate oxygen therapy and respiratory support
• Urgent cardiology consultation
• Consider CT pulmonary angiogram based on Wells score and D-dimer results
• Echocardiogram to assess cardiac function
• Optimize heart failure management with ACE inhibitors, diuretics, and beta-blockers
• Anticoagulation if pulmonary embolism confirmed
• Smoking cessation counseling and pulmonary rehabilitation referral
• Close follow-up within 48-72 hours

Susi Green SOAP Note

Patient: Susi Green Subjective Data

CC: 63-year-old female presents with “sudden shortness of breath and severe difficulty breathing”

HPI: 63-year-old female presents today with complaints of acute onset severe dyspnea that began as she was getting off a plane today. The patient describes having to stop walking to catch her breath and reports significant difficulty with stairs, needing to stop walking every 10 or 20 yards. She denies shortness of breath at rest, cough, wheezing, bilateral lower extremity swelling, or fever. She also denies any palpitations, chest pain, or excessive sweating. The patient appears anxious and distressed about her breathing difficulty. Upon physical examination, the patient has significantly compromised respiratory status with oxygen saturation of 70% and labored breathing.

Medications: Antihypertensive medications (specific medications to be clarified)

Allergies: (medication, environmental, food) The patient denies any known medication, environmental, or food allergies

PMH: Hypertension, COPD, anxiety, and depression. Significant smoking history starting at age 19 for 17 years. Denies other chronic medical conditions.

LNMP/OB History (if indicated): Post-menopausal female, obstetric history deferred for this acute presentation.

PSH: Denies any recent surgical procedures.

Sexual History (if indicated): Deferred for this exam.

Hospitalizations: Previous hospitalizations to be clarified.

Health Maintenance: Reports following up with primary care provider for hypertension and COPD management.

Immunizations: Immunizations status to be updated, likely due for pneumonia and influenza vaccines.

Family History: Family history of cardiovascular and pulmonary disease to be elicited.

Substances (Tobacco, alcohol, illicit drugs, caffeine): Significant smoking history – started smoking at age 19 and continued for 17 years. Current tobacco use status to be clarified. Denies illicit drug use. Alcohol consumption history to be obtained.

Home environment: Lives independently, home safety assessment needed given respiratory compromise.

Employment type: Employment status and recent activities including air travel to be detailed.

Diet: Dietary habits and sodium intake assessment needed for heart failure management.

Sleep: Sleep patterns and presence of orthopnea or paroxysmal nocturnal dyspnea to be assessed.

Exercise: Exercise tolerance significantly decreased with current presentation.

Safety: Safety assessment needed given respiratory distress and potential falls risk.

Objective Data

ROS: (Perform an appropriate ROS based on the C/C and HPI; documented in i-Human assignment; performed in final focused exam)

General: Patient appears stressed and anxious with significant respiratory distress. Alert and oriented but appears uncomfortable secondary to breathing difficulty.

Skin, Hair and Nails: Skin assessment for cyanosis, diaphoresis, and perfusion status. Check capillary refill and skin temperature.

HEENT: Assess for signs of respiratory distress, use of accessory muscles, nasal flaring. Check for central cyanosis around lips and oral mucosa.

NECK: Assess jugular venous distention as indicator of right heart failure or volume overload. Check for lymphadenopathy or masses.

Thorax and Lungs: Respiratory rate elevated at 26 with labored breathing. Lung sounds clear in all lung fields with no wheezing or rales noted. Assess for use of accessory muscles and chest wall movement symmetry.

Cardiovascular: Blood pressure elevated at 155/90. S4 gallop heard on auscultation. Assessment for additional heart sounds, murmurs, and peripheral perfusion. Check for signs of heart failure including displaced PMI.

Peripheral Vascular: No bilateral lower extremity edema noted. Assess peripheral pulses and signs of deep vein thrombosis.

Abdomen: Assess for hepatomegaly or ascites as signs of right heart failure. Check for abdominal distention or tenderness.

Genitourinary: Deferred for this acute presentation.

Metabolic/Hematologic: Assess for signs of hypoxia, fatigue, and metabolic derangements.

Psychiatric: Patient appears anxious and distressed secondary to respiratory symptoms. Assess for baseline anxiety and depression management.

Musculoskeletal: Assess for signs of chronic respiratory disease including barrel chest or clubbing.

Neurologic: Assess for signs of hypoxia including confusion, restlessness, or altered mental status.

Vital Signs: Temperature: 98.6°F, Pulse: 88, BP: 155/90, Respirations: 26 (labored) SpO2: 70%

Assessment

General: 63-year-old female in moderate to severe respiratory distress, appears anxious and uncomfortable. Alert and oriented but showing signs of respiratory compromise with significantly low oxygen saturation.

Skin, Hair and Nails: Skin assessment reveals possible cyanosis, warm and dry skin with delayed capillary refill consistent with poor oxygenation.

HEENT: No acute distress noted in head and neck examination. No jugular venous distention appreciated. Oral mucosa may show central cyanosis.

NECK: Full range of motion, no stiffness or pain noted. Thyroid examination within normal limits.

Thorax and Lungs: Respiratory rate significantly elevated at 26 with labored breathing effort. Lung fields clear to auscultation bilaterally with no wheezing, crackles, or rhonchi. Chest expansion symmetric.

Cardiovascular: Hypertensive with BP 155/90. Notable S4 gallop on cardiac auscultation suggesting decreased ventricular compliance. Regular rate and rhythm, no murmurs or rubs appreciated.

Peripheral Vascular: No peripheral edema noted in bilateral lower extremities. Peripheral pulses palpable but may be diminished secondary to poor perfusion.

Abdomen: Soft, non-tender, no organomegaly or masses appreciated. Bowel sounds normal.

Psychiatric: Anxious affect appropriate to clinical situation. Cooperative with examination but appears distressed.

Musculoskeletal: No acute musculoskeletal distress noted. Assessment for chronic changes related to COPD.

Neurologic: Alert and oriented, no focal neurological deficits. Mild restlessness consistent with hypoxia.

Differential Diagnoses

Pulmonary Embolism: The patient’s presentation with acute dyspnea following air travel, along with significantly low oxygen saturation (70%) and clear lung sounds, strongly suggests possible pulmonary embolism. Recent air travel is a major risk factor, and the acute onset with severe hypoxia is characteristic.

Acute Heart Failure Exacerbation: The presence of an S4 gallop, hypertension, and acute dyspnea with exercise intolerance suggests acute heart failure. The patient’s age, hypertension history, and smoking history are significant risk factors for heart failure.

COPD Exacerbation: Given the patient’s established COPD diagnosis and significant smoking history, an acute exacerbation could explain the respiratory distress. However, the clear lung sounds without wheezing make this less likely as the primary diagnosis.

Anxiety Attack: The patient has a history of anxiety and appears stressed/anxious. However, the significantly low oxygen saturation and clear physical findings suggest an organic cause rather than purely psychological.

Most Likely Diagnosis: Acute heart failure with possible concurrent pulmonary embolism. The combination of acute dyspnea following air travel, S4 gallop, hypertension, and severely decreased oxygen saturation (70%) with clear lung sounds strongly suggests these diagnoses. Further diagnostic testing including CT pulmonary angiogram, echocardiogram, and BNP levels would help confirm the diagnosis.

Plan

Health Promotion: (appropriate screening, disease prevention, and health promotion according to the patient’s age, gender, and identified risk factors…not diagnosis specific)

✓ Cardiovascular Health – Continue monitoring and optimization of blood pressure control, lipid screening, and diabetes screening given age and risk factors.

✓ Pulmonary Health – Smoking cessation counseling if still smoking, pulmonary function testing, and vaccination against pneumonia and influenza.

✓ Osteoporosis Screening – Bone density screening for post-menopausal female with risk factors.

Screening

✓ Cancer Screening – Age-appropriate mammography, colonoscopy, and cervical cancer screening if applicable.

✓ Cardiovascular Screening – Lipid panels, diabetes screening, and cardiac risk assessment.

Immunizations

✓ Pneumococcal vaccine – Especially important given COPD and age ✓ Annual influenza vaccine ✓ COVID-19 vaccination – High risk patient

Complete Step-by-Step Guide to Writing the Susi Green iHuman Case Study

Completing the Susi Green iHuman case requires a systematic approach focused on acute cardiopulmonary assessment in older adults. This comprehensive guide will walk you through each section of the simulation, providing specific strategies and key points to ensure you achieve the required 70% score.

Step 1: Pre-Case Preparation and Initial Approach

Before diving into the case, review the doorway information and formulate your initial clinical approach for an acute respiratory presentation.

Key Information to Note:

• 63-year-old female with “sudden shortness of breath and severe difficulty breathing”
• Acute onset following air travel
• Consider immediate life-threatening causes: pulmonary embolism, acute heart failure, pneumothorax

Initial Clinical Mindset: Approach this case with emergency assessment priorities. The combination of acute dyspnea, post-travel presentation, and significantly low oxygen saturation requires immediate systematic evaluation for life-threatening conditions.

Step 2: Conducting the History of Present Illness (HPI)

The HPI is crucial for identifying the cause of acute dyspnea. Use the OLDCARTS method systematically:

Onset: Ask about exact timing and circumstances

• Key points to elicit: Started today after getting off airplane, acute onset

Location: Determine if dyspnea is associated with chest pain or discomfort

• Target response: Denies chest pain or pressure

Duration: How long episodes last and pattern

• Important detail: Continuous since onset, worse with minimal exertion

Character: Detailed description of breathing difficulty

• Critical descriptor: Severe, “can’t catch my breath,” suffocating sensation

Aggravating factors: What makes breathing worse

• Essential findings: Any minimal exertion, walking, stairs

Relieving factors: What provides any relief

• Key response: Minimal relief even at rest

Timing/Treatment: Pattern and any attempted treatments

• Important pattern: Acute onset, progressively worsening

Severity: Breathing difficulty scale rating

• Typical response: 8-9/10 severity

Associated Symptoms:

• Ask specifically about: chest pain (denied), palpitations (denied), leg swelling (denied), cough (denied)
• Key finding: Severe exercise intolerance, anxiety/distress

Step 3: Review of Systems (ROS)

Conduct a thorough but focused ROS for acute dyspnea:

Cardiovascular:

• Chest pain/pressure, palpitations, syncope
• Exercise tolerance changes (significant finding)
• Orthopnea, paroxysmal nocturnal dyspnea
• Peripheral edema

Respiratory:

• Cough, sputum production, hemoptysis
• Wheezing, chest tightness
• Recent respiratory infections

General:

• Recent travel history (critical finding)
• Immobilization, recent surgery
• Weight changes, fever

Hematologic:

• Easy bruising, bleeding
• Previous clotting disorders

Step 4: Past Medical History, Social History, and Family History

Past Medical History:

• COPD, hypertension, anxiety, depression
• Previous hospitalizations for respiratory or cardiac issues
• Recent surgeries or procedures

Family History:

• Family history of clotting disorders, heart disease, lung disease
• Sudden cardiac death or pulmonary embolism

Social History:

• Smoking history: started at age 19, smoked for 17 years
• Current tobacco use status
• Alcohol consumption, drug use
• Recent travel details (flights, duration, immobility)
• Occupation and activity level

Step 5: Physical Examination Strategy

Perform a systematic examination focusing on cardiopulmonary systems:

Vital Signs:

• Expected findings: Hypertension (155/90), tachypnea (RR 26), severely low oxygen saturation (70%)

Cardiovascular Examination:

• Inspection: Look for jugular venous distention, peripheral cyanosis
• Palpation: Check PMI, peripheral pulses, assess for leg swelling
• Auscultation: Listen for S4 gallop (key finding), murmurs, rubs

Pulmonary Examination:

• Inspection: Assess respiratory effort, use of accessory muscles
• Palpation: Check for chest wall tenderness, crepitus
• Percussion: Assess for dullness or hyperresonance
• Auscultation: Clear lung sounds (important negative finding)

Additional Key Exams:

• Lower extremity examination: Check for edema (none noted), signs of DVT
• Neurologic: Assess for signs of hypoxia or confusion
• Skin: Check for cyanosis, diaphoresis

Step 6: Developing Differential Diagnoses

Propose appropriate differentials with rationales:

Primary Considerations:

Pulmonary Embolism

• Supporting evidence: Recent air travel, acute dyspnea, severely low oxygen saturation, clear lung sounds
• High-probability diagnosis given presentation

Acute Heart Failure

• Supporting evidence: S4 gallop, hypertension, age, exercise intolerance
• Could be concurrent with PE

Secondary Considerations:

• COPD Exacerbation: Less likely given clear lung sounds and lack of wheezing
• Pneumonia: Less likely given clear lung sounds and no fever
• Anxiety: Cannot explain severe hypoxia

Step 7: Diagnostic Test Interpretation

Order and interpret appropriate tests:

Immediate Tests Needed:

• Chest X-ray: Rule out pneumothorax, pneumonia
• ECG: Look for signs of right heart strain
• ABG: Assess oxygenation and acid-base status
• D-dimer: Screen for clotting (if low, helps rule out PE)

Additional Tests:

• CT Pulmonary Angiogram: Gold standard for PE diagnosis
• Echocardiogram: Assess cardiac function and right heart strain
• BNP: Evaluate for heart failure
• CBC, Basic metabolic panel: Baseline studies

Step 8: Final Diagnosis and Most Significant Active Problem (MSAP)

Primary Diagnosis: Acute Heart Failure with possible Pulmonary Embolism

Justification:

• Acute dyspnea following air travel with severely low oxygen saturation (70%)
• S4 gallop indicating cardiac dysfunction
• Clear lung sounds ruling out primary pulmonary causes
• Post-travel presentation raising PE suspicion

MSAP Selection: Choose “Acute Heart Failure” or “Pulmonary Embolism” as your Most Significant Active Problem, depending on diagnostic test results.

Step 9: Comprehensive Management Plan

Develop an immediate and long-term treatment approach:

Immediate Management:

• Oxygen therapy to maintain SpO2 >90%
• Continuous cardiac monitoring
• IV access for emergency medications
• Wells score calculation for PE probability

Pharmacological Interventions:

• Diuretics: If heart failure confirmed (furosemide)
• Anticoagulation: If PE suspected (heparin protocol)
• ACE inhibitors: For heart failure management (when stable)
• Beta-blockers: Heart rate and blood pressure control (when appropriate)

Diagnostic Workup:

• Urgent CT pulmonary angiogram if PE suspected
• Echocardiogram for cardiac function assessment
• Serial cardiac enzymes and BNP levels

Follow-up Plan:

• Cardiology consultation
• Pulmonology referral if PE confirmed
• Close monitoring for 48-72 hours
• Smoking cessation counseling
• Cardiac rehabilitation referral

Step 10: Documentation and Submission Tips

Writing Your Summary:

• Create a concise 350-word summary emphasizing the emergency nature
• Include how you prioritized life-threatening diagnoses
• Cite specific assessment findings and critical lab values
• Use emergency medicine terminology appropriately

Key Documentation Elements:

• Assessment Statement: Emphasize acuity and severity of presentation
• Clinical Reasoning: Explain emergency diagnostic approach
• Evidence Correlation: Link physical findings to probable diagnoses
• Management Rationale: Justify immediate interventions

Final Submission Checklist:

• ✓ Complete acute dyspnea assessment with OLDCARTS
• ✓ Comprehensive cardiopulmonary physical exam
• ✓ Appropriate emergency differential diagnoses
• ✓ Correct prioritization of life-threatening conditions
• ✓ Evidence-based emergency management plan
• ✓ Professional documentation with proper medical terminology

Susi Green iHuman Case Summary

Grading Criteria: The Susi Green iHuman case evaluates your ability to assess acute cardiopulmonary conditions in older adults. Here’s what you need to focus on to maximize your score:

(1) History Taking (Critical Points):

You must ask targeted questions about dyspnea characteristics and associated symptoms. Essential questions include: onset timing (acute vs chronic), relationship to recent travel, exercise tolerance changes, presence of chest pain, palpitations, or leg swelling, and orthopnea/PND symptoms. Don’t miss asking about: smoking history, previous cardiac or pulmonary disease, recent immobilization, and family history of clotting disorders. The rubric rewards students who ask about recent travel history and immobilization risks.

(2) Physical Examination (Emergency Focus):

Prioritize cardiopulmonary systems with attention to signs of respiratory distress. Must-do components: complete vital signs (noting severe hypoxia), cardiac auscultation for gallops and murmurs, comprehensive lung examination, assessment of JVP, and lower extremity examination for DVT signs. Pro tip: The rubric awards significant points for recognizing the S4 gallop and correlating clear lung sounds with the clinical presentation.

(3) Differential Diagnosis (Life-threatening First):

You need to consider life-threatening causes first. Expected differentials include: pulmonary embolism (primary concern given travel), acute heart failure, COPD exacerbation, and pneumothorax. Scoring secret: The rubric heavily weighs your ability to recognize the significance of post-travel acute dyspnea with severe hypoxia.

(4) Final Diagnosis & MSAP:

You must correctly identify acute heart failure with possible pulmonary embolism as your primary concerns. Justification should cite the post-travel presentation, S4 gallop, and severe hypoxia as supporting evidence.

(5) Management Plan (Emergency Protocols):

The rubric expects immediate stabilization measures including oxygen therapy, cardiac monitoring, and urgent diagnostic testing. High-scoring responses mention: Wells score calculation, CT pulmonary angiogram indications, echocardiogram necessity, and appropriate anticoagulation protocols.

(6) Patient Communication:

Demonstrate understanding of the emergency nature while providing reassurance. Bonus points for: explaining the need for immediate testing, discussing travel-related risks, and providing clear discharge instructions for warning signs.

Example of a High-Scoring Clinical Summary

Here’s how a top-performing student might document this case:

Patient Summary – Susi Green

Situation: 63-year-old female presenting with acute onset severe dyspnea following air travel with critically low oxygen saturation.

Background: Significant risk factors including COPD, hypertension, extensive smoking history, and recent prolonged air travel. No acute chest pain but severe exercise intolerance requiring frequent rest stops.

Assessment: Physical examination notable for respiratory distress, hypertension (155/90), S4 gallop, and critically low oxygen saturation (70%) with paradoxically clear lung sounds. This constellation of findings following air travel strongly suggests pulmonary embolism with possible concurrent acute heart failure.

Recommendation:

• Immediate oxygen therapy and continuous monitoring
• Urgent CT pulmonary angiogram based on high Wells score
• Echocardiogram to assess right heart strain and left ventricular function
• Anticoagulation protocol if PE confirmed
• BNP and troponin levels to evaluate heart failure
• Cardiology consultation for ongoing management
• DVT prophylaxis education and smoking cessation counseling
• Close follow-up within 24-48 hours

Patient Education Provided: Explained the serious nature of symptoms, importance of immediate diagnostic testing, travel-related clotting risks, and clear instructions to return immediately for worsening symptoms or chest pain.

Conclusion

By following this comprehensive approach to the Susi Green case, you’ll demonstrate the critical thinking skills needed for acute cardiopulmonary assessment. Remember, success in emergency presentations requires rapid systematic evaluation: prioritize life-threatening conditions, perform focused but complete physical examination, consider high-probability diagnoses first, and implement immediate stabilization measures. The key is treating each iHuman simulation as a real emergency – be thorough, think critically, and always prioritize patient safety through appropriate urgency. With this guide, you’re well-prepared to excel in this challenging acute care simulation.

Frequently Asked Questions

What is the correct diagnosis for Susi Green’s breathing difficulty?

Susi Green’s presentation most likely represents acute heart failure with possible concurrent pulmonary embolism. The key distinguishing features include acute onset dyspnea following air travel, critically low oxygen saturation (70%), S4 gallop indicating cardiac dysfunction, and paradoxically clear lung sounds. Students often focus on COPD given her history, but the acute presentation, travel history, and severe hypoxia point toward more serious conditions requiring emergency intervention.

What are the critical physical exam components I need to perform for this case

Essential physical exam elements include complete vital signs (emphasizing the low oxygen saturation), comprehensive cardiac auscultation to identify the S4 gallop, thorough lung examination noting clear breath sounds, assessment of jugular venous pressure, and careful lower extremity examination for signs of deep vein thrombosis. Many students miss the significance of the S4 gallop combined with clear lung sounds, which is a crucial combination pointing toward heart failure rather than primary pulmonary disease.

How do I pass the Susi Green case and meet the 70% requirement?

Success requires recognizing this as an emergency presentation requiring immediate intervention. Focus on systematic assessment of acute dyspnea using OLDCARTS, emphasizing recent travel history and acute onset. Perform complete cardiopulmonary examination, propose appropriate life-threatening differentials (pulmonary embolism and heart failure), and develop an emergency management plan including oxygen therapy, cardiac monitoring, and urgent diagnostic testing. The key is demonstrating emergency medicine thinking rather than routine outpatient assessment.

What diagnostic tests should I order and why?

The diagnostic workup should prioritize ruling out life-threatening conditions. Given the post-travel presentation with severe hypoxia, immediate tests should include CT pulmonary angiogram to rule out pulmonary embolism, echocardiogram to assess cardiac function and right heart strain, arterial blood gas to quantify hypoxia, and D-dimer as a screening test. Additional tests include chest X-ray, ECG for right heart strain patterns, BNP for heart failure assessment, and basic metabolic panel. Students often forget to consider the Wells score calculation for PE probability, which is crucial for proper risk stratification.