Case on Clinical

Reasoning

ACELAJADO, MD

●At the end of this case, you are expected to make a report on the following:

Differential Diagnosis, Diagnostic Tests to be requested, Primary Working Diagnosis,

Assessment and Plan for this case.

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•Steve, a 46-year-old accountant who lives in a condo in Makati, is

complaining of episodes of shortness of breath that have been

increasing in frequency and severity.

IDENTIFYING DATA AND CHIEF

COMPLAINT

•The episodes of shortness of breath last about 30 minutes. The first

episode occurred one month ago while Steve was at a friend’s house:

woke up with shortness of breath and coughing (no sputum), and

were only able to manage the symptoms when he stepped onto the

balcony and took deep breaths. Since then, he have had more similar

episodes, and have noticed that he also sometimes experiences

shortness of breath and coughing during or after morning runs. He

has 2-3 episodes per week, and they seem to resolve with rest.

HISTORY OF PRESENT

ILLNESS

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•Steve is in good health, and exercise regularly. He does not take any

medications and have no diagnosed allergies. He used to sneeze a lot

as a child when visiting grandmother’s house; grandmother has

smoked a pack of cigarettes per day and owns three cats.

PAST MEDICAL

HISTORY

•His father has hypertension, and his mother has asthma.

FAMILY MEDICAL

HISTORY

•He drink 5 drinks per week and smoke occasionally, in a social

situation (1-2 cigarettes/week for about 3 years).

PERSONAL AND SOCIAL

HISTORY

Physical Examination:

•General Appearance: Speaks in phrases

•Vital Signs: BP 140/90 HR 108 RR28 T36.8 O2sat 92%

•Chest: (+)wheezes, bilateral lobe

•Heart: no neck vein distention, regular rhythm, no murmurs, no gallop

•Extremities: No edema, no cyanosis

07/03/23, 8:59 AM

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doctor of medicine (MD 2022)

Lyceum-Northwestern University

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Case on Clinical

Reasoning

ACELAJADO, MD

● At the end of this case, you are expected to make a report on the following:

Differential Diagnosis, Diagnostic Tests to be requested, Primary Working Diagnosis,

Assessment and Plan for this case.

Loading...

• Steve, a 46-year-old accountant who lives in a condo in Makati, is

complaining of episodes of shortness of breath that have been

increasing in frequency and severity.

IDENTIFYING DATA AND CHIEF

COMPLAINT

• The episodes of shortness of breath last about 30 minutes. The first

episode occurred one month ago while Steve was at a friend’s house:

woke up with shortness of breath and coughing (no sputum), and

were only able to manage the symptoms when he stepped onto the

balcony and took deep breaths. Since then, he have had more similar

episodes, and have noticed that he also sometimes experiences

shortness of breath and coughing during or after morning runs. He

has 2-3 episodes per week, and they seem to resolve with rest.

HISTORY OF PRESENT

ILLNESS

Loading...

• Steve is in good health, and exercise regularly. He does not take any

medications and have no diagnosed allergies. He used to sneeze a lot

as a child when visiting grandmother’s house; grandmother has

smoked a pack of cigarettes per day and owns three cats.

PAST MEDICAL

HISTORY

• His father has hypertension, and his mother has asthma.

FAMILY MEDICAL

HISTORY

• He drink 5 drinks per week and smoke occasionally, in a social

situation (1-2 cigarettes/week for about 3 years).

PERSONAL AND SOCIAL

HISTORY

Physical Examination:

• General Appearance: Speaks in phrases

• Vital Signs: BP 140/90 HR 108 RR28 T36 O2sat 92%

• Chest: (+)wheezes, bilateral lobe

• Heart: no neck vein distention, regular rhythm, no murmurs, no gallop

• Extremities: No edema, no cyanosis