Differential Diagnosis
The patient's presentation of worsening chest pain, exertional dyspnea, cough, swollen axillary lymph nodes, erythema nodosum, and scattered wheezes throughout the lung fields, along with a history of lymphoma and smoking, suggests a complex clinical picture. Here's a categorized differential diagnosis:
Single most likely diagnosis
- C. sarcoidosis: This diagnosis is favored due to the presence of erythema nodosum, which is a common skin manifestation of sarcoidosis, along with lymphadenopathy and respiratory symptoms. Sarcoidosis can also cause granulomatous inflammation in the lungs, leading to symptoms like dyspnea and cough.
Other Likely diagnoses
- B. lung cancer: Given the patient's 20 pack-year smoking history, lung cancer is a significant concern. The symptoms of chest pain, cough, and dyspnea could be indicative of lung cancer, especially if there are metastases to the lymph nodes.
- A. follicular lymphoma: Although the patient has a history of lymphoma, follicular lymphoma itself might not directly cause all the symptoms presented, especially the respiratory ones. However, it's possible that the lymphoma has relapsed or is contributing to the patient's immune system dysfunction, making her more susceptible to other conditions.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- E. tuberculosis: TB is a critical diagnosis not to miss due to its infectious nature and the potential for severe outcomes if left untreated. The patient's symptoms of cough, dyspnea, and lymphadenopathy could be consistent with TB, especially if she has been exposed to it through her work on the farm or due to her immunocompromised state from lymphoma.
- D. systemic lupus erythematosus (SLE): While less likely, SLE can cause a wide range of symptoms including lung involvement, lymphadenopathy, and skin manifestations. It's a diagnosis that could be missed but is critical to identify due to its potential for severe organ damage.
Rare diagnoses
- Other rare conditions such as lymphomatoid granulomatosis or angioimmunoblastic T-cell lymphoma could also be considered, although they are less likely. These conditions can present with a mix of lymphadenopathy, skin lesions, and respiratory symptoms, but they are much rarer and would typically require more specific diagnostic testing to confirm.