PBL Case Discussion: Pulmonary Part One (graded)
Setting: A free medical clinic that provides health care for the under-insured.
Your next patient, Margaret R., age 40, is a regular of the clinic and the last patient of the day. The chart states she is here for recent episodes of shortness of breath.
You enter the room and Margaret is dressed in work clothes, standing up looking at a health poster on the wall. You introduce yourself and ask her what brings her to the clinic today. "I think I have a cold. I've been having a hard time breathing on and off lately."
HPI: "I am short of breath sometimes and I'm not overly exerting myself when it happens. Sometimes it happens when I'm walking, talking or sitting. Reports that she has been noticing over the last three months that she has been getting short of breath during the week.
PMHx: Margaret R. reports her overall health as good.
Childhood/previous illnesses: chickenpox and eczema as a child
Chronic illnesses: Has seasonal allergies, spring is her worst season. Was seen by an allergy specialist ten years ago, Took allergy shots for five years with great results, now only takes Zyrtec when needed.
Surgeries: Tonsillectomy, Cholecystectomy
Hospitalizations: childbirth x 3.
Immunizations: up-to-date on all vaccinations.
Allergies: erythromycin: severe GI upset.
Blood transfusions: none
Drinks alcohol socially, smoked rarely in her 20's. Denies illicit drug use.
Sleeps 6 to 7 hours a night. Exercises four to five days per week.
Current medications: Multivitamin, Vit E (takes for hot flashes), CoQ10, fish oil, Zyrtec
Social History: Married, lives with husband and 3 children. Worked in advertising up until nine months ago when she got laid off. In order to help with the household finances she took a job as a Baker's assistant at an Artisan Bread Bakery. She arrives at 4 a.m. every morning to begin baking breads/pastries for the day.
Family History: Children are healthy. Parents are deceased. Mother at age 80 from congestive heart failure. Father died at age 82 from lung cancer, diagnosed when metastasized to brain. PGM: died from unknown causes, PGF: Stroke at age 82. MGM: died at 83, had HTN, atherosclerosis and many heart attacks. PGF: died at 71 from complications of COPD.
Discussion Questions Part One:
- What are Margaret's lifestyle factors that contribute to her symptoms?
- List any further questions you have for Margaret and link them to their respective differential diagnoses.
- What are the three (3) most common, most likely differential diagnoses for this visit thus far with pathophysiology and evidence-based rationale? Please include the pertinent information from the case study that leads you to consider this diagnosis.
- Based on your differential diagnosis list, identify what body systems will you examine along with pertinent positive/negatives symptoms you'd be looking for to support or rule out your differential diagnoses.
- List any relevant labs/diagnostic tests and link them to each diagnosis in the differential list. Remember to include evidence-based support for any testing you order along with rationale if you feel no testing is warranted.