NR 601 Week 2 COPD Case Study Part 1
NR 601 Week 2 COPD Case Study Part 1
Week 2: COPD Case Study Part 1 (Initial post due Tuesday, faculty and peer responses due Sunday)
A 62 year-old Caucasian male presents to the office with persistent cough and recent onset of shortness of breath. Upon further questioning you discover the following subjective information regarding the chief complaint.
| History of Present Illness |
| Onset |
6 months |
| Location |
Chest |
| Duration |
Cough is intermittent but frequent, worse in the AM |
| Characteristics |
Productive; whitish-yellow phlegm |
| Aggravating factors |
Activity |
| Relieving factors |
Rest |
| Treatments |
Tried Robitussin DM without relief of symptoms
|
| Severity |
Unable to walk > 20ft without stopping to catch his breath. Last year at
this time he routinely walked 1 mile per day without difficulty |
| Review of Systems (ROS) |
| Constitutional |
Denies fever, chills, or weight loss |
| Ears |
Denies otalgia and otorrhea |
| Nose |
Denies rhinorrhea, nasal congestion, sneezing or post nasal drip. |
| Throat |
Denies ST and redness |
| Neck |
Denies lymph node tenderness or swelling |
| Chest |
Describes a persistent productive cough upon wakening for the
last 6 months. Color of phlegm is usually white-yellowish.
Shortness of breath with activity. |
| Cardiovascular |
Denies chest pain and lower extremity edema |
|
| History |
| Medications |
Metoprolol succinate ER (Toprol-XL) 50mg daily for hypertension; Multivitamin
daily |
| PMH |
Primary hypertension |
| PSH |
Cholecystectomy, appendectomy |
| Allergies |
Penicillin (hives) |
| Social |
Married, 3 children
Senior accountant at a risk management firm |
| Habits |
Former smoker (20 pack-year), quit “cold turkey” when father died; Denies
alcohol or
illicit drug use. |
| FH |
Father died of MI & CHF at age 59 years (diabetes, hypertension, smoker)
Mother is alive (osteoporosis)
Healthy siblings |
|
NR 601 Week 2 COPD Case Study Part 1
Physical exam reveals the following:
| Physical Exam |
| Constitutional |
Adult male in NAD, alert and oriented, able to speak in full sentences |
| VS |
Temp-98.1, P-66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds,
O2sat 94% on RA |
| Head |
Normocephalic |
| Ears |
Tympanic membranes gray and intact with light reflex noted. Pinna
and tragus nontender. NR 601 Week 2 COPD Case Study Part 1 |
| Nose |
Nares patent. Nasal turbinates clear without redness or edema. Nasal
drainage is clear. |
| Throat |
Oropharynx moist, no lesions or exudate. Tonsils ÂĽ bilaterally.
Teeth in good repair, no cavities noted. |
| Neck |
Neck supple. No lymphadenopathy. Thyroid midline, small and
firm without palpable masses. No JVD |
| Cardiopulmonary |
Heart S1 and S2 with no murmurs, noted. Lungs clear to auscultation
bilaterally with faint forced expiratory wheezes in bilateral bases.
Respirations unlabored. Legs without edema. |
| Abdomen |
Soft, non-tender. No organomegaly |
|
NR 601 Week 2 COPD Case Study Part 1
| DISCUSSION CONTENT |
| Category |
Points |
% |
Description |
| Application of Course Knowledge |
15 |
30% |
- A brief AND concise summary of the history and physical (H&P) findings is presented without redundancy or irrelevant information; AND
- Three (3) appropriate diagnoses in the differential are presented which can explain the patient’s chief complaint; AND
- A brief statement of pathophysiology is included for each diagnosis; AND
- Each diagnosis in the differential is analyzed using pertinent positive and negative subjective and objective findings as support; AND
- The differential is ranked in order from most likely to least likely; AND
- Clinical reasoning skills are demonstrated by linking testing to diagnoses as applicable; AND
- Testing decisions are well supported with EBP arguments that are in-line with the clinical scenario and appropriate for the primary care setting
(7 critical elements) |
NR 601 Week 2 COPD Case Study Part 1
