Chapter 9: The Respiratory System | Daniel Elliott's Chart Note


Patient Name: Elliott, Daniel
ID Number: FRU9764
Examination Date: January 30, 20xx

This is a 54-year-old male with emphysema, dyspnea, and increasing weakness. For the last 2 months he has had recurring nocturnal (occurring at night) dyspnea up to 3 times a night but denies problems of orthopnea (difficult breathing when lying flat). He states that he uses an albuterol inhaler for asthma, which seems to relieve the symptoms. He is barrel-chested with a productive cough of white sputum. Patient is a nonsmoker. Afebrile (without fever) with no chills or lower-extremity edema.

Mr. Elliott is a thin, gaunt gentleman appearing older than his stated age. BP is 148/64. Pulse is 92. Respirations are 30. Heart is regular in rhythm. Lungs display good air movement with diffuse expiratory (pertaining to exhaling or breathing out) wheezing and prolongation of the expiratory phase. CXR reveals flattened diaphragm, increased AP (anteroposterior) diameter and box-car lung shapes consistent with severe emphysema. Pulmonary function test before and after albuterol treatment shows severe obstructive changes with no improvement following treatment.

Patient has shortness of breath secondary to COPD exacerbation (symptoms made worse by another disease).

Refer patient to pulmonary medicine specialist.

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