A 20-year-old woman with a 9-year history of shortness of breath

A 20-year-old woman with a 9-year history of shortness of breath A 20-year-old woman presented to an internal medi- cine physician at our community-based free clinic due to increasing diffi culty breathing.Her symptoms began 9 years earlier with the feeling of "something stuck in her throat."At that time she was living in South America and did not seek medical attention.Over the years, her shortness of breath progressively worsened without relief.After immigrating to the United States at age 18, she was seen by a variety of clinicians and was given diagnoses of bronchitis, asthma, and COVID-19.She was treated with antibiotics, including tetracycline, erythromycin, and amoxicillin, as well as inhaled bronchodilators and steroids, without improvement.Before presenting to our clinic, she was seen by a nurse practitioner, who documented decreased breath sounds and wheezing on physical examination and prescribed amoxicillin and guaifenesin.The patient knew that these medications did not improve her symptoms in the past and did not fi ll these prescriptions.She presented to our community-based clinic the following day and was not taking any medications.On presentation, the patient complained of chest tightness and shortness of breath that worsened on exertion.She was having considerable diffi culty performing normal activities of daily living, was unable to walk up a fl ight of stairs, had frequent nighttime waking due to shortness of breath, and had an intermittent nonproductive cough.She reported no fever, chills, night sweats, weight loss, or hemoptysis and did not have a history of tuberculosis or prior hospitalizations, surgeries, or intubations.Her family history was signifi cant for an older brother who experienced similar symptoms that resolved after surgery.She did not use tobacco, alcohol, or recreational drugs, and had no known history of occupational or toxic environmental exposures.