Week 2: COPD Case Study
Week 2: COPD Case Study Part 1
Due Date:
Tuesday; peer response by Sunday
Total Points Possible:
50 Case Study - Part 1
Date of visit: November 20,2019
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
Activity
factors
Relieving factors Rest
Tried Robitussin DM without relief of symptoms
Treatments
Unable to walk > 20f t without stopping to catch his breath. Last year
Severity
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
Describes a persistent productive cough upon wakening for the last 6
Chest months. Color of phlegm is usually white-yellowish. Shortness of breath
with activity.
Cardiovascular Denies chest pain and lower extremity edema
History
Metoprolol succinate ER (Toprol-XL) 50mg daily for hypertension;
Medications
Multivitamin daily
PMH Primary hypertension
PSH Cholecystectomy, appendectomy
Allergies Penicillin (hives)
Married, 3 children
Social
Senior accountant at a risk management firm
Former smoker (20 pack-year), quit “cold turkey” when father died; Denies
Habits
alcohol or illicit drug use.
Father died of MI & CHF at age 59 years (diabetes, hypertension, smoker)
FH Mother is alive (osteoporosis)
Healthy siblings
Physical exam reveals the following:
Physical Exam
Adult male in NAD, alert and oriented, able to speak in full
Constitutional
sentences
Temp-98.1, P-66, RR-20, BP 156/94, Height 68.9in,
VS Weight 258 pounds,
O2sat 94% on RA
, Head Normocephalic
Tympanic membranes gray and intact with light reflex noted. Pinna
Ears
and tragus nontender.
Nares patent. Nasal turbinates clear without redness or edema.
Nose
Nasal drainage is clear.
Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally.
Throat Teeth in
good repair, no cavities noted.
Neck supple. No lymphadenopathy. Thyroid midline, small and firm
Neck
without palpable masses. No JVD
Heart S1 and S2 with no murmurs, noted. Lungs clear to
Cardiopulmonary auscultation bilaterally with faint forced expiratory wheezes in
bilateral bases. Respirations unlabored. Legs without edema.
Abdomen Soft, non-tender. No organomegaly
Requirements/Questions:
1. Briefly and concisely summarize the history and physical (H&P) findings as if you
were presenting it to your preceptor using the pertinent facts from the case. May use
approved medical abbreviations. Avoid redundancy and irrelevant information.
A 62 year-old Caucasian male presents to the office with persistent cough that started 6 months
ago and recent onset of shortness of breath that is aggravated with activity. The cough is
intermittent but frequent and worse in the AM. Tried Robitussin DM without relief of
symptoms. The cough is productive with whitish-yellow phlegm. He is unable to walk > 20ft
without stopping to catch his breath but last year at this time he routinely walked 1 mile per
day without difficulty. Based on the ROS he recent illness. Denies fever, chills, or weight loss.
Denies otalgia and otorrhea. Denies rhinorrhea, nasal congestion, sneezing or post-nasal
drip. Denies ST and redness and lymph node tenderness or swelling. The patient has a history
of primary hypertension and is a former 20 year smoker. He has an allergy to penicillin. He has
a past surgical history of cholecystectomy and appendectomy. His vital signs were Temp-98.1,
P- 66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA. Physical
assessment the patient was alert and oriented x4. His had no abnormal heart sounds and lungs
were clear despite faint forced expiratory wheezes in bilateral bases
2. Provide a differential diagnosis (minimum of 3) which might explain the patient's
chief complaint along with a brief statement (2-3 sentences) of pathophysiology for
each.
Week 2: COPD Case Study Part 1
Due Date:
Tuesday; peer response by Sunday
Total Points Possible:
50 Case Study - Part 1
Date of visit: November 20,2019
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
Activity
factors
Relieving factors Rest
Tried Robitussin DM without relief of symptoms
Treatments
Unable to walk > 20f t without stopping to catch his breath. Last year
Severity
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
Describes a persistent productive cough upon wakening for the last 6
Chest months. Color of phlegm is usually white-yellowish. Shortness of breath
with activity.
Cardiovascular Denies chest pain and lower extremity edema
History
Metoprolol succinate ER (Toprol-XL) 50mg daily for hypertension;
Medications
Multivitamin daily
PMH Primary hypertension
PSH Cholecystectomy, appendectomy
Allergies Penicillin (hives)
Married, 3 children
Social
Senior accountant at a risk management firm
Former smoker (20 pack-year), quit “cold turkey” when father died; Denies
Habits
alcohol or illicit drug use.
Father died of MI & CHF at age 59 years (diabetes, hypertension, smoker)
FH Mother is alive (osteoporosis)
Healthy siblings
Physical exam reveals the following:
Physical Exam
Adult male in NAD, alert and oriented, able to speak in full
Constitutional
sentences
Temp-98.1, P-66, RR-20, BP 156/94, Height 68.9in,
VS Weight 258 pounds,
O2sat 94% on RA
, Head Normocephalic
Tympanic membranes gray and intact with light reflex noted. Pinna
Ears
and tragus nontender.
Nares patent. Nasal turbinates clear without redness or edema.
Nose
Nasal drainage is clear.
Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally.
Throat Teeth in
good repair, no cavities noted.
Neck supple. No lymphadenopathy. Thyroid midline, small and firm
Neck
without palpable masses. No JVD
Heart S1 and S2 with no murmurs, noted. Lungs clear to
Cardiopulmonary auscultation bilaterally with faint forced expiratory wheezes in
bilateral bases. Respirations unlabored. Legs without edema.
Abdomen Soft, non-tender. No organomegaly
Requirements/Questions:
1. Briefly and concisely summarize the history and physical (H&P) findings as if you
were presenting it to your preceptor using the pertinent facts from the case. May use
approved medical abbreviations. Avoid redundancy and irrelevant information.
A 62 year-old Caucasian male presents to the office with persistent cough that started 6 months
ago and recent onset of shortness of breath that is aggravated with activity. The cough is
intermittent but frequent and worse in the AM. Tried Robitussin DM without relief of
symptoms. The cough is productive with whitish-yellow phlegm. He is unable to walk > 20ft
without stopping to catch his breath but last year at this time he routinely walked 1 mile per
day without difficulty. Based on the ROS he recent illness. Denies fever, chills, or weight loss.
Denies otalgia and otorrhea. Denies rhinorrhea, nasal congestion, sneezing or post-nasal
drip. Denies ST and redness and lymph node tenderness or swelling. The patient has a history
of primary hypertension and is a former 20 year smoker. He has an allergy to penicillin. He has
a past surgical history of cholecystectomy and appendectomy. His vital signs were Temp-98.1,
P- 66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA. Physical
assessment the patient was alert and oriented x4. His had no abnormal heart sounds and lungs
were clear despite faint forced expiratory wheezes in bilateral bases
2. Provide a differential diagnosis (minimum of 3) which might explain the patient's
chief complaint along with a brief statement (2-3 sentences) of pathophysiology for
each.
