Janis, a 59-year-old female, presents with tachypnea, dyspnea, on exertion, and mild chest discomfort

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Janis, a 59-year-old female, presents with tachypnea, dyspnea, on exertion, and mild chest discomfort. She was diagnosed with emphysema 4 years ago and was placed on a bronchodilator therapy. She has an 80 pack year history of smoking. "I feel short of breath when I walk, and my chest is sore." She describes her chest soreness as mild pressure, rated 2 on a 1-10 scale. The pain is over the anterior thorax, more pronounced in the ribs, which she believes has developed from coughing hard. She states she has had a nonproductive cough for 4 days and feels more fatigued than usual.

Subjective

Past medical history: she has osteoarthritis in the hands and knees. She has a surgical history of appendectomy and cholecystectomy. In the past year, she has had 2 exacerbations of her COPD and has attempted to stop smoking, using nicotine gum replacement unsuccessfully.

Family history: Noncontributory

Social history: She lives with her husband who also smokes 2 packs of cigarettes per day and cares for her elderly mother, who lives with them and is frail but ambulatory.

Medications: Albuterol MDI, 90 mcg/inhalation, 2 puffs as needed every 4-6 hours; ipratropium bromide MDI, 18 mcg/inhalation, 2 puffs 4 times/day; ibuprofen as needed for arthritic pain.

Allergies: Janis is allergic to Keflex and penicillin

Objective: Janis is dyspneic at rest, sitting. Use of accessory muscles evident. Pursed lip breathing noted.

Vital signs: B/P 122/64; P: 92; R: 26; T: 102; SpO2: 88. AP to transverse ratio is 1:1

Skin: warm and dry

HEENT: Negative

Cardiovascular: RRR; S1/S2; no murmurs, clips, rubs, or gallops. No evidence of peripheral edema. Posterior tibial and dorsalis pedis pulses 2+/4+

Respiratory: Lungs have diffused wheezing and crackles in the right upper lobe. Tenderness to palpation along intercostal spaces on right and left anterior and lateral thorax from 2nd to 5th intercostal spaces. PFT conducted 2 months ago prior to visit showed obstructive flow patterns and reduced FEV1/FVC.

Abdomen: soft, with bowel sounds; tympanic to percussion

Neurologic: Negative

Critical Thinking!

 

Which diagnostic or imaging studies would be considered to assist with or confirm the diagnosis?

What is the most likely differential diagnosis and why?

What is your plan of treatment?

What is your plan for follow-up care?

Are there any referrals?

What additional risk factors are evident for this patient?

Are there any standardized guidelines that you should use to treat this patient?