History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Differential Diagnosis
Relevant Next Steps
Test Results
Interim Differential Diagnoses
Relevant Next Steps 2
Test Results 2
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
Anemia in a 42-year-old woman
Review of Systems
General
: Patient says she felt fine until about 2 months ago when she had "the flu," which she describes as a low-grade fever, diffuse joint pain, malaise, and a non-pruritic rash primarily over her extremities. She took acetaminophen and her symptoms resolved after 4 days. Except for her fatigue and dyspnea, she has since felt well with normal appetite and no fever or chills.
Skin
: No rash or lesions noted.
HEENT
: Denies pain or swelling in her neck, no nasal discharge or bleeding.
Pulmonary
: Dyspnea climbing stairs, worsening over the past 3 weeks to the point that she cannot climb a flight of steps without pausing to rest. No cough or wheezing.
Cardiovascular
: No exertional chest pain, palpitations, orthopnea, or paroxysmal nocturnal dyspnea.
Gastrointestinal
: No nausea, vomiting, diarrhea or abdominal pain.
Genitourinary
: Menses normal, last period 2 weeks prior, normal amount of bleeding for her. No other vaginal bleeding. Urination normal, no visible blood.
Musculoskeletal
: No swelling or pain in joints or extremities.
Neurologic
: Unremarkable
Psychiatric
: Unremarkable
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