PC: Shortness of breath
History of Present Illness: A 30-year-old male presents with shortness of breath (SOB) for 3 days. He reports having a cough and runny nose 2 weeks ago, which resolved spontaneously. Three days ago, he began to feel SOB, which has been gradually worsening. He denies fever, pleuritic chest pain, orthopnea, or paroxysmal nocturnal dyspnea. He also denies any other associated symptoms, such as leg swelling, abdominal pain, or headache.
The patient reports that he changed his vape device 3 days ago, and he is wondering if this could be the cause of his SOB. He also has a history of anxiety, but he is not sure if this is causing his symptoms. He reports having one episode of palpitations that lasted for one minute.
Past Medical History: Anxiety
Social History: Smokes vape
Family History: Non-contributory
Physical Examination:
Vital signs: Normal
General appearance: Well-developed, well-nourished male in no acute distress
Respiratory examination: Lungs clear to auscultation bilaterally, respiratory rate 20 breaths/minute, oxygen saturation 99% on room air
Cardiovascular examination: Regular heart rate at 80 beats/minute, blood pressure 120/80 mmHg
Abdomen: Soft, non-tender, non-distended
Extremities: No edema or clubbing
Notes:
This case demonstrates the importance of considering all possible causes of SOB, even in young patients with no significant medical history.
Anxiety can also be a cause of SOB, so it is important to assess the patient for anxiety and other psychiatric disorders.
It is also important to consider the patient's social history, such as smoking status, when evaluating the possible causes of SOB.
In this case, the patient's recent change in vape device is a potential cause of his SOB. Vaping can irritate the airways and cause inflammation, which can lead to SOB.
It is important to start the patient on oxygen therapy and monitor their respiratory status closely if they are experiencing SOB.
If the patient's SOB is not relieved with oxygen therapy, or if they have other signs of respiratory distress, such as retractions or cyanosis, it is important to consult with cardiology and pulmonology.