NR 509 Advanced Physical & Family Assessment Practicum – James
Taylor | 39-Year-Old Male With Progressive Shortness of Breath
Chamberlain University | Complete Case Study, Comprehensive Patient
Assessment, Advanced Differential Diagnoses, Clinical Decision-
Making & Evidence-Based Management Plan
,PATIENT PROFILE
Parameter Value
Patient Name James Taylor
Age 39 years
Sex Male
Race/Ethnicity Caucasian
Height 5'8" (173 cm)
Weight 140 lb (63.6 kg)
BMI 21.3 kg/m² (Normal weight)
Occupation Auto Mechanic
Setting Outpatient Primary Care Clinic
Chief Complaint (CC) "I've been having shortness of breath for the past 5 days."
SUBJECTIVE DATA
History of Present Illness (HPI) — OLDCARTS Format
, Component Details
Gradual onset over 5 days; began after what he describes as a "bad co
Onset
about 1 week ago
Location Diffuse chest; bilateral lung fields
Duration Persistent, progressively worsening each day
Dyspnea, worse with exertion and when lying flat (orthopnea);
Character
intermittent chest tightness, non-radiating, rated 3/10
Aggravating
Physical exertion (walking up stairs); lying flat; nighttime
Factors
Relieving
Rest; sitting upright
Factors
Timing Worse at night; progressive throughout the day
Severity 3/10 for chest tightness; dyspnea is moderate and limiting activity
Associated Symptoms:
• Dry cough, now worsening; denies hemoptysis
• Subjective fever and chills
• Fatigue
• Increasing wheezing over the past 48 hours
• "Can't catch his breath" at night
Taylor | 39-Year-Old Male With Progressive Shortness of Breath
Chamberlain University | Complete Case Study, Comprehensive Patient
Assessment, Advanced Differential Diagnoses, Clinical Decision-
Making & Evidence-Based Management Plan
,PATIENT PROFILE
Parameter Value
Patient Name James Taylor
Age 39 years
Sex Male
Race/Ethnicity Caucasian
Height 5'8" (173 cm)
Weight 140 lb (63.6 kg)
BMI 21.3 kg/m² (Normal weight)
Occupation Auto Mechanic
Setting Outpatient Primary Care Clinic
Chief Complaint (CC) "I've been having shortness of breath for the past 5 days."
SUBJECTIVE DATA
History of Present Illness (HPI) — OLDCARTS Format
, Component Details
Gradual onset over 5 days; began after what he describes as a "bad co
Onset
about 1 week ago
Location Diffuse chest; bilateral lung fields
Duration Persistent, progressively worsening each day
Dyspnea, worse with exertion and when lying flat (orthopnea);
Character
intermittent chest tightness, non-radiating, rated 3/10
Aggravating
Physical exertion (walking up stairs); lying flat; nighttime
Factors
Relieving
Rest; sitting upright
Factors
Timing Worse at night; progressive throughout the day
Severity 3/10 for chest tightness; dyspnea is moderate and limiting activity
Associated Symptoms:
• Dry cough, now worsening; denies hemoptysis
• Subjective fever and chills
• Fatigue
• Increasing wheezing over the past 48 hours
• "Can't catch his breath" at night
