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Missing Elements of the History

Larry A. Allen, M.D., Amrut V. Ambardekar, M.D., Kalpana M. Devaraj, M.D., Joseph J. Maleszewski, M.D., and Eugene E. Wolfel, M.D.

​In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors' commentary follows.
A 59-year-old woman presented to her primary care physician with cough, exertional dyspnea, and foot swelling that had developed 2 weeks earlier while she was vacationing in Denmark. She had no rhinorrhea, pharyngitis, fever, rash, diarrhea, or new joint symptoms. Her medical history was notable for polyarthritis, for which her rheumatologist prescribed minocycline and meloxicam.
She had undergone right total hip replacement 4 years previously, left total hip replacement 3 years previously, and left total knee replacement 1 year previously. There was no history of hypertension or diabetes. She had never used tobacco, illicit drugs, or herbal supplements and did not consume large amounts of alcohol. She was married and primarily had been a homemaker for her three children, and she did not have known occupational exposures. There was no family history of early-onset pulmonary or cardiovascular disease. Vital signs were within normal limits. She received a diagnosis of pneumonia and “travel-related edema” and was treated with a course of antibiotics; no chest imaging or blood tests were performed, and she did not receive diuretics.
New-onset dyspnea and cough in an otherwise healthy middle-aged person is most commonly due to acute bronchitis. However, the differential diagnosis is broad. Deep-vein thrombosis with pulmonary embolus and endemic infectious diseases should be considered in someone who has recently traveled. Primary myocardial, pulmonary, and vascular diseases may also result in persistent cough, dyspnea, and edema.