Janis 59 – year – old female

SUBJECTIVE:
Janis, a 59 – year – old female, presents with tachypnea, dyspnea on exertion, and mild chest discomfort. She was diagnosed with emphysema four years ago and was placed on bronchodilator therapy. She has an 80-pack-year history of smoking. “ I feel short of breath when I walk, and my chest is sore. ” She describes her chest soreness as mild pressure, rated as two on a 1 – 10 scale. The pain is over the anterior thorax, more pronounced in the ribs, which she believes has developed from coughing hard. She states that she has had a nonproductive cough for four days and feels more fatigued than usual.

Past medical history: She has osteoarthritis in the hands and knees. She has a surgical history of appendectomy and cholecystectomy. In the past year, she has had two exacerbations of her COPD and has attempted to stop smoking, using nicotine gum replacement unsuccessfully.
Family history: Noncontributory.
Social history: She lives with her husband, who also smokes two packs of cigarettes per day and cares for her elderly mother, who lives with them and is frail but ambulatory.
Medications: Albuterol MDI, 90 mcg/inhalation, two puffs as needed every 4 – 6 hours; ipratropium bromide MDI, 18 mcg/inhalation, two puffs four times/day; ibuprofen as needed for arthritic pain.
Allergies: Janis is allergic to Keflex and penicillin.
OBJECTIVE:
General: Janis is dyspneic at rest, sitting. The use of accessory muscles is evident. Pursed lip breathing noted.
Vital signs: BP: 122/64; P: 92; R: 26; T: 100.2; SpO2: 88. AP to transverse ratio is 1:1.
Skin: Warm and dry.
HEENT: Negative.
Cardiovascular: RRR: S1/S2; no murmurs, clips, rubs, or gallops. No evidence of peripheral edema. Posterior tibial and dorsalis pedis pulses 2 + /4 + .
Respiratory: Lungs have diffused wheezing and crackles in the right upper lobe. Tenderness to palpation along intercostal spaces on the right and left anterior and lateral thorax from the 2nd to 5th intercostal spaces. PFT conducted two months prior to the visit showed obstructive flow patterns and reduced FEV1/FVC.
Abdomen: Soft, with bowel sounds; tympanic to percussion.
Neurologic: Negative.
Based on the described case scenario, please answer two of the following questions:

1. -Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?
2. -What is the most likely differential diagnosis and why?
3. -What is your plan of treatment?
4. -What is your plan for follow-up care?
5. -Are any referrals needed?
6. -What are additional risk factors evident for this patient?
7. -Are there any standardized guidelines that you should use to treat this patient?