,Patient Information
Name: Jacob Miller
Age: 15 years
Gender: Male
Setting: Emergency Department with Full Imaging and Laboratory
Capabilities
Chief Complaint: Shortness of breath
Date of Visit: July 17, 2025
History of Present Illness (HPI):
Jacob Miller, a 15-year-old Caucasian male, presents to the ED via
ambulance with a 1-day history of acute shortness of breath that began
abruptly during a basketball game at school 24 hours ago. He describes
the dyspnea as a tight, constricting sensation in his chest, rated 7/10 in
severity, accompanied by audible wheezing and difficulty completing
sentences. The symptoms escalated over the past 12 hours, with
increasing respiratory effort and a nonproductive, dry cough. Jacob
reports associated chest tightness but denies chest pain, fever, chills,
hemoptysis, or trauma. He used his albuterol metered-dose inhaler
(MDI, 90 mcg/puff, 2 puffs) three times today (6 puffs total, last dose 2
hours ago) with only transient relief, which is atypical as albuterol
, usually resolves his symptoms. His mother, present at the bedside,
reports Jacob has a history of asthma diagnosed at age 8, with
intermittent exacerbations (1-2 per year, typically triggered by exercise
or allergens). His last ED visit for asthma was 2 years ago, with no prior
hospitalizations or intubations. Jacob’s controller medication,
fluticasone propionate (110 mcg/puff, 1 puff twice daily), has been
used inconsistently, with missed doses 2-3 times per week due to
forgetting or feeling “fine” without it. The mother notes recent pollen
exposure (high pollen counts reported locally this week) and Jacob’s
increased basketball practice (3-4 sessions/week) as potential triggers.
No recent upper respiratory infections, travel, or new allergen
exposures (e.g., pets, foods) were reported. Jacob denies syncope,
palpitations, leg swelling, numbness, or neurological symptoms but
appears anxious about his breathing difficulty, stating, “I just want to
breathe normally again.” EMS administered oxygen (4 L/min via nasal
cannula) en route, improving his oxygen saturation from 90% (room air)
to 94%. The mother is concerned about the severity of this episode
compared to prior exacerbations and seeks immediate treatment and
prevention strategies.Explanation of HPI:
The HPI focuses on characterizing the shortness of breath to guide
diagnosis and urgency. The acute onset during exercise, presence of
wheezing, chest tightness, and nonproductive cough strongly suggest
Name: Jacob Miller
Age: 15 years
Gender: Male
Setting: Emergency Department with Full Imaging and Laboratory
Capabilities
Chief Complaint: Shortness of breath
Date of Visit: July 17, 2025
History of Present Illness (HPI):
Jacob Miller, a 15-year-old Caucasian male, presents to the ED via
ambulance with a 1-day history of acute shortness of breath that began
abruptly during a basketball game at school 24 hours ago. He describes
the dyspnea as a tight, constricting sensation in his chest, rated 7/10 in
severity, accompanied by audible wheezing and difficulty completing
sentences. The symptoms escalated over the past 12 hours, with
increasing respiratory effort and a nonproductive, dry cough. Jacob
reports associated chest tightness but denies chest pain, fever, chills,
hemoptysis, or trauma. He used his albuterol metered-dose inhaler
(MDI, 90 mcg/puff, 2 puffs) three times today (6 puffs total, last dose 2
hours ago) with only transient relief, which is atypical as albuterol
, usually resolves his symptoms. His mother, present at the bedside,
reports Jacob has a history of asthma diagnosed at age 8, with
intermittent exacerbations (1-2 per year, typically triggered by exercise
or allergens). His last ED visit for asthma was 2 years ago, with no prior
hospitalizations or intubations. Jacob’s controller medication,
fluticasone propionate (110 mcg/puff, 1 puff twice daily), has been
used inconsistently, with missed doses 2-3 times per week due to
forgetting or feeling “fine” without it. The mother notes recent pollen
exposure (high pollen counts reported locally this week) and Jacob’s
increased basketball practice (3-4 sessions/week) as potential triggers.
No recent upper respiratory infections, travel, or new allergen
exposures (e.g., pets, foods) were reported. Jacob denies syncope,
palpitations, leg swelling, numbness, or neurological symptoms but
appears anxious about his breathing difficulty, stating, “I just want to
breathe normally again.” EMS administered oxygen (4 L/min via nasal
cannula) en route, improving his oxygen saturation from 90% (room air)
to 94%. The mother is concerned about the severity of this episode
compared to prior exacerbations and seeks immediate treatment and
prevention strategies.Explanation of HPI:
The HPI focuses on characterizing the shortness of breath to guide
diagnosis and urgency. The acute onset during exercise, presence of
wheezing, chest tightness, and nonproductive cough strongly suggest
