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CASE STUDY:
23-Year-Old African American Female With Shortness of Breath and Cough for 3 to 4 Months
CLINICAL INFORMATION
ADDITIONAL DATA
PAST MEDICAL and SURGICAL HISTORY: None.
ALLERGIES: Flowers caused nasal stuffiness and watery eyes.
MEDICINES: Albuterol inhaler. Denied use of over-the-counter medicines.
FAMILY HISTORY: Asthma in 1 son; her father had COPD.
SOCIAL HISTORY: The patient smoked 5 to 8 cigarettes per day. She denied alcohol or recreational drug use. The patient denied any history of blood transfusions and she was involved in a monogamous relationship.
OCCUPATIONAL HISTORY: She had worked at "odd jobs," mainly in department stores.
MENSTRUAL HISTORY: G1P1, pregnancy was uncomplicated. Menses are normal.
REVIEW OF SYSTEMS
GENERAL: Weight loss, not due to anorexia.
HEENT: Denied visual problems.
LUNGS: Positive for cough and shortness of breath.
HEART: No palpitations or chest pain.
GI: No abdominal pain, diarrhea, or constipation.
GU: No menorrhagia.
MUSCULOSKELETAL: Mild large joint arthralgias without myalgias.
NEUROLOGICAL: No headaches or weakness.
SKIN: No rashes.
PHYSICAL EXAMINATION
GENERAL: Comfortable appearing female.
VITAL SIGNS: BP: 133/90 mm Hg; HR: 100 bpm regular; Temp: 99.3° F; RR: 18 bpm; pO2: 98 mm HG RA; WEIGHT: 125 lbs.
HEENT: Normal without scleral icterus or conjunctival pallor.
NECK: No jugular venous distension, thyroid gland diffusely enlarged but without bruit.
CARDIOVASCULAR SYSTEM: PMI was in 5th IC space, mid-clavicular line, S1 S2 RRR, without S3 or S4, murmurs, rubs, heave, or thrills.
RESPIRATORY SYSTEM: Equal expansion bilaterally. Diaphragm excursion was normal. Good air entry bilaterally. Normal vesicular breath sounds without any adventitious sounds.
BREAST EXAM: Normal, without any masses or cysts.
EXTREMITIES: No edema or distended veins. Good peripheral pulses. No nail clubbing was noted.
ABDOMEN: Bowel sounds were normoactive. No tenderness or masses. Liver span was 11 cm; no splenomegaly was noted.
LYMPHATIC SYSTEM: No lymphadenopathy detected.
MUSCULOSKELETAL SYSTEM: Mildly limited range of motion of the knee joints bilaterally due to pain; absence of joint swelling, erythema, bony tenderness, or masses.
NEUROLOGICAL: The patient was alert and oriented. Cranial nerves were intact and sensory exam was normal. Motor exam was normal and no cerebellar signs were present.
SKIN: No rashes or eruptions were seen.
LABORATORY WORKUP
- Hg: 11.6
- WBC: 7.3 (Neutrophils: 5.5, Lymphocytes: 1.4, Basophils 0.1)
- Platelets: 409
- MCV: 85
- Na+: 142
- K+: 4.1
- CO2 content: 24
- Cl-: 109
- BUN/Cr: 12/0.8
- TSH: 2.44
- AST: 23
- ALT: 23
- Alkaline Phos.: 102
- Ca+: 9.2
- Glucose: 83
- PTT and PT: Normal
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