Chronic Obstructive Pulmonary Disease

3277 Words Jan 26th, 2018 13 Pages
Patient was admitted to the hospital with a chief complaint of difficulty breathing; diagnosis includes congestive heart failure exacerbation (CHF) with pneumonia (PNA). He has a full code status. Past medical history includes congestive heart failure, COPD, peptic ulcer, chronic kidney disease stage 3, anemia, and hypernatremia. Patient is a widower who lives with son and consumes no alcohol or illicit drugs, he has is an ex-smoker with a 70 pack year history. Patient is a retired mechanic with no family medical history on file; it is suspected that father had heart issues. He has no known allergies although is contraindicated to take aspirin due to GI bleeding.
Upon physical examination the patient looked well-nourished and in relatively good spirits. He exclaimed his “chest is heavy and hurts.” His vitals showed a respiratory rate of 24 breaths per minute, his tachypnea is possibly due to his exacerbation of congestive heart failure and/or pneumonia. Heart rate of 75 beats per minute is within normal limits of 60-100 beats per minute. Blood pressure of 130/86 suggesting prehypertension and/or a result of discomfort from CHF and/or pneumonia. Temperature of 96.8 °F showing the patient is afebrile. SpO₂ was 92% on room air which is within normal limits of an individual who has COPD. Physical inspection showed his skin was warm and dry. Pedal edema was detected possibly due to…
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