History of present illness

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Reference no: EM133805671

Question

Chief complaint:"SOB and Fatigue" History of present illness: A 65 year old woman presents to the office complaining of worsening shortness of breath and palpitations for about 1 week. She reports "feeling dizzy" on and off for the past year, the dizziness is associated with weakness that has been worsening for the pastonth, she has been feeling "too tires" to even walk to her backyard and water her flower bed, which she used to do "all the time". She had a normal screening colonoscopy about 5 years ago. Past medical history: None Past surgical history : None Family history: Allergies :NKA Medications:. MVI ( multivitamins ) Immunizations: UTD ( up-to-date ) Social history : she occasionally has an alcoholic drinks and denies tobacco or drug use. Review of systems: Review of systems is significant for knee pain, for which she frequently takes aspirin or ibuprofen. Physical Exam: V/ S Oxygen 99% on RA, BP 150/85, HR 98, RR 14, Temp 98.4, weight : 150 lbs, height 5ft 7 inches, BMI 23.49 Significant findings on examination include conjunctival pallor, mild tenderness with deep palpation in the epigastric and left upper quadrant (LUQ) region of the abdomen, normal bowel sounds, and no organomegaly.

1. What other components of the HPI would you ask and why?

2. What ROS body systems would you ask about to solicit pertinent positives and Petrone t negatives and why? Consider specific body systems for whatever condition you are evaluating.

3. What are your differential diagnosis?

4. What is your suspected diagnosis?

5. What is the potential treatment and testing for this diagnosis?

Reference no: EM133805671

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