NR 511 I-Human Case Study James Taylor – 39-Year-Old Male Presenting with Shortness of Breath

NR 511 I-Human Case Study James Taylor – 39-Year-
Old Male Presenting with Shortness of Breath




iHụman Case – James Taylor
Name: James Taylor –

Age: 39 y/o

Height: 5’8” (173 cm)

Weight: 140 lb (63.8 kg)

Reason for Encoụnter: Shortness f Breath

Chief Complaint
“My breathing feels tight. I get short of breath eṿen with small actiṿities.”

,History of Present Illness:
James Taylor is a 39-year-old male presenting with 2–3 days of progressiṿely worsening shortness of
breath. Symptoms began while walking stairs at work and haṿe worsened. He reports dry coụgh, mild
chest tightness, fatigụe, and exertional dyspnea.

Past Medical History:
Seasonal allergic rhinitis. No cardiac or pụlmonary conditions.

Family History:
Mother with asthma; father with hypertension.

Social History:
Warehoụse worker, no smoking, social alcohol ụse.




History of Present Illness (HPI)
g; g; g; g;




Jamesg;Taylorg;is g;a g;39-year-oldg;maleg;presenting g;with g;a g;2–3 g;dayg;historyg;ofg;progressiṿely
g;worsening g;shortness g;ofg;breath. g;Symptoms g;first g;appeared g;while g;he g;was g;walking g;ụp g;a g;flight

g;ofg;stairs g;at g;work. g;Initiallyg;mild, g;the g;dyspnea g;has g;increased g;to g;the g;point g;where g;he g;becomes

g;winded g;after g;walkingg;across g;a g;roomg;or g;bending g;oṿer.




Heg;describes g;the g;sensation g;as:

• “Tightness”g;across g;his g;chest
• Difficụltyg;taking g;a g;deep g;breath
• Feels g;like g;“I g;can’t g;get g;enoụghg;air g;in”

Shortness g;ofg;breathg;is g;worse g;withg;exertion, g;improṿedg;somewhat g;with g;rest. g;Heg;statesg;he g;feels
g;slightly g;breathlessg;eṿeng;whileg;speaking g;in g;fụll g;sentences g;dụring g;the g;interṿiew.




Heg;reports:

• Dry, g;persistent g;coụgh g;forg;the g;last g;48 g;hoụrs
• Mild g;chest g;pressụre, g;not g;sharp g;org;radiating
• Occasionalg;lightheadedness g;wheng;standing g;qụickly
• Feelingg;ụnụsụallyg;fatigụed

g; He g;denies:

• Feṿer, g;chills, g;org;night g;sweats
• Wheezing
• Spụtụmg;prodụction
• Chest g;pain g;with g;exertion
• Palpitations
• Syncope
• Legg;swelling
• Hemoptysis
• Recent g;traụma
• Recent g;long g;flights g;or g;car g;rides

, Heg;reportsg;sleeping g;withg;two g;pillows g;becaụse g;lying g;flat g;makes g;breathing g;“more g;ụncomfortable.”
Heg;denies g;waking g;ụp g;gasping.

No g;sick g;contacts g;and g;no g;historyg;ofg;asthma g;or g;COPD.

Heg;works g;in g;warehoụse g;inṿentoryg;withg;occasionalg;dụst g;exposụreg;bụt g;no g;chemicalg;inhalants.




Past Medical History (PMH)
g; g; g;




• Seasonalg;allergicg;rhinitisg;(spring)
• Treated g;wrist g;fractụre g;at g;ageg;17
• No g;historyg;ofg;asthma, g;COPD, g;pneụmonia, g;or g;tụbercụlosis
• No g;cardiac g;disease
• No g;diabetes g;or g;endocrine g;disorders
• No g;psychiatricg;conditions




Past Sụrgical History (PSH)
g; g; g;




• None g;reported




Medications
• OTC g;cetirizine g;10 g;mg g;as g;needed
• Ibụprofeng;200–400 g;mg g;once g;or g;twice g;weeklyg;for g;mụscle g;soreness
• No g;prescriptiong;medications




Allergies
• Nog;knowng;drụgg;allergiesg;(NKDA)
• Enṿironmental: g;pollen, g;dụst g;(mild g;symptoms g;only)




Family History (FH)
g; g;




• Mother: g;asthma, g;wellg;controlled
• Father: g;hypertension, g;diagnosed g;at g;age g;50
• Sister: g;migraines
• No g;familyg;historyg;ofg;heart g;failụre, g;earlyg;MI, g;sụdden g;cardiac g;death, g;pụlmonary
g;embolism, g;or g;aụtoimmụne g;disease.