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Chronic Obstructive Pulmonary Disease in the respiratory system.

Student’s Name:

Professor:

Course:

Date:
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PATIENT INFORMATION

Name: Mr. L

Age: 67-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Calcium CarbonateNitamin D 600 mg BID, Aspirin 81 mg per diem,

albuterol inhaler two puffs four times daily.

PMH: Hypertension (I10)

Immunizations: Tetanus and hepatitis A and B.

Surgical History: Hernia repair surgery (K 46.9)

Family History: Father- Alive, 101 years old, does not report information

Mother died of Coronary Heart Disease at the age of 82.

Married with healthy kids.

Social Hx: He engages in tobacco smoking during the weekends and occasionally uses alcoholic

beverage consumption on social celebrations. He is married with four kids.

SUBJECTIVE:

Chief complaint: New onset of chest

Symptom analysis/HPI:

The patient is 67 years old male who appears younger than his stated age. He comes in today for

a follow-up of his chronic obstructive pulmonary disease (COPD) and reports that he has been

experiencing episodes of chest pain over the past few days. Concerning the state of COPD, the

patient has been experiencing fewer episodes of shortness of breath with activity ever since the
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change of his inhalers the last he visited the facility. He can do stair climbing unaccompanied by

shortness of breath. His cough has reduced.

Regarding chest pains, he complains that he has to wake up from sleep because the episodes

usually occur at night. Chest pains get better with the help of pillows used to elevate the sleeping

ground. He engages in daily exercise, that is, running 2-3 miles daily but has not experienced any

discomfort or accompanying pain. The onset of the symptoms coincides with his current habit of

eating more food late at night. The patient denies palpitation, diaphoresis, nausea, and SOB.

ROS:

CONSTITUTIONAL: Fatigue, anxiety, denies night sweats, fever, weakness, or weight loss.

NEUROLOGIC: No seizures, headache, and faints.

HEENT: HEAD: No injury or change in LOC. Eyes: No obvious visual changes, sclera normal,

Retinal oxygen level normal. Ear: Denies pain or loss of hearing. Nose: No congestion;

THROAT: slightly coarse; denies difficulty swallowing—no neck pain.

Respiratory: Reduced cough and shortness of breath.

Cardiovascular: Chest pain, No edema, no palpitations, slightly increased heart rate after

physical activity.

Gastrointestinal: No abdominal pain, bloating, indigestion, or slight nausea due to productive

cough.

Genitourinary: No polyuria, hematuria, or dysuria.

MUSCULOSKELETAL: Denies hearing a clicking or snapping sound. Denies muscle pain.

Skin: Slight cyanosis on the fingertips, no rashes

Objective Data
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CONSTITUTIONAL: Vital signs: Temperature: 97.5 °F, Pulse: 70, BP: 116/64mmhg, RR 10,

Weight 126lbs, Ht- 62 in, BMI 23 kg/m2.

General appearance: Anxiety, fatigued, disturbed sleep pattern. No bruise. Physical examination

shows cyanosis on fingertips; skin is pale.

NEUROLOGIC: Normal body posture, oriented to person, place, and time. Conscious,

sensation intact, muscle strength equal bilaterally.

HEENT: Head: Normocephalic, atraumatic. Eyes: Extraocular motility and alignment are

normal, and Maxillary sinuses have no tenderness. Ears: intact canals. No pharyngeal

abnormalities, Neck: slightly swollen neck arteries. No jugular vein distention

Cardiovascular: Chest pain, No palpations.

Respiratory: Productive cough, the shape of the chest was slightly barreled, wheezing.

Gastrointestinal: paradoxical abdominal movement present; no mass or hernia observed. No

abdominal pain, abdomen soft non-tender, no distention on palpation

Musculoskeletal: Active and passive ROM within normal limits, No pain to palpation.

Integumentary: no lesions or rashes, Dry skin cyanosis on the fingers.

Assessment

COPD is well managed with the recent medication change: occasional coughing and improved

shortness of breath. However, recent chest pain is likely to have occurred from GERD, based on

the fact that there is a change in eating habits; it is only when lying down and not existent with

exertion (Candemir, 2021).

Differential diagnosis:

 Congestive heart failure (150.20)

 Pneumothorax (J 93.9)
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 Cardiac arrhythmia (149.9)

Plan

Do laboratory tests as follows:

 Arterial blood gas (ABG) test

 Spirometry test

 Chest x-ray

 Pulmonary Function Tests (PFTs)

Pharmacological treatment:

The patient is to continue medications for COPD.

Non-Pharmacologic treatment: The patient was advised to desist from eating 2-2.5 hours

before sleeping to manage the nocturnal chest pain and to call the facility for additional advice if

chest pain continues despite a change in eating habits (Joean, & Welte, 2022).

Education

 Give Instructions about medication intake compliance

 Provide information on lifestyle habits and nutrition.

 Education on the importance of physical activity and possible complications.

Follow-ups/Referrals

 No referrals are needed at this time.

 Follow-up in 4 weeks to reexamine chest pain.

 Seek care immediately if pain reinitiates with activity.

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References

Candemir, I. (2021). The narrative review of chronic obstructive pulmonary disease management

in Turkey: medical treatment, pulmonary rehabilitation and endobronchial volume

reduction. Journal of Thoracic Disease, 13(6), 3907.

Joean, O., & Welte, T. (2022). Vaccination and modern management of chronic obstructive

pulmonary disease–a narrative review. Expert Review of Respiratory Medicine, 16(6),

605-614.