Chronic Obstructive Pulmonary Disorder Retrospecitve Analysis Paper

2960 Words Jun 16th, 2018 12 Pages
Subjective
S: MJ is a 74 year old African-American female who presents to the clinic today with complaints of shortness of breath with exertion and increasing fatigue over the past two to three months. The shortness of breath is increased with exercise or when walking up stairs and has progressively gotten worse. She states that she presented to the emergency room approximately one year ago for shortness of breath and was prescribed an albuterol inhaler. She additionally has a chronic productive cough with clear sputum and denies hemoptysis. She has had no recent upper respiratory infections and denies fever. She denies chest pain or tightness. She also states that she has noticed some ankle edema over that has developed over the past
…show more content…
The information collected in the history was highly suggestive of COPD. One of the best predictors of airflow obstruction was the patient’s smoking history (Qaseem, et al., 2011, pp. 181). According to Qaseem, et al. (2011), the presence of the patient’s smoking history and wheezing on physical examination is indicative of airflow obstruction (pp. 181). Additionally, the patient’s presenting complaint was dyspnea on exertion, which is one of the most commonly presenting complaints in patients with COPD (Boardman, 2013, pp. 446). The chronic nature of the patient’s cough and slow progression of symptoms are consistent with a diagnosis of COPD rather than asthma. Finally, the diminished breath sounds on auscultation is indicative of airflow obstruction and considered to be a reliable finding in the diagnosis of COPD (Boardman, 2013, pp. 447). In addition to the new diagnosis of COPD, the patient also had current diagnoses of hypertension, hyperlipidemia, and osteoarthritis.
Plan
1. Diagnostics: Spirometry, Chest X-Ray PA and Lateral
2. Labs: CBC
3.
Open Document