Develop an assessment and differential diagnosis as well as an appropriate next diagnostic workup. 

Bates Visual Guide to Physical Examination

A 27 year-old woman presents with chest pains, fever and shortness-of-breath for 2 weeks. The patient is otherwise well and has never had significant medical problems in her past.

She appears to be healthy, but she has mild skin rashes on her chest area and back. Auscultation shows no crackles, wheezes, or crackles in her lungs. On room air, her pulse oximetry reading is 98%.

The initial assessment should include a differential diagnosis based on the patient’s history, symptoms, physical examination findings and lab results. You can consider bronchitis/pneumonia, viral or bacterial asthma, exacerbation of symptoms or interstitial lung diseases or pulmonary embolism.

The appropriate next diagnostic workup will vary depending on which condition is suspected to be causing the patient’s symptoms. If pneumonia is suspected, then lab tests such as complete blood counts and culture of sputum for infectious agents should be performed. Imaging studies such as Xrays can also be helpful in this situation. However, interstitial lung disease should be suspected and further testing should be done including CT scans and pulmonary function tests.

These tests are not the only ones that may be useful. You might also want to have other lab tests like liver function (LFTs), and urinalysis to rule out any other possible causes, such as hepatitis A (UTI), or a urinary tract infection.

Additional investigations that may provide information about her clinical presentation include allergy skin testing and spirometry/diffusion capability measurements, if she has asthma/allergies.

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