NR 601 Week 2 COPD Case Study Part 1

Week 2: COPD Case Study Part 1 (Initial post due Tuesday, faculty and peer responses due Sunday)

A 62 year-old Caucasian male presents to the office with persistent cough and recent onset of shortness of breath. Upon further questioning you discover the following subjective information regarding the chief complaint.

History of Present Illness 
Onset6 months
DurationCough is intermittent but frequent, worse in the AM
CharacteristicsProductive; whitish-yellow phlegm
Relieving factorsRest
TreatmentsTried Robitussin DM without relief of symptoms
SeverityUnable to walk > 20ft without stopping to catch his breath. Last year atthis time he routinely walked 1 mile per day without difficulty
Review of Systems (ROS)
ConstitutionalDenies fever, chills, or weight loss 
EarsDenies otalgia and otorrhea
NoseDenies rhinorrhea, nasal congestion, sneezing or post nasal drip.
ThroatDenies ST and redness
NeckDenies lymph node tenderness or swelling
ChestDescribes a persistent productive cough upon waking for thelast 6 months. Color of phlegm is usually white-yellowish.Shortness of breath with activity.
CardiovascularDenies chest pain and lower extremity edema
MedicationsMetoprolol succinate ER (Toprol-XL) 50mg daily for hypertension; Multivitamindaily
PMHPrimary hypertension
PSHCholecystectomy, appendectomy
Allergi esPenicillin (hives)
SocialMarried, 3 children Senior accountant at a risk management firm
HabitsFormer smoker (20 pack-year), quit “cold turkey” when father died; Deniesalcohol or illicit drug use.
FHFather died of MI & CHF at age 59 years (diabetes, hypertension, smoker)Mother is alive (osteoporosis)

Physical exam reveals the following:

Physical Exam
ConstitutionalAdult male in NAD, alert and oriented, able to speak in full sentences
VSTemp-98.1, P-66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA
EarsTympanic membranes gray and intact with light reflex noted. Pinnaand tragus nontender.
NoseNares patent. Nasal turbinates clear without redness or edema. Nasaldrainage is clear.
ThroatOropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally.Teeth in good repair, no cavities noted.
NeckNeck supple. No lymphadenopathy. Thyroid midline, small andfirm without palpable masses. No JVD
CardiopulmonaryHeart S1 and S2 with no murmurs, noted. Lungs clear to auscultationbilaterally with faint forced expiratory wheezes in bilateral bases.Respirations unlabored. Legs without edema.
AbdomenSoft, non-tender. No organomegaly
Application of Course Knowledge1530%● A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy orirrelevant information; AND ● Three (3) appropriate diagnoses in the differential are presented which canexplain the patient’s chief complaint; AND ● A brief statement of pathophysiology is included for each diagnosis; AND● Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND● The differential is ranked in order from most likely to least likely; AND● Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND● Testing decisions are well supported with EBP arguments that are in-line with the clinical scenario and appropriate for the primary care setting
   (7 critical elements)