· Patient statement: “For almost 2 weeks, I have been coughing a dry and non-productive cough, and I feel some chills”.

Subjective

Chief Complaints:

· Patient statement: “For almost 2 weeks, I have been coughing a dry and non-productive cough, and I feel some chills”.

History of Present Illness:

· This is 59 old African American man who is received in the clinic complaining of cough that has been going on for almost 2 weeks. The patient describes a dry and non-productive cough that mainly take place at night and has caused him pain at the central of the chest. He stated he is short of breath and that he is not able to sleep on his bed but on his chair because it is easier for him to breath and catch some sleep while sitting on the chair. He reported the short of breast is increased with activity such moving the chair close to the bed. He reported sore throat in the morning. He reported that his cough along with being tired, fatigued, anxious and feeling chilly breeze have been worsening the last 3-4 days. He took his inhaler for his emphysema last night and is here today to seek medical attention.

Past Medical History:

· Diabetes Type II

· Emphysema

Past surgical History:

· None

Family History:

· One older brother, one living with osteoporosis and hypertension at age 65.

· One young sister is alive and well.

· Father is alive and healthy

· Mother is alive with diabetes Type II

Social History:

· Not married but single with 1 child of 27 years old.

· Drug: No illicit drugs

· Smoking: 1 pack a day

· Alcohol: 1- 2 beers on the week-end

Medications:

· Tylenol 650 mg PO Q4 hours PRN for pain

· Metformin 500 mg BID

· Combivent Inhaler 2 puff Q4 hours PRN

Allergies:

· Sulfa: cause him rash and itching

Review of system

General:

· African American male reports unintentional weight gain, recently. Reports fatigue.

HEENT:

· Denies any headache, impaired vision or hearing, discharge, or ringing.

· Denies any nose bleeds, nasal stuffiness.

· Denies lymphadenopathy or thyromegaly.

· Denies any loose teeth or bleeding gum.

· Denies any pain or difficulty swallowing.

· Report sore throat in the morning

Cardiovascular:

· Report slight chest pain at the center after night coughing

Respiratory:

· Reports short of breath.

Gastrointestinal:

· Denies any pain abdominal pain.

· Denies any abnormal bowel movement or bloody stools

· Denies nausea or vomiting

Genitourinary:

· Denies any dysuria, hesitancy, or urinary abnormalities.

Integumentary:

· Denies any lesions, moles, bruises.

Musculoskeletal:

· Denies swelling, stiffness, or decreased joint motion.

Endocrine/Hematologic:

· Denies any endocrine or hematologic disorder.

Musculoskeletal:

· Denies swelling, stiffness, or decreased joint motion.

Endocrine/Hematologic:

· Denies any known endocrine or hematologic disorder.

Immunization/Prevention:

· Not up to date

Neurological/Psychologic:

· Denies any motor, reflexes, sensory, coordination, or gait deficits.

· Denies any depression or hallucinations or mental issues.

Objective

Vital Signs:

· BP: 138/62, T: 101 orally, P: 100, R: 20, Weight: 139, Height: 5’3”, BMI: 30.21, Temp 100.1. Saturation 91% RA.

Constitutional:

· Pleasant African American male, cooperative, articulate, and appropriately dressed for fall-winter weather.

HEENT:

· Head: Good hair distribution. No lesions at the scalp.

· Eyes/Ear: No vision or hearing impairments noted. Wears reading glasses

· Nose: No frequent nasal congestion/stuffiness or nosebleeds.

· Uvula is on midline

· Pharynx is noticeably without erythema, edema or exudate. No presence of odor is noted.

· Neck is supple, and non-tender

· Trachea is on midline.

· Thyroid palpation is non-enlarged, non-tender, and no presence of mass or nodule noted.

Lymph Nodes:

· No nodules present.

Carotids:

· No JVD. Mild AV nicking.

Lungs:

· Wheezes bilaterally at the upper lobes

· Diminished breath sounds to auscultation at lower lobes.

· Positive for short of breath

· lung wall yields no abnormal findings.

Heart:

· Heart Rate is irregular with no murmurs or gallops.

Abdomen:

· Soft, non-tender with active bowel sounds in all 4 quadrants

· No abdominal bruits.

Genitourinary:

· Deferred.

Rectal:

· Deferred

Extremities/Pulses:

· Pulses normal and present throughout. No edema.

Neurologic/Psychic:

· Alert and oriented x 3.

· CN II-XII tested intact.

· Strength and sensation symmetric and intact.

· Appropriate and aware of surroundings

Diagnostic Test:

· EKG: Normal Regular Sinus Rhythm

· Chest X ray: Hyperinflation of both lungs and an increased anterior-posterior chest wall diameter.

Assessment

1- COPD – J44.9:

2- Asthma – J45.909:

3- Stable angina pectoris – I20.9:

Diagnosis Differential:

1-Acute coronary syndrome – I24.9: Even though there is presence of exacerbation of short of breath, there is no chest pain radiating to both arms which is persistent in ACS. Additionally, ACS has chest pain associated with diaphoresis. We can fairly rule it out.

2-Pleural Effusion – J91.8: X Ray does not show any blunting of the right and left costophrenic angles which is highly considered a suspicious of pleural effusion (Blanchette, Grenier, 2014). Chest X ray shows hyperinflation of both lungs and an increased anterior-posterior chest wall diameter. Despite of some similarities, per chest X ray, patient may not have pleural effusion.

3-Pulmonary embolism – I26. 9: Symptoms as increased or irregular heartbeat, difficulty catching breath, which may develop either suddenly. Chest pain that is sharp and stabbing. It is a medical emergency. We can rule it out as well.

Agreeing with the patient’s problems as listed in the assessment and ruling out those of the diagnostic differentials, will now conduct a plan of care as below.

Plan of Care

COPD – J44.9: Difficulty in emptying air out of the lungs (airflow obstruction) can lead to shortness of breath or feeling tired because you are working harder to breathe. COPD is a term that is used to include chronic bronchitis, emphysema, or a combination of both conditions (American thoracic society, 2018). Symptoms are persistent to COPD and patient has history of emphysema and he is a smoker. This our primary diagnosis. A recent chest x-ray also showed evidence of emphysema with hyperinflation of both lungs and an increased anterior-posterior chest wall diameter. The plan of care is very much about the COPD which, we believe is this patient main problem.

· The patient reported that she was previously given samples of an inhaler for management of her emphysema symptoms. The National Institutes of Health (NIH) (2013) recommend an inhaled bronchodilator for management of emphysema symptoms. Bronchodilators relax the muscles around your airways, which makes breathing easier. Combivent is used as an inhaled medication to prevent bronchospasm in people with chronic obstructive pulmonary disease (COPD) who are also using other medicines to control their condition (drugs.com, 2014).

Asthma – J45.909: It’s a disease where it is difficult to empty the air out of the lungs, and It is not uncommon, however for a patient with COPD to also have some degree of asthma. flare-ups or asthma attacks are often caused by allergies and exposure to allergens such as pet dander, dust mites, pollen or mold. Non-allergic triggers include smoke, pollution or cold air or changes in weather.

· Plan of care will have the same as above which is our primary diagnostic. We will not focus on the asthma as a problem for the patient but will cover some related asthma issues that are present in COPD.

Stable angina pectoris – I20.9: As patient’s symptoms include midsternal chest pain described as a tightness and pressure that radiated down left arm. As Talbert stated, “there are three factors that determine myocardial oxygen demand: heart rate, contractility, and intra-myocardial wall tension, with the latter considered the most important” (Talbert, 2011).

· Will not consider it in the care plan as it is not relevant for this patient case.

Considering the plan, we will have as follow:

Medication:

· Oxygen: Administration of oxygen can help the patient breathe better even though COPD patient runs low on oxygen saturation: 2 LNC.

· Combivent: 2 puff Q4 hours as needed.

· Advair (fluticasone and salmeterol): 1 puff q4 hours PRN is recommended to prevent flare ups or worsening of COPD associated with chronic bronchitis or emphysema (drugs.com, 2015).

· Azithromycin 250 mg Po BID,