Outpatient Clinic Case Report
1. Patient Information:
Patient ID/Number: 206001
Date of Birth: 01/15/1985
Age: 75 years
Gender: Male
Address: 123 Elm Street, Springfield, IL 62701
Phone Number: (217) 555-1234
Email Address: johndoe@email.com
2. Presenting Complaint:
Primary Complaint: Persistent shortness of breath and fatigue over the last 3 weeks
Duration of Complaint: 3 weeks
Severity: Moderate
Related Symptoms: Mild chest tightness, occasional dizziness, and occasional dry cough.
3. Medical History:
Past Medical History:
Hypertension (diagnosed in 2050)
Type 2 Diabetes Mellitus (diagnosed in 2060)
Coronary Artery Disease (CAD) – 2 stent placements in 2070
Chronic Obstructive Pulmonary Disease (COPD) (diagnosed in 2080)
Family History:
Father: Deceased at 80 from heart failure
Mother: Alive, 78, history of hypertension
Medications:
Amlodipine 5mg daily (for hypertension)
Metformin 500mg twice daily (for diabetes)
Aspirin 81mg daily (for CAD)
Albuterol inhaler as needed (for COPD)
Allergies: No known drug allergies
Social History:
Smoked 1 pack per day for 30 years, quit 5 years ago
Occasional alcohol use (1-2 drinks per week)
Retired, lives alone, active in gardening
4. Physical Examination:
Vital Signs:
General Appearance:
Systemic Examination:
Cardiovascular:
Respiratory:
Mild wheezing on auscultation, and decreased breath sounds in the lower lobes.
No crackles or rales were noted.
Abdominal:
Neurological:
Alert and oriented to time, place, and person.
Cranial nerves intact, normal muscle strength and reflexes.
5. Investigations:
Laboratory Tests:
CBC: WBC 7.8 x 10^3/µL, Hemoglobin 13.5 g/dL, Platelets 250 x 10^3/µL
BMP: Sodium 140 mEq/L, Potassium 4.1 mEq/L, Creatinine 1.0 mg/dL, Glucose 120 mg/dL (fasting)
HbA1c: 7.4% (indicating suboptimal diabetes control)
Imaging Studies:
Chest X-ray (06/15/2060): Mild hyperinflation consistent with COPD, no acute infiltrates.
Electrocardiogram (ECG): Normal sinus rhythm, no evidence of acute ischemia.
Other Tests/Results:
6. Diagnosis:
Primary Diagnosis: Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) with concurrent hypertension and poorly controlled diabetes.
Differential Diagnosis:
Additional Notes:
7. Treatment Plan:
Medications Prescribed:
Fluticasone/Salmeterol inhaler 250/50mcg, 1 puff twice daily (for COPD exacerbation)
Lisinopril 10mg daily (to manage blood pressure more effectively)
Insulin glargine 10 units at bedtime (adjustment for diabetes control)
Non-Pharmacological Interventions:
Pulmonary rehabilitation referral
Smoking cessation support
Weight management and dietary counseling
Follow-up Plan:
Referrals:
8. Outcome and Prognosis:
Immediate Outcome:
The patient reported mild improvement in shortness of breath following initial treatment.
Increased use of inhaler as prescribed, with some relief of chest tightness.
Prognosis:
The prognosis is guarded due to the presence of multiple chronic conditions (COPD, hypertension, and diabetes). With appropriate treatment, the patient may experience improved symptom management but will require ongoing monitoring.
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