Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with progressive dyspnea on exertion, non-productive cough, and significant fatigue. Symptoms have worsened over [Number] weeks. History significant for known primary malignancy ([Type]). Denies fever, chest pain, or orthopnea. Symptoms are refractory to standard bronchodilator therapy.
Clinical Examination Findings
Vitals: Tachypneic (RR: [Number]), O2 saturation [Number]% on room air. Chest auscultation reveals bilateral fine inspiratory crackles, predominantly basal. No wheezing or rhonchi. Cardiac exam: Tachycardic, regular rhythm, no murmurs. Extremities: No peripheral edema or cyanosis. Signs of underlying malignancy noted (e.g., lymphadenopathy, cachexia).
Treatment Protocol
Management plan: 1. Supplemental oxygen to maintain SpO2 >92%. 2. Systemic chemotherapy/targeted therapy as per oncology consultation for primary malignancy. 3. Diuretic therapy if pulmonary congestion is present. 4. Corticosteroids to reduce peribronchial inflammation. 5. Palliative care referral for symptom management and dyspnea control.