Directions:? Answer the case study questions. Each post must be at least 150 words.??References:? APA format 7th ed.? Three current references (not more tha

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:

1. What three conditions would be considered in your differential diagnosis, with most

likely condition listed first (with rationale)?

2. What further history questions would you ask?

3. What further examination, and diagnostic studies are warranted to

explore your differential diagnosis?

4. What is the final most likely diagnosis?

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