Question

Chief Complaint A 58 y.o. presents with fatigue and difficulty catching her breath. Although she has frequently coughed for months, the fatigue and shortness of breath have come on 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, finally quitting successfully on her 58th birthday. Past Medical History • Negative for asthma and other respiratory conditions • Type 2 diabetes, hypertension, and increased lipids • Surgeries: hysterectomy at age 55; an appendectomy in her teens; cataract removals earlier this year Current Meds • Metformin 500 mg BID • HCTZ 25 mg daily • Atenolol 25 mg daily • Atorvastatin 10 mg daily Psychosocial History 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 this lately, as she says, “It is all I can do to make the bed some days!” 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. Articulate and seems to be a good historian. Fluid movements. • HEENT: Normal. • CV: RR&R. S1/S2 without audible extra sounds or murmurs. • Respiratory: Initially some crackles, which cleared with forceful cough. Decreased breath sounds, slight wheeze noted. Slight increased AP ratio. • Skin: Intact, pink, resilient. No rashes or lesions noted. • MS: Full ROM, nonpitting edema ankles/feet bilaterally. Pulses 2+ bilaterally. Questions 1. What three conditions would be considered in your differential diagnosis, with most likely condition listed first (with rationale)? 2. What further history, further examination, and diagnostic studies are warranted to explore your differential diagnosis? • History: • Physical examination: • Diagnostic studies: Further Evaluation The subsequent additional history and physical yields no positive findings. A chest x-ray demonstrates flattened diaphragm, no masses or other abnormalities. Spirometry: FEV1: 58% of predicted, FVC: 70% of predicted. FEV1/FVC: 54%. CBC WNL. Chemistries WNL. 3. What is the final diagnosis?

Chief Complaint
A 58 y.o. presents with fatigue and difficulty catching her breath. Although she has frequently coughed for months, the fatigue and shortness of breath have come on 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, finally quitting successfully on her 58th birthday.

Past Medical History
• Negative for asthma and other respiratory conditions
• Type 2 diabetes, hypertension, and increased lipids
• Surgeries: hysterectomy at age 55; an appendectomy in her teens; cataract removals earlier this year

Current Meds
• Metformin 500 mg BID
• HCTZ 25 mg daily
• Atenolol 25 mg daily
• Atorvastatin 10 mg daily

Psychosocial History
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 this lately, as she says, “It is all I can do to make the bed some days!”

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. Articulate and seems to be a good historian. Fluid movements.
• HEENT: Normal.
• CV: RR&R. S1/S2 without audible extra sounds or murmurs.
• Respiratory: Initially some crackles, which cleared with forceful cough. Decreased breath sounds, slight wheeze noted. Slight increased AP ratio.
• Skin: Intact, pink, resilient. No rashes or lesions noted.
• MS: Full ROM, nonpitting edema ankles/feet bilaterally. Pulses 2+ bilaterally.

Questions
1. What three conditions would be considered in your differential diagnosis, with most likely condition listed first (with rationale)?
2. What further history, further examination, and diagnostic studies are warranted to explore your differential diagnosis?
• History:
• Physical examination:
• Diagnostic studies:

Further Evaluation
The subsequent additional history and physical yields no positive findings. A chest x-ray demonstrates flattened diaphragm, no masses or other abnormalities. Spirometry: FEV1: 58% of predicted, FVC: 70% of predicted. FEV1/FVC: 54%. CBC WNL. Chemistries WNL.

3. What is the final diagnosis?

Added by Brian M.

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