Case Study: James Taylor, 39-Year-Old Male With
Shortness of Breath – Comprehensive Clinical Assessment,
Differential Diagnosis, and Management
This case study reviews James Taylor, a 39-year-old male presenting with shortness of breath. It
includes a detailed patient assessment, differential diagnosis, diagnostic considerations, and
evidence-based treatment strategies for adult respiratory complaints in primary care.
James Taylor shortness of breath,
39-year-old male respiratory case,
adult dyspnea evaluation,
differential diagnosis shortness of breath,
primary care respiratory assessment,
,Patient Name: James Taylor
Age: 39 years
Gender: Male
Chief Complaint: Shortness of breath
S – Subjective
Chief Complaint (CC):
“I’ve been feeling short of breath.”
History of Present Illness (HPI):
James Taylor is a 39-year-old male who presents with complaints of shortness of breath that
began approximately several days ago. The patient reports that the dyspnea has gradually
,worsened and is now present with minimal exertion. He describes a sensation of chest tightness
and difficulty taking a deep breath. The shortness of breath is intermittent but has become more
frequent. He denies acute chest pain but reports occasional dry cough and fatigue. Symptoms are
exacerbated by physical activity and partially relieved by rest. He denies hemoptysis, dizziness, or
syncope. No recent travel or known exposure to individuals with respiratory illness is reported.
Past Medical History (PMH):
• Asthma (childhood or intermittent, if applicable)
• Seasonal allergies
• Denies history of COPD, heart failure, or thromboembolic disease
Past Surgical History (PSH):
• Denies any previous surgeries
Medications:
• Albuterol inhaler PRN (if applicable)
• Over-the-counter antihistamines as needed
Allergies:
• No known drug allergies (NKDA)
Family History:
• Father with hypertension
• Mother with asthma
• No family history of early cardiac disease or pulmonary embolism
Social History:
• Denies tobacco use (or specify current/former smoker if applicable)
• Denies illicit drug use
• Occasional alcohol use
• Works full-time; no occupational chemical exposures reported
Review of Systems (ROS):
• General: Reports fatigue; denies fever or weight loss
• HEENT: Denies sore throat or nasal congestion
• Respiratory: Positive for shortness of breath and occasional cough; denies wheezing or
hemoptysis
• Cardiovascular: Denies chest pain, palpitations, or edema
, • GI: Denies nausea, vomiting, or abdominal pain
• Neurological: Denies dizziness or weakness
• Psychiatric: Denies anxiety or panic attacks
O – Objective
Vital Signs:
• Temperature: 98.6°F (37°C)
• Blood Pressure: 128/82 mmHg
• Heart Rate: 102 bpm
• Respiratory Rate: 22 breaths/min
• Oxygen Saturation: 94% on room air
General Appearance:
Patient appears mildly anxious and mildly dyspneic but is alert and oriented.
HEENT:
• Head atraumatic, normocephalic
• Oropharynx clear, moist mucous membranes
Neck:
• Supple
• No jugular venous distention
• No lymphadenopathy
Respiratory:
• Increased work of breathing noted
• Mild use of accessory muscles
• Breath sounds diminished bilaterally
• Scattered expiratory wheezes present
• No crackles or rhonchi
Cardiovascular:
• Tachycardic
• Regular rhythm
• No murmurs, rubs, or gallops
Shortness of Breath – Comprehensive Clinical Assessment,
Differential Diagnosis, and Management
This case study reviews James Taylor, a 39-year-old male presenting with shortness of breath. It
includes a detailed patient assessment, differential diagnosis, diagnostic considerations, and
evidence-based treatment strategies for adult respiratory complaints in primary care.
James Taylor shortness of breath,
39-year-old male respiratory case,
adult dyspnea evaluation,
differential diagnosis shortness of breath,
primary care respiratory assessment,
,Patient Name: James Taylor
Age: 39 years
Gender: Male
Chief Complaint: Shortness of breath
S – Subjective
Chief Complaint (CC):
“I’ve been feeling short of breath.”
History of Present Illness (HPI):
James Taylor is a 39-year-old male who presents with complaints of shortness of breath that
began approximately several days ago. The patient reports that the dyspnea has gradually
,worsened and is now present with minimal exertion. He describes a sensation of chest tightness
and difficulty taking a deep breath. The shortness of breath is intermittent but has become more
frequent. He denies acute chest pain but reports occasional dry cough and fatigue. Symptoms are
exacerbated by physical activity and partially relieved by rest. He denies hemoptysis, dizziness, or
syncope. No recent travel or known exposure to individuals with respiratory illness is reported.
Past Medical History (PMH):
• Asthma (childhood or intermittent, if applicable)
• Seasonal allergies
• Denies history of COPD, heart failure, or thromboembolic disease
Past Surgical History (PSH):
• Denies any previous surgeries
Medications:
• Albuterol inhaler PRN (if applicable)
• Over-the-counter antihistamines as needed
Allergies:
• No known drug allergies (NKDA)
Family History:
• Father with hypertension
• Mother with asthma
• No family history of early cardiac disease or pulmonary embolism
Social History:
• Denies tobacco use (or specify current/former smoker if applicable)
• Denies illicit drug use
• Occasional alcohol use
• Works full-time; no occupational chemical exposures reported
Review of Systems (ROS):
• General: Reports fatigue; denies fever or weight loss
• HEENT: Denies sore throat or nasal congestion
• Respiratory: Positive for shortness of breath and occasional cough; denies wheezing or
hemoptysis
• Cardiovascular: Denies chest pain, palpitations, or edema
, • GI: Denies nausea, vomiting, or abdominal pain
• Neurological: Denies dizziness or weakness
• Psychiatric: Denies anxiety or panic attacks
O – Objective
Vital Signs:
• Temperature: 98.6°F (37°C)
• Blood Pressure: 128/82 mmHg
• Heart Rate: 102 bpm
• Respiratory Rate: 22 breaths/min
• Oxygen Saturation: 94% on room air
General Appearance:
Patient appears mildly anxious and mildly dyspneic but is alert and oriented.
HEENT:
• Head atraumatic, normocephalic
• Oropharynx clear, moist mucous membranes
Neck:
• Supple
• No jugular venous distention
• No lymphadenopathy
Respiratory:
• Increased work of breathing noted
• Mild use of accessory muscles
• Breath sounds diminished bilaterally
• Scattered expiratory wheezes present
• No crackles or rhonchi
Cardiovascular:
• Tachycardic
• Regular rhythm
• No murmurs, rubs, or gallops
