I Human Case week #4 A 15 Year Old
Male Reason For Encounter:
Shortness Of Breath Case
Assessment
CASE
Patient Information:
Initials: J.D.
Age/Sex: 15-year-old Male
Race/Ethnicity: African American
, Source: Self (accompanied by mother)
Reliability: Reliable
CHIEF COMPLAINT
"I can't catch my breath."
HISTORY OF PRESENT ILLNESS
The patient is a 15-year-old male who presents to the clinic with a chief complaint of
shortness of breath that began approximately 24 hours ago. He reports that the
shortness of breath started gradually but has progressively worsened. He describes it as
a feeling of "tightness" in his chest and an inability to get enough air. He rates the
severity as a 6/10 at rest, but it increases to 9/10 with minimal exertion, such as walking
to the bathroom.
Associated Symptoms:
Cough: Reports a non-productive, dry cough that started at the same time as the
SOB.
Wheezing: Endorses audible expiratory wheezing, which his mother also noticed
last night.
Chest Tightness: As described above.
Allergy Symptoms: Reports mild nasal congestion and sneezing over the past 3
days, which he attributes to "seasonal allergies."
Fever/Chills: Denies fever, chills, or night sweats.
Male Reason For Encounter:
Shortness Of Breath Case
Assessment
CASE
Patient Information:
Initials: J.D.
Age/Sex: 15-year-old Male
Race/Ethnicity: African American
, Source: Self (accompanied by mother)
Reliability: Reliable
CHIEF COMPLAINT
"I can't catch my breath."
HISTORY OF PRESENT ILLNESS
The patient is a 15-year-old male who presents to the clinic with a chief complaint of
shortness of breath that began approximately 24 hours ago. He reports that the
shortness of breath started gradually but has progressively worsened. He describes it as
a feeling of "tightness" in his chest and an inability to get enough air. He rates the
severity as a 6/10 at rest, but it increases to 9/10 with minimal exertion, such as walking
to the bathroom.
Associated Symptoms:
Cough: Reports a non-productive, dry cough that started at the same time as the
SOB.
Wheezing: Endorses audible expiratory wheezing, which his mother also noticed
last night.
Chest Tightness: As described above.
Allergy Symptoms: Reports mild nasal congestion and sneezing over the past 3
days, which he attributes to "seasonal allergies."
Fever/Chills: Denies fever, chills, or night sweats.
