CASE STUDY FOR JAMES TAYLOR –
39-YEAR OLD MALE WITH
SHORTNESS OF BREATH
(CHAMBERLAIN UNIVERSITY) |
ADVANCED DDX CASE PLAY SETUP
& FULL CASE ANALYSIS
Patient: James Taylor
Age: 39 years
Chief Complaint: “Shortness of breath.”
,◆
HISTORY OF PRESENT ILLNESS:
39-year-old male presenting with 3 days of progressively worsening
shortness of breath. Initially exertional, now present at rest. Associated
dry cough, mild dull chest tightness, and increased fatigue. Denies fever,
chills, sputum, leg swelling, recent travel, or sick contacts. Works in a
dusty warehouse environment. Former smoker (quit 6 years ago). History
of childhood intermittent asthma.
REVIEW OF SYSTEMS:
• Constitutional: Fatigue; no fever.
• HEENT: No congestion.
• Respiratory: Dyspnea, dry cough; no wheezing.
• Cardiac: Mild chest tightness; no palpitations.
• GI/GU: Negative.
• Extremities: No edema.
• Neuro: No dizziness/syncope.
VITAL SIGNS:
• BP 128/78
• HR 102
• RR 22
• Temp 98.6°F
, • SpO₂ 93% on RA
PHYSICAL EXAM:
General: Mild respiratory distress.
Lungs: Decreased breath sounds left lower lobe; faint crackles; no
wheezing.
Heart: Regular rhythm, tachycardic.
Extremities: No edema; no calf tenderness.
Neuro: A&O × 4.
Skin: Warm, dry.
LABS / IMAGING:
• CBC: WBC 12.4
• D-dimer: Normal
• CXR: Left lower lobe infiltrate c/w pneumonia
• ECG: Sinus tachycardia
ASSESSMENT:
Primary Diagnosis:
• J18.G – Community-acquired pneumonia, LLL
Secondary:
• R06.02 – Shortness of breath
• R05.1 – Acute cough
• R07.89 – Chest tightness
, • Z87.891 – Former smoker
• Z77.090 – Dust exposure at workplace
PLAN:
Medications
• Azithromycin: 500 mg PO day 1, then 250 mg PO daily × 4 days
• Albuterol HFA: 2 puffs q4–6h PRN
• Ibuprofen/acetaminophen PRN for chest discomfort
Non-pharmacologic
• Rest, hydration
• Avoid dust/smoke exposure
• Deep-breathing exercises, humidification
• Home monitoring for symptom progression
Education
• Complete full antibiotic course
• Return/ER precautions: worsening SOB, fever, chest pain,
hemoptysis, syncope
• Avoid smoking/vaping
Follow-up
• Clinic visit in 48–72 hours
• Consider repeat CXR in 6–8 weeks if symptoms persist
• Spirometry after recovery due to asthma history and dust exposure
Signature:
Date:
39-YEAR OLD MALE WITH
SHORTNESS OF BREATH
(CHAMBERLAIN UNIVERSITY) |
ADVANCED DDX CASE PLAY SETUP
& FULL CASE ANALYSIS
Patient: James Taylor
Age: 39 years
Chief Complaint: “Shortness of breath.”
,◆
HISTORY OF PRESENT ILLNESS:
39-year-old male presenting with 3 days of progressively worsening
shortness of breath. Initially exertional, now present at rest. Associated
dry cough, mild dull chest tightness, and increased fatigue. Denies fever,
chills, sputum, leg swelling, recent travel, or sick contacts. Works in a
dusty warehouse environment. Former smoker (quit 6 years ago). History
of childhood intermittent asthma.
REVIEW OF SYSTEMS:
• Constitutional: Fatigue; no fever.
• HEENT: No congestion.
• Respiratory: Dyspnea, dry cough; no wheezing.
• Cardiac: Mild chest tightness; no palpitations.
• GI/GU: Negative.
• Extremities: No edema.
• Neuro: No dizziness/syncope.
VITAL SIGNS:
• BP 128/78
• HR 102
• RR 22
• Temp 98.6°F
, • SpO₂ 93% on RA
PHYSICAL EXAM:
General: Mild respiratory distress.
Lungs: Decreased breath sounds left lower lobe; faint crackles; no
wheezing.
Heart: Regular rhythm, tachycardic.
Extremities: No edema; no calf tenderness.
Neuro: A&O × 4.
Skin: Warm, dry.
LABS / IMAGING:
• CBC: WBC 12.4
• D-dimer: Normal
• CXR: Left lower lobe infiltrate c/w pneumonia
• ECG: Sinus tachycardia
ASSESSMENT:
Primary Diagnosis:
• J18.G – Community-acquired pneumonia, LLL
Secondary:
• R06.02 – Shortness of breath
• R05.1 – Acute cough
• R07.89 – Chest tightness
, • Z87.891 – Former smoker
• Z77.090 – Dust exposure at workplace
PLAN:
Medications
• Azithromycin: 500 mg PO day 1, then 250 mg PO daily × 4 days
• Albuterol HFA: 2 puffs q4–6h PRN
• Ibuprofen/acetaminophen PRN for chest discomfort
Non-pharmacologic
• Rest, hydration
• Avoid dust/smoke exposure
• Deep-breathing exercises, humidification
• Home monitoring for symptom progression
Education
• Complete full antibiotic course
• Return/ER precautions: worsening SOB, fever, chest pain,
hemoptysis, syncope
• Avoid smoking/vaping
Follow-up
• Clinic visit in 48–72 hours
• Consider repeat CXR in 6–8 weeks if symptoms persist
• Spirometry after recovery due to asthma history and dust exposure
Signature:
Date:
