Chamberlain University NR 509 James Taylor Case Study – 39 Year-Old
Male With Progressive Worsening Dyspnea | Advanced Physical &
Family Assessment Practicum Track | Comprehensive Clinical
Assessment, Full History & Physical, Differential Diagnosis
I. Patient Demographics and Encounter Data
Field Information
Patient Name James Taylor
Age 39 years
Sex Male
,Field Information
Race/Ethnicity Caucasian
Occupation Warehouse Supervisor
Marital Status Married
Chief Complaint "I've been having shortness of breath for 3 days, and it's getting worse."
Encounter Type Acute outpatient evaluation
Source of History Patient, reliable historian
Language English
II. Comprehensive Health History
A. History of Present Illness (HPI)
James Taylor is a 39-year-old male who presents to the clinic with a 3-day history of
progressively worsening shortness of breath (dyspnea). He describes the onset as gradual,
beginning while he was performing routine supervisory duties at his warehouse workplace.
Initially, the dyspnea occurred only with moderate exertion (e.g., walking across the warehouse
floor), but over the past 24 hours, it has progressed to occur at rest and with minimal activity.
He rates his current breathlessness as 6/10 in severity.
He reports associated dry, non-productive cough that began approximately 48 hours
ago, intermittent dull chest tightness described as a "pressure" or "heaviness" across the
anterior chest (non-radiating, 2–3/10 intensity), and increased fatigue over the past week. He
notes mild orthopnea, requiring two pillows to sleep comfortably, which is new for him. He
denies fever, chills, night sweats, hemoptysis, pleuritic chest pain, palpitations, syncope, or leg
swelling. He reports that his symptoms are worse with exertion and improved somewhat with
rest. He has not tried any medications for these symptoms.
, The patient describes the sensation as "I can't get enough air in" and "my chest feels tight." He
reports feeling breathless even while speaking in full sentences. He denies any recent upper
respiratory infection, sick contacts, or known exposures to COVID-19.
Dyspnea is a subjective respiratory sensation characterized by insufficient air intake, arising
from complex physiologic, psychological, social, and environmental interactions. Acute
presentations occur in pulmonary embolism, asthma exacerbation, pneumonia, or heart failure,
whereas chronic manifestations develop in chronic obstructive pulmonary disease, interstitial
lung disease, obesity, or neuromuscular weakness. The symptom may appear as air hunger,
chest constriction, tachypnea, or increased respiratory effort, often restricting activity and
diminishing functional capacity.
B. Past Medical History (PMH)
Condition Details
Childhood Asthma Mild intermittent; never hospitalized; no inhaler use since adolescence
Seasonal Allergic Rhinitis Spring and fall exacerbations; managed with OTC antihistamines
No known cardiac history No hypertension, coronary artery disease, or heart failure
No history of DVT/PE No prior thromboembolic events
No history of pneumonia No prior hospitalizations for respiratory infections
Surgical History Appendectomy at age 16; no other surgeries
Immunizations Up to date; last influenza vaccine 10 months ago; COVID-19 vaccinated with boo
C. Current Medications
Male With Progressive Worsening Dyspnea | Advanced Physical &
Family Assessment Practicum Track | Comprehensive Clinical
Assessment, Full History & Physical, Differential Diagnosis
I. Patient Demographics and Encounter Data
Field Information
Patient Name James Taylor
Age 39 years
Sex Male
,Field Information
Race/Ethnicity Caucasian
Occupation Warehouse Supervisor
Marital Status Married
Chief Complaint "I've been having shortness of breath for 3 days, and it's getting worse."
Encounter Type Acute outpatient evaluation
Source of History Patient, reliable historian
Language English
II. Comprehensive Health History
A. History of Present Illness (HPI)
James Taylor is a 39-year-old male who presents to the clinic with a 3-day history of
progressively worsening shortness of breath (dyspnea). He describes the onset as gradual,
beginning while he was performing routine supervisory duties at his warehouse workplace.
Initially, the dyspnea occurred only with moderate exertion (e.g., walking across the warehouse
floor), but over the past 24 hours, it has progressed to occur at rest and with minimal activity.
He rates his current breathlessness as 6/10 in severity.
He reports associated dry, non-productive cough that began approximately 48 hours
ago, intermittent dull chest tightness described as a "pressure" or "heaviness" across the
anterior chest (non-radiating, 2–3/10 intensity), and increased fatigue over the past week. He
notes mild orthopnea, requiring two pillows to sleep comfortably, which is new for him. He
denies fever, chills, night sweats, hemoptysis, pleuritic chest pain, palpitations, syncope, or leg
swelling. He reports that his symptoms are worse with exertion and improved somewhat with
rest. He has not tried any medications for these symptoms.
, The patient describes the sensation as "I can't get enough air in" and "my chest feels tight." He
reports feeling breathless even while speaking in full sentences. He denies any recent upper
respiratory infection, sick contacts, or known exposures to COVID-19.
Dyspnea is a subjective respiratory sensation characterized by insufficient air intake, arising
from complex physiologic, psychological, social, and environmental interactions. Acute
presentations occur in pulmonary embolism, asthma exacerbation, pneumonia, or heart failure,
whereas chronic manifestations develop in chronic obstructive pulmonary disease, interstitial
lung disease, obesity, or neuromuscular weakness. The symptom may appear as air hunger,
chest constriction, tachypnea, or increased respiratory effort, often restricting activity and
diminishing functional capacity.
B. Past Medical History (PMH)
Condition Details
Childhood Asthma Mild intermittent; never hospitalized; no inhaler use since adolescence
Seasonal Allergic Rhinitis Spring and fall exacerbations; managed with OTC antihistamines
No known cardiac history No hypertension, coronary artery disease, or heart failure
No history of DVT/PE No prior thromboembolic events
No history of pneumonia No prior hospitalizations for respiratory infections
Surgical History Appendectomy at age 16; no other surgeries
Immunizations Up to date; last influenza vaccine 10 months ago; COVID-19 vaccinated with boo
C. Current Medications
