COPD Case Study (Week 2)

Date of visit: November 20,2019 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