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.
Cough is intermittent but frequent, worse in the AM
Characteristics
Productive; whitish-yellow phlegm
Aggravatingfactors
Activity
Relieving factors
Rest
Treatments
Tried Robitussin DM without relief of symptoms
Severity
Unable 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)
Constitutional
Denies fever, chills, or weight loss
Ears
Denies otalgia and otorrhea
Nose
Denies rhinorrhea, nasal congestion, sneezing or post nasal drip.
Throat
Denies ST and redness
Neck
Denies lymph node tenderness or swelling
Chest
Describes a persistent productive cough upon waking for thelast 6 months. Color of phlegm is usually white-yellowish.Shortness of breath with activity.
Cardiovascular
Denies chest pain and lower extremity edema
History
Medications
Metoprolol succinate ER (Toprol-XL) 50mg daily for hypertension; Multivitamindaily
PMH
Primary hypertension
PSH
Cholecystectomy, appendectomy
Allergi es
Penicillin (hives)
Social
Married, 3 children Senior accountant at a risk management firm
Habits
Former smoker (20 pack-year), quit “cold turkey” when father died; Deniesalcohol or illicit drug use.
FH
Father died of MI & CHF at age 59 years (diabetes, hypertension, smoker)Mother is alive (osteoporosis)
Physical exam reveals the following:
Physical Exam
Constitutional
Adult male in NAD, alert and oriented, able to speak in full sentences
VS
Temp-98.1, P-66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA
Nares patent. Nasal turbinates clear without redness or edema. Nasaldrainage is clear.
Throat
Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally.Teeth in good repair, no cavities noted.
Neck
Neck supple. No lymphadenopathy. Thyroid midline, small andfirm without palpable masses. No JVD
Cardiopulmonary
Heart S1 and S2 with no murmurs, noted. Lungs clear to auscultationbilaterally with faint forced expiratory wheezes in bilateral bases.Respirations unlabored. Legs without edema.
Abdomen
Soft, non-tender. No organomegaly
DISCUSSION CONTENT
Category
Points
%
Description
Application of Course Knowledge
15
30%
● 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
