SUBJECTIVE : The patient, who is an 89-year-old male, presents himself at the clinic for a general health evaluation. From the information given, the patient indicates that he has been experiencing a challenge due to ‘belching’, but all other data suggests that he is feeling pretty good.
There is no history of allergies that the patient has complained of as part of his previous treatment. The patient has a history of smoking where he was smoking at least two packets of cigarette a day for 69 years. The patient has not had any prior hospital admissions that may be of importance to note as part of this health evaluation.
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Noncontributory. The patient’s family does not have a history of any symptoms that are similar to those being presented by the patient.
OBJECTIVE :
General: An 89-year-old male, who has a history of smoking spanning for 69 years during which time he was involved in smoking two packets per day.
Chest: Faint ‘whistling’ sound associated with his respiratory effort, shortness of breath, breath sounds are course and diminished in the lower lobes bilaterally (Martinez, 2016).
Lungs: Reports a cough, which is especially prominent in the mornings, resulting in the production of thick clear to white sputum (Barnes, 2016).
No laboratory tests have been undertaken.
No radiology tests have been taken.
ASSESSMENT : Chronic Obstructive Pulmonary Disease (COPD).
PLAN:
Therapeutics : The plan involves a mix of bronchodilator and steroid (Lange et al., 2015). The use of this mix of pharmacological interventions aids in ensuring that the patient can deal with the infection arising from the condition.
Educational : Patient education will be undertaken on the importance of having to engage in healthy eating and exercising as a way of improving on health outcomes (Postma, Bush, & van den Berge, 2015).
Consultation/Collaboration : N/A
References
Barnes, P. J. (2016). Inflammatory mechanisms in patients with chronic obstructive pulmonary disease. Journal of Allergy and Clinical Immunology , 138 (1), 16-27.
Lange, P., Celli, B., Agustí, A., Boje Jensen, G., Divo, M., Faner, R., ... & Meek, P. (2015). Lung-function trajectories are leading to chronic obstructive pulmonary disease. New England Journal of Medicine , 373 (2), 111-122.
Martinez, F. D. (2016). Early-life origins of chronic obstructive pulmonary disease. New England Journal of Medicine , 375 (9), 871-878.
Postma, D. S., Bush, A., & van den Berge, M. (2015). Risk factors and early origins of chronic obstructive pulmonary disease. The Lancet , 385 (9971), 899-909.
