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
- Negative for asthma and other respiratory conditions
- Type 2 diabetes, hypertension, and dyslipidemia
- Surgeries: hysterectomy at age 55; an appendectomy in her teens; right eye cataract removal earlier this year
- Had a QuantiFERON tuberculosis screening test 2 years ago which was negative
Current Meds – NKDA
•Metformin 500 mg bid
•HCTZ 25 mg daily
•Atenolol 25 mg daily
•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
•Vital signs: T 98, BP 138/86, HR 92, RR 34, HT 64, WT 155 lbs.
•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.
•HEENT: Normal.
•CV: RR&R. S1/S2 without audible extra sounds, rubs or murmurs.
•Respiratory: Initially some course crackles, which cleared with forceful coughing. Decreased breath sounds bilaterally with slight wheezing noted. Slightly increased AP ratio.
•Skin: Intact, pink, resilient. No rashes or lesions noted.
•MS: Full ROM, non-pitting edema ankles/feet bilaterally. Pulses 2+ bilaterally.
Critical Thinking Questions:
- What three conditions would be considered in your differential diagnosis, with most
likely condition listed first (with rationale)?
- What further history questions would you ask?
- What further examination, and diagnostic studies are warranted to
explore your differential diagnosis?
- What is the final most likely diagnosis?
