breath real case (chamberlain university) |
advanced ddx case play setup & full case
analysis 2025 November
Patient Information
Name: James Taylor
Age: 39 years
Sex: Male
Height: 5’8” (173 cm)
Weight: 140 lb (63.6 kg)
Occupation: Auto mechanic
Reason for Encounter: Shortness of breath
,HISTORY OF PRESENT ILLNESS
James is a 39-year-old man who presents with progressive
shortness of breath for the past 5 days.
Symptoms began gradually after he had what he describes
as a “bad cold” about 1 week ago.
He reports dry cough, now worsening, but denies coughing
up blood.
Shortness of breath is worse with exertion and when lying
flat.
He notes intermittent chest tightness, non-radiating, rated
3/10.
No chest pain at rest.
Reports fever (subjective), chills, and fatigue.
He denies:
Recent travel
History of asthma
History of DVT/PE
Known heart disease
Toxic exposures at work
He has also noticed increasing wheezing over the past 48 hours
and states he “can’t catch his breath” at night.
PAST MEDICAL HISTORY
Seasonal allergies
, No chronic lung disease
No cardiac history
No hypertension or diabetes
Medications:
Occasional loratadine during allergy season
OTC ibuprofen
Allergies:
NKDA
FAMILY HISTORY
Father: heart failure (onset age 58)
Mother: asthma
No family history of early cardiac death or thromboembolic
disease
SOCIAL HISTORY
Smokes ½ pack/day × 15 years
Drinks socially
No illicit drug use
Works in an auto shop with occasional exposure to dust and
fumes
REVIEW OF SYSTEMS
Positive:
Fever
Night sweats