Chamberlain university iHuman Case Study: James Taylor – 39 Year-Old Male Presenting With Shortness of Breath

Chamberlain university iHuman Case Study: James
Taylor – 39 Year-Old Male Presenting With Shortness of
Breath




iHuman Case – James Taylor
Name: James Taylor –

Age: 39 y/o

Height: 5’8” (173 cm)

Weight: 140 lb (63.8 kg)

Reason for Encounter: Shortnesss3fs3Breath

Chief Complaint
“Mys3breathings3feelss3tight.s3Is3gets3shorts3ofs3breaths3evens3withs3smalls3activities.”

,Historys3ofs3Presents3Illness:
Jamess3Taylors3iss3as339-year-olds3males3presentings3withs32–
3s3dayss3ofs3progressivelys3worsenings3shortnesss3ofs3breath.s3Symptomss3begans3whiles3walkings
3stairss3ats3works3ands3haves3worsened.s3Hes3reportss3drys3cough,s3milds3chests3tightness,s3fatigu
e,s3ands3exertionals3dyspnea.

Pasts3Medicals3History:
Seasonals3allergics3rhinitis.s3Nos3cardiacs3ors3pulmonarys3conditions.

Familys3History:
Mothers3withs3asthma;s3fathers3withs3hypertension.

Socials3History:
Warehouses3worker,s3nos3smoking,s3socials3alcohols3use.




History of Present Illness (HPI)
s3 s3 s3 s3


Jamess3Taylors3iss3as339-year-olds3males3presentings3withs3as32–
3s3days3historys3ofs3progressivelys3worsenings3shortnesss3ofs3breath.s3Symptomss3firsts3appeare
ds3whiles3hes3wass3walkings3ups3as3flights3ofs3stairss3ats3work.s3Initiallys3mild,s3thes3dyspneas3hass3
increaseds3tos3thes3points3wheres3hes3becomess3windeds3afters3walkings3acrosss3as3rooms3ors3bendi
ngs3over.

Hes3describess3thes3sensations3as:

 “Tightness”s3acrosss3hiss3chest
 Difficultys3takings3as3deeps3breath
 Feelss3likes3“Is3can’ts3gets3enoughs3airs3in”

Shortnesss3ofs3breaths3iss3worses3withs3exertion,s3improveds3somewhats3withs3rest.s3Hes3statess3he
s3feelss3slightlys3breathlesss3evens3whiles3speakings3ins3fulls3sentencess3durings3thes3interview.


Hes3reports:

 Dry,s3persistents3coughs3fors3thes3lasts348s3hours
 Milds3chests3pressure,s3nots3sharps3ors3radiating
 Occasionals3lightheadednesss3whens3standings3quickly
 Feelings3unusuallys3fatigue

ds3Hes3denies:

 Fever,s3chills,s3ors3nights3sweats
 Wheezing
 Sputums3production
 Chests3pains3withs3exertion
 Palpitations
 Syncope
 Legs3swelling
 Hemoptysis
 Recents3trauma

,  Recents3longs3flightss3ors3cars3rides