1. Briefly and concisely summarize the history and physical (H&P) findings as if you were
presenting it to your preceptor using the pertinent facts from the case. Use shorthand
where possible and approved medical abbre
...
1. Briefly and concisely summarize the history and physical (H&P) findings as if you were
presenting it to your preceptor using the pertinent facts from the case. Use shorthand
where possible and approved medical abbreviations. Avoid redundancy and irrelevant
information
HPI
Pt is a 62-year-old male with a CC of persistence cough X 6 months and acute onset SOB. He
describes the cough as intermittent but more frequent in the AM. He characterizes his cough as
productive with white-yellow phlegm c/o. He identifies activity as an aggravating factor and has
experienced some relief with rest but has tried Robitussin DM with no relief from symptoms. He
denies chest pain, however he states that he has a decrease in activity tolerance in the last year
stating that he isn’t able to go more then 20 feet without stopping for breath.
Pertinent PMH
He has a history of primary hypertension and takes 50mg metoprolol succinate ER daily along
with a multivitamin. He is has an allergy to PNC accompanied by a rash. He has a hx of smoking
cigarettes 20 packs a year when he quite “cold turkey” after the death of his father. No illicit
drugs or alcohol use. He is married with 2 children and works as an accountant at a risk
management firm. His family hx includes the death of his father at 59 due to CHF and MI. His
father also suffered from diabetes, hypertension and smoking. His mother is still living and has
osteoporosis and his siblings are living and healthy.
Pertinent ROS findings:
The patient is + for persistent cough in AM x 6 months. + for productive whitish, yellow phlegm.
+SOB with activity. He is - for fever, chills, or weight loss. He is also - for otalgia, otorrhea,
rhinorrhea, congestion, sneezing or PND. He is - for ST or redness, lymph node tenderness, or
swelling, chest pain, or LE edema.
Pertinent PE findings:
Adult male, who is he is AAOx3, in NAD, + for complete sentences. Temp, RR, P are normal.
Patient is + for Obesity with BMI of 39.24. +for elevated BP at 156/94. +normocephalic. +
patent nares, + clear nasal turbinates, +clear nasal drainage bilaterally, - redness, - edema, OP +
moisture, - exudate or lesions. +tonsils at ¼, +normal dentation. Neck -for thyromegaly,
lymphadenopathy, or masses, - JVD. Heart sounds with +S1 and S2, -murmurs. +clear lung
sound bilaterally, -labored breathing. + faint forced expiratory wheezes bilaterally in the bases. –
labored respirations. -for lower extremity edema bilaterally. Abdomen is + softness,
-organomegaly, - abdominal tenderness.
2. Provide a differential diagnosis (minimum of 3) which might explain the patient's chief
complaint along with a brief statement of pathophysiology for each.
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Diagnosis #1 Chronic Obstructive Pulmonary Disease (COPD)
Pathophysiology statement – The pathophysiology of COPD is complex but ultimately
results in obstruction in the airway caused by damage to the pulmonary lumen, airway wall, or
the structures that support the surrounding airway (Hammer & McPhee, 2019). Damage to the
airway either by cigarette smoking, or by inhaling chemicals causes scarring of the airway
structures (Hammer & McPhee, 2019). COPD caused by cigarette smoking is also known as
emphysema and is thought to be caused by the chronic inflammation and tissue damage that
occurs due to exposure to noxious chemicals (Hammer & McPhee, 2019). The scarring of the
structures causes a loss in the elastin-containing alveolar structures which decreases the
mailability of the alveoli. This decrease in elasticity allows air molecules to enter the alveoli and
hyperinflation causes a decrease in the recoil of alveoli and their ability to refill with air
molecules and exchange oxygen. As a result of this cascade, the airways prematurely collapse
and cause airway obstruction (Hammer & McPhee, 2019). The chronic inflammation and the
immune mediated inflammatory response causes an increase in phlegm production and chronic
bronchitis occurs.
Diagnosis #2 Mild asthma with acute exacerbation
Pathophysiology statement – Asthma is the result of multiple factors that has several
phenotypes (Hammer & McPhee, 2019). An airway disease, the pathophysiology of asthma is
not completely understood. Thought to be an autoimmune mediated response by cytokine
release, asthma is caused by exposure to allergens or other stimuli that causes a cellular cascade
of inflammation. The constant cellular cascade of inflammation can decrease muscle tone in the
lung tissue, narrowing the airway pathways due to inflammation and an increase in secretions
(Hammer & McPhee, 2019). The constant inflammation process can continue to damage tissue
and continue to erode the airways structures of the lungs causing a decrease in the body’s ability
to take in air or expel air for gas exchange (Hammer & McPhee, 2019).
Diagnosis #3 Congestive heart failure
Pathophysiology statement – Congestive heart failure (CHF) is most commonly caused
by longstanding, uncontrolled hypertension and is extremely complex and multifactorial
(Hammer & McPhee, 2019). Left sided heart failure is the most common form of CHF. In most
cases, CHF is caused when the left side of the heart is unable to circulate blood to the extremities
due to obstruction due to increase blood pressure. This increase in pressure causes and increase
in the stroke volume of heart. Over time, the left side of the heart enlarges due to increased
muscle fiber creation and a decrease in left side heart chamber size. The body is then unable to
properly pump oxygenated blood to the extremities and the heart must work even harder to
circulate the blood (Hammer & McPhee, 2019). This feedback loop continues and the heart
continues to remodel creating more muscle fibers and increasing the workload of the heart
further. The increased work load to the heart creates “leaky” blood vessels due to the rise in
pressure causing fluid to leak into the interstitial tissues of the lower extremities and lungs
(Hammer & McPhee, 2019).
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3. Analyze the differential by using the pertinent findings from the history and physical to
argue for or against a diagnosis.
Diagnosis #1 – COPD
The primary diagnosis I have chosen is COPD. The symptoms of COPD include
shortness of breath, activity intolerance, chronic cough, clear or yellow tinged secretion with a
previous history of smoking, exposure to noxious chemicals or fumes (Domino, Baldor, Golding,
& Stephens, 2019). Other symptoms include decreased breath sounds, expiratory wheezes and
prolonged expiration (Papadakis, McPhee, & Rabow, 2019). COPD is also seen in patients over
the age of forty.
Positive findings –
He is positive for chronic cough x 6 months, with acute SOB with activity, progressive decline in
activity tolerance, productive whitish/yellow sputum, history of smoking and 52 years old. He
has tried OTC remedies for his cough that have not improved his condition (Domino et al.,
2019). He is also positive for faint forced expiratory wheezes bilaterally in the bases of his lungs.
Negative findings –
He has no other signs or symptoms for a possible viral or bacterial infection as the cause of his
productive cough (Domino et al., 2019). He is negative for boggy turbinates, abnormal nasal
discharge bilaterally, or nasal redness or edema, fever or chills. He has no relief in his symptoms
by using OTC cough suppressant (Hammer & McPhee, 2019). He is also negative for PND,
otalgia, otorrhea, rhinorrhea, congestion or sneezing. His lungs are clear bilaterally to
auscultation and his O2 saturation at room air is within normal range (Domino et al., 2019).
Diagnosis #2 Asthma with acute exacerbation
The secondary diagnosis I have chosen is Asthma. While asthma is considered an
obstructive airway disease, the major defining characteristic is that is typically immune mediated
and doesn’t have a slow increase in progression when compared with COPD (Papadakis et al.,
2019). Another defining difference is that it is typically triggered by pollen, cold, exercise or
animal dander and is accompanied with chest tightness, pain or pressure and inspiratory and
expiratory wheezes and normal respirations in between attacks (Papadakis et al., 2019).
Positive findings –
He has faint forced expiratory wheezes bilaterally in the bases with a productive cough and acute
SOB with activity (Domino et al., 2019).
Negative finding –
He is negative for inspiratory wheezing, acute cough with return to normal breathing which is a
common symptom of asthma (Papadakis et al., 2019). He is negative for allergy’s or previous
diagnosis of asthma and his O2 saturation at room air is within normal range He is also negative
for chest tightness or chest pain, he is a smoker, and he is over the age of 40 with a progressive
decline in activity tolerance.
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