What is the plan of care for a 49-year-old female patient presenting with exacerbation of dyspnea (shortness of breath), unilateral lower extremity edema (leg swelling), dizziness, and headache, with a past medical history of Asthma, chronic constipation, Polyneuropathy, bile duct disease, disorder of the upper esophageal sphincter, pyloric stenosis, anemia, mandibular fracture, Polycystic Ovary Syndrome (PCOS), cervical dysplasia, hemorrhagic fever, umbilical hernia, and Attention Deficit Hyperactivity Disorder (ADHD), and currently taking multiple medications for ADHD, Chronic Obstructive Pulmonary Disease (COPD), Asthma, depression, and hypothyroidism?

Differential Diagnosis for 49-year-old Female Patient

The patient presents with a complex array of symptoms including shortness of breath, unilateral leg swelling, dizziness, and headache. Given her extensive past medical history and the current symptoms, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis
  • Pulmonary Embolism (PE): This is considered due to the combination of shortness of breath, unilateral leg swelling (suggestive of deep vein thrombosis), and dizziness. These symptoms, especially in the context of her history of immobilization due to conditions like polyneuropathy and recent exacerbations, increase the risk for venous thromboembolism.
• Other Likely Diagnoses
  • Exacerbation of Chronic Obstructive Pulmonary Disease (COPD): Given her history of COPD and asthma, an exacerbation could explain the shortness of breath and potentially the dizziness if there's associated hypoxia or hypercapnia.
  • Congestive Heart Failure (CHF): With a family history of CHF and considering her symptoms of shortness of breath and dizziness, CHF should be considered, especially if there's any evidence of fluid overload or if the unilateral leg swelling is indicative of dependent edema.
  • Anemia: Given her history of anemia, if untreated or undertreated, this could contribute to her shortness of breath and dizziness.
• Do Not Miss Diagnoses
  • Deep Vein Thrombosis (DVT): Even if considered under the umbrella of PE, it's crucial to diagnose and treat DVT to prevent further complications like PE.
  • Stroke or Transient Ischemic Attack (TIA): Although headache and dizziness are non-specific, they could be indicative of a cerebrovascular event, especially in the context of her complex medical history.
  • Hypothyroidism Crisis: Given her history of hypothyroidism, if her medication regimen is not adequately managed, she could be at risk for a hypothyroid crisis, which can present with a wide range of symptoms including shortness of breath and dizziness.
• Rare Diagnoses
  • Thrombocytopenia or other coagulopathies: Given her history of hemorrhagic fever and current presentation, although rare, a coagulopathy could be contributing to her symptoms, especially if there's any evidence of bleeding or easy bruising.
  • Neurological disorders: Conditions like multiple sclerosis or other demyelinating diseases could explain some of her neurological symptoms, though they would be less likely given the acute presentation and her known polyneuropathy.

Plan of Care

1. Immediate Assessment: Evaluate oxygen saturation, perform a complete blood count (CBC) to assess for anemia, and consider D-dimer or CT pulmonary angiography if PE is suspected.
2. Imaging: Consider ultrasound of the affected leg for DVT, chest X-ray, and potentially an echocardiogram if CHF is a concern.
3. Medication Review: Ensure all medications, especially those for ADHD, COPD, asthma, depression, and hypothyroidism, are optimized and not contributing to her symptoms.
4. Symptomatic Treatment: Manage shortness of breath with oxygen if necessary, and consider anticoagulation if PE or DVT is confirmed.
5. Referral: Consider referral to a specialist (e.g., pulmonologist, cardiologist) based on the suspected underlying cause of her symptoms.

This approach ensures a comprehensive evaluation and management plan that addresses the patient's complex presentation and history.