Case Study - Part 1
Date of visit: November 14,2021
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
Onset 6 months
Location Chest
Duration Cough is intermittent but frequent, worse in the
AM
Characteristics Productive; whitish-yellow phlegm
Aggravating factors 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 at this 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
wakening for the last 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
This study source was downloaded by 100000830604181 from CourseHero.com on 11-13-2021 17:00:40 GMT -06:00
https://www.coursehero.com/file/59587924/COPD-case-study-part-1docx/
, for hypertension; Multivitamin daily
PMH Primary hypertension
PSH Cholecystectomy, appendectomy
Allergies 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; Denies alcohol or
illicit drug use.
FH Father died of MI & CHF at age 59 years
(diabetes, hypertension, smoker)
Mother is alive (osteoporosis)
Healthy siblings
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
Head Normocephalic
Ears Tympanic membranes gray and intact with light
reflex noted. Pinna and tragus nontender.
Nose Nares patent. Nasal turbinates clear without
redness or edema. Nasal drainage 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 and firm without palpable
masses. No JVD
Cardiopulmonary Heart S1 and S2 with no murmurs, noted. Lungs
clear to auscultation bilaterally with faint forced
expiratory wheezes in bilateral bases.
This study source was downloaded by 100000830604181 from CourseHero.com on 11-13-2021 17:00:40 GMT -06:00
https://www.coursehero.com/file/59587924/COPD-case-study-part-1docx/
Date of visit: November 14,2021
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
Onset 6 months
Location Chest
Duration Cough is intermittent but frequent, worse in the
AM
Characteristics Productive; whitish-yellow phlegm
Aggravating factors 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 at this 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
wakening for the last 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
This study source was downloaded by 100000830604181 from CourseHero.com on 11-13-2021 17:00:40 GMT -06:00
https://www.coursehero.com/file/59587924/COPD-case-study-part-1docx/
, for hypertension; Multivitamin daily
PMH Primary hypertension
PSH Cholecystectomy, appendectomy
Allergies 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; Denies alcohol or
illicit drug use.
FH Father died of MI & CHF at age 59 years
(diabetes, hypertension, smoker)
Mother is alive (osteoporosis)
Healthy siblings
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
Head Normocephalic
Ears Tympanic membranes gray and intact with light
reflex noted. Pinna and tragus nontender.
Nose Nares patent. Nasal turbinates clear without
redness or edema. Nasal drainage 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 and firm without palpable
masses. No JVD
Cardiopulmonary Heart S1 and S2 with no murmurs, noted. Lungs
clear to auscultation bilaterally with faint forced
expiratory wheezes in bilateral bases.
This study source was downloaded by 100000830604181 from CourseHero.com on 11-13-2021 17:00:40 GMT -06:00
https://www.coursehero.com/file/59587924/COPD-case-study-part-1docx/
