Bates visual guide to physical examination
A 27-year-old female presents with fever, malaise, chest pain and shortness of breath for the past 2 weeks. She is an otherwise healthy individual who has not had any significant medical issues in the past.
On physical examination she appears to be afebrile but has a mild rash on her chest and upper back region. Her lungs are clear and there is no evidence of crackles or wheezes on auscultation. Her pulse oximetry is 98% on room air.
The initial assessment should include a differential diagnosis based on the patient’s history, symptoms, physical examination findings and lab results. Possible diagnoses that can be considered include bronchitis/pneumonia (viral or bacterial), asthma exacerbation, interstitial lung disease or pulmonary embolism.
The appropriate next diagnostic workup will vary depending on which condition is suspected to be causing the patient’s symptoms. For example, if pneumonia is suspected then laboratory tests should be ordered such as complete blood count and sputum cultures for infectious agents; imaging studies such as X-rays may also be useful in this case; however if interstitial lung disease is suspected then more extensive testing including pulmonary function tests and CT scans should be ordered to confirm the diagnosis.
In addition to these tests, it may also be beneficial to order other laboratory tests such as liver function tests (LFTs) and urinalysis (UA) in order to rule out other potential causes of her symptoms such as hepatitis A or urinary tract infection.
Other investigations that could potentially provide additional information regarding her clinical presentation would include allergy skin testing or spirometry/diffusion capacity measurements if asthma/allergies are being considered as possible etiologies of her illness.
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