Subjective:
The patient, Mr. X, a 52-year-old male, presents to the clinic with complaints of persistent cough and shortness of breath for the past two weeks. He reports that the cough is non-productive and that he has been experiencing wheezing. Additionally, the patient complains of fatigue and chest tightness. He denies any fever, chills, night sweats, hemoptysis, or weight loss. He has a medical history significant for hypertension and hyperlipidemia for which he is taking Lisinopril and Atorvastatin. The patient is a non-smoker and denies any history of allergies.
Objective:
On physical examination, the patient is afebrile, and his vital signs are within normal limits. Lung auscultation reveals expiratory wheezing and prolonged expiration. Pulmonary function tests show a restrictive pattern, with decreased forced vital capacity (FVC) and decreased forced expiratory volume in one second (FEV1). Chest X-ray shows hyperinflation with no focal infiltrates. Arterial blood gas analysis shows hypoxemia with a PaO2 of 70 mmHg and a PaCO2 of 35 mmHg.
Assessment:
The patient presents with symptoms and signs suggestive of chronic obstructive pulmonary disease (COPD). The diagnosis of COPD is based on the presence of chronic respiratory symptoms and a history of exposure to risk factors such as tobacco smoke or environmental pollutants. In this case, the patient has a history of hypertension, which is a risk factor for COPD, and he presents with chronic cough, wheezing, and dyspnea. The pulmonary function tests show a restrictive pattern with decreased FVC and FEV1, which is consistent with COPD. The chest X-ray and arterial blood gas analysis findings support the diagnosis of COPD.
Plan:
The patient’s management plan includes smoking cessation counseling, pulmonary rehabilitation, and pharmacotherapy. The patient will be referred to a smoking cessation program, and nicotine replacement therapy will be initiated. Pulmonary rehabilitation will consist of exercise training, nutritional counseling, and education on breathing techniques. The pharmacotherapy will include bronchodilators and inhaled corticosteroids. The patient will be scheduled for follow-up appointments to monitor his symptoms and response to therapy.
References:
Global Initiative for Chronic Obstructive Lung Disease. (2018). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Retrieved from https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf
Labaki, W. W., & Han, M. K. (2018). Chronic obstructive pulmonary disease: epidemiology and risk factors. Clinics in chest medicine, 39(4), 643-655.
Laniado-Laborín, R. (2018). Smoking and chronic obstructive pulmonary disease (COPD). Parallel epidemics of the 21 century. International journal of environmental research and public health, 15(4), 760.
Tashkin, D. P., & Leidy, N. K. (2018). Management of chronic obstructive pulmonary disease: a review. Clinical therapeutics, 40(4), 514-552.
