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Shortness of Breath Case Study Chief Complaint: shortness of breath HPI: 82-year-old female comes in to the office today with a 3-day complaint of shortness. It has been constant since the onset but worsens when performing ADLs. She denies body aches, fevers, chills, chest pain, lightheadedness or dizziness. She states her legs are swollen for the last 2 days. Question #1 What other questions are important to ask regarding the complaint of SOB?(4 points) Question #2 STOP! Do not read any further. What are your top 5 differentials just based off of the HPI? Provide your rationale with source. (10 points) PMH: COPD PSH: denies surgical history Allergies: NKA Medications: Albuterol MDI 2 puffs Q6H needed for SOB Immunizations: reports UTD Question #3 The social history is missing for this patient. What question is important to ask? (2 points) Review of Systems: General: denies fevers and chills Skin, hair, nails: denies rash Eyes: denies eye redness or drainage Nose/Sinuses: denies runny, stuffy nose Throat/mouth: denies sore throat pain Respiratory: c/o SOB that worsens with exertion Cardiac: denies chest pain, c/o swollen legs Vital Signs: 99.0, 118 bpm, 24 RR, 144/82, SpO2 87% RA Physical Exam: General: ill-appearing female, well-nourished, well-groomed, heavy odor of cigarette smell Skin, hair, nails: warm and clammy Respiratory: labored respirations. Pausing to speak in between words. + supraclavicular retractions. Crackles throughout. Wet, nonproductive cough. Cardiovascular: tachycardic rate with a regular rhythm. S1S2. No M/R/G. Radial, pedal, and posttibial pulses 2+ equal bilaterally with brisk capillary refill to fingers and toes. BLE with 3+ pitting edema Question #4 What is your primary diagnosis based off of your interview with the patient and your physical exam? Be as specific as possible using an actual ICD-10 code. Do not use “shortness of breath” as your diagnosis. Provide your rationale for your diagnosis. (4 points) Question #5 You send the patient to the emergency department (ED) after calling report to the ED NP. What labs and diagnostic testing do you anticipate being ordered and why? (12 points) Please provide references APA 7th Edition Thanks

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