Reference no: EM133838437
Problem
Respiratory System Case Study
Chief Complaint: Fatigue and shortness of breath.
HPI: A 58-year-old female presents with fatigue and difficulty catching her breath. Although she has frequently coughed for months, the fatigue and shortness of breath have new onset over the past 2 months. She has been treated twice in the past year for bronchitis, which included a severe cough with yellow sputum, shortness of breath, and fever. Once treated, the shortness of breath resolved until recently. She is a former smoker, describing a 40-pack-a-year history and finally quitting successfully on her 56th birthday.
Past Medical History
1) Negative for asthma and other respiratory conditions
2) Type 2 diabetes, hypertension, and dyslipidemia
3) Surgeries: hysterectomy at age 55; an appendectomy in her teens; right eye cataract removal earlier this year
4) Had a QuantiFERON tuberculosis screening test 2 years ago which was negative
Current Meds - NKDA
1) Metformin 500 mg bid
2) HCTZ 25 mg daily
3) Atenolol 25 mg daily
4) Atorvastatin 10 mg daily
Family Medical History
Father deceased at age 80 - stroke
Mother 81 years old - alive and well
Son - 32 years old - alive and well
Psychosocial History
Married. Works 2 days a week as a sales associate in the local department store and volunteers 1 day a week at the local library. Has recently taken a leave from her volunteer role and has decreased from 8-hour to 4-hour work days at the store because of the fatigue. Used to walk daily but has quit lately, as she says, "It is all I can do to make the bed some days!" Has a few drinks on the weekend - no more than two or three total.
Physical Examination
1) Vital signs: T 98, BP 138/86, HR 92, RR 34, HT 64, WT 155 lbs.
2) General: Appearance in no acute distress. Alert and oriented. Well groomed. Well developed, well nourished. Articulate and seems to be a good historian. Fluid movements.
3) HEENT: Normal.
4) CV: RR&R. S1/S2 without audible extra sounds, rubs or murmurs.
5) Respiratory: Initially some course crackles, which cleared with forceful coughing. Decreased breath sounds bilaterally with slight wheezing noted. Slightly increased AP ratio.
6) Skin: Intact, pink, resilient. No rashes or lesions noted.
7) MS: Full ROM, non-pitting edema ankles/feet bilaterally. Pulses 2+ bilaterally.
Task
A. What three conditions would be considered in your differential diagnosis, with most likely condition listed first (with rationale)?
B. What further history questions would you ask? Get the instant assignment help.
C. What further examination, and diagnostic studies are warranted to explore your differential diagnosis?
D. What is the final most likely diagnosis?