Identify the patient chief complaint

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Question

A 30-year-old white female presents with feeling unwell with shortness of breath on exertion.

She reports that she was seen for similar symptoms previously at her primary care physician's office 6 months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid. Symptoms improved but now have gradually worsened over 6 months. She returns today stating, "My symptoms improved but the shortness of breath has progressed." She complains of being more fatigued and SOB with exertion and exercise.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, 6 months ago. She denies alcohol and illicit drug use. She is in a married, monogamous relationship and has two children aged 18 months and 4 years. She is employed in a cookie bakery.

Allergies: No known medicine, food, or environmental allergies

Past Medical History: Hypertension

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10 mg by mouth every day

Identify the patient's chief complaint.

Identify what physical exams and diagnostic tests would be most appropriate to gather more information about the patient's condition. Be specific and explain your reasoning.

Explain how the results would be used to make a diagnosis.

Identify three to five (3-5) possible conditions that may be considered in a differential diagnosis for the patient. Explain your thinking.

Reference no: EM133676128

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