Case Study For James Taylor 39-Year Old Male With Shortness Of Breath (Chamberlain University) | Advanced Ddx Case

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 98.6F SpO 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: J18.9 - Community-acquired pneumonia, LLL Secondary: R06.02