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CASE STUDY:
58-Year-Old Female With Mild Dyspnea With Heavy Exertion
CLINICAL INFORMATION
CHIEF COMPLAINT
Mild dyspnea with heavy exertion over past 7 months.
HISTORY OF PRESENT ILLNESS
Patient is a 58-year-old female who noted breathlessness with heavy exertion after returning from an overseas trip. There was associated mild chest discomfort. She denied cough, weight change, gastrointestinal symptoms, joint symptoms, skin changes, or neurologic symptoms.
ADDITIONAL DATA
Past Medical History
She had a history of mild gastroesophageal reflux disease. There is no prior history of cardiovascular or pulmonary disease.
She has never smoked, owned pets, or had an occupational exposure. She is employed as a health care professional.
There is a history of a brother who died at an early age of idiopathic pulmonary fibrosis.
Her medications included a proton pump inhibitor, low-dose aspirin, and vitamin supplements.
Physical Exam
On physical exam she was in no distress.
| VITALS |
Heart rate: 80 bpm
Blood pressure: 140/70 mm Hg
Respiratory rate: 20 bpm
Oxygen saturation: 97% at rest, and 96% with 1848 feet of exertion during a 6-minute walk study breathing room air
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| CHEST | Mild basilar rales |
| CV | Normal |
| ABDOMEN | Normal |
| EXTREMITIES | Normal |
| NEUROLOGIC | Normal |
Lab work revealed normal complete blood count and chemistries. Serologic study results were negative.
A chest radiograph revealed bilateral reticular opacities.
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