Chronic Obstructive Pulmonary Disease COPD Medical Case Report

HPI: John Master, a 47-year-old male, visits Doctor P’s office presenting with a productive cough with haemoptysis, wheezing, and shortness of breath. He indicates that the cough has been intermittent. He also complains of pleuritic chest pain. John Master indicates that he feels well at rest but when working, he markedly gets short of breath. The patient also indicates that over the last few weeks, he has not been as energetic as before.

Background Notes: John Master happens to be a heavy smoker and admittedly smokes 1 cigarette pack a day. His father died of lung cancer 15 years ago. The patient is married and two children (a 9 year old son and a 6-year old girl)

Examination: Examination revealed 87% oxygen saturation, increased respiratory rate at rest (23/min), and blood pressure 118/69?mm Hg. Further, John Master’s heartbeat was 105/min (resting). The patient weighs 223 lbs and has a height of 5’9. The vitals have been indicated in short form below. The rest of the examination (physical) could be described as unremarkable.

Vitals: T 98.9F, HR 105/min, R 23/min, BP 118/69?mm Hg, W 223 lbs., Ht 5’9.

Chest Auscultation Results: Left lung breath sounds diminished. Whizzing (expiratory) can be heard, albeit mild.