Comprehensive Adult Primary Care Case: James Taylor – Acute
Dyspnea, Right Calf Pain, and High-Risk DVT/PE Presentation |
Full Clinical Workup (2025)
, 1. Chief Complaint
Provider
Patient Answer
Question
“I’ve been having sudden shortness of breath since this
What brings
morning, and my right calf has been hurting and swollen
you in today?
for two days.”
2. History of Present Illness (HPI)
Provider Question Patient Answer
When did your shortness of breath “It started suddenly a few hours
start? ago.”
“I was just sitting at my desk when
Did anything trigger it?
it hit me.”
Is your shortness of breath constant “It’s been constant since it
or does it come and go? started.”
Can you rate the severity of your
“About a 7.”
breathing difficulty from 0–10?
Have you had breathing issues
“Never like this.”
before?
“Yes… sharp pain on the right side
Any chest pain?
when I breathe in.”
“Taking a deep breath or lying
Does anything make the pain worse?
flat.”
Do you feel dizzy or lightheaded? “A little.”
Have you had a cough? “Yes, a dry cough.”
“I noticed a small streak of blood
Any coughing up blood?
once.”
Dyspnea, Right Calf Pain, and High-Risk DVT/PE Presentation |
Full Clinical Workup (2025)
, 1. Chief Complaint
Provider
Patient Answer
Question
“I’ve been having sudden shortness of breath since this
What brings
morning, and my right calf has been hurting and swollen
you in today?
for two days.”
2. History of Present Illness (HPI)
Provider Question Patient Answer
When did your shortness of breath “It started suddenly a few hours
start? ago.”
“I was just sitting at my desk when
Did anything trigger it?
it hit me.”
Is your shortness of breath constant “It’s been constant since it
or does it come and go? started.”
Can you rate the severity of your
“About a 7.”
breathing difficulty from 0–10?
Have you had breathing issues
“Never like this.”
before?
“Yes… sharp pain on the right side
Any chest pain?
when I breathe in.”
“Taking a deep breath or lying
Does anything make the pain worse?
flat.”
Do you feel dizzy or lightheaded? “A little.”
Have you had a cough? “Yes, a dry cough.”
“I noticed a small streak of blood
Any coughing up blood?
once.”
