Chief complaint: A 67 year old man presents with a three month history of increasing SOB and decreased activity tolerance.
History: The patient was in his usual state of health until three months ago when he began to experience dyspnea while climbing stairs. The SOB has gradually worsened, and now occurs after he walks approximately one block or climbs a flight of stairs. He denies any acute changes in his breathing, but he does have a chronic cough that produces one to two tablespoons of clear sputum daily. The cough and sputum production have not recently changed. He denies chest pains, hemoptysis, and wheezing. He quit smoking three months ago because of his dyspnea. Prior to that time, he smoked one pack of cigarettes a day for 50 years. He denies alcohol use. He takes no medications. He is a retired salesman and lives with his nonsmoking wife. He has had no significant medical illnesses or surgeries.
The client was admitted to Crozer Medical Center via the ER with an acute exacerbation of his SOB 3 days ago. The client's condition has stabilized.
PHYSICAL EXAM:A thin elderly man who appears older than his stated age
VS:
Pulse 100
Respirations 18
BP 130/86
Temperature 37
Skin: dry and intact t/o
Lymph: no palpable adenopathy
HEENT: PERRLA; EOMI
Neck: no thyromegaly; JVD 7 cm above the sternal angle
Chest: increased AP diameter; hyperresonant with poor diaphragmatic excursion (1 cm); decreased breath sounds throughout without wheezing or crackles
Cor: RRR, normal S1-S2, prominent S4
Abd: normal bowel sounds; nondistended; nontender; liver edge palpable 2 cm below the right costal margin;
spleen tip not felt; no other masses palpated
Ext: decreased pulses throughout the LE; no cyanosis; 2+ pitting edema to the knees in both lower extremities
Neuro: normal mental status; CN II-XII intact; strength 5/5 all ext, reflexes 2+, sensation - intact
LABS:
WBC 9700 Hgb 17.2 Hct 53.5 Plt 356,000 AST 65 (normal range: 0-37)
alkaline phosphatase 165 (normal range: 30-115)
FEV1 1.34 (45% predicted) FVC 3.11 (88% predicted) FEV1/FVC 43% DLCO 45% predicted TLC 150% predicted RV 135% predicted ABGs (on room air)
pH 7.37 pCO2 44 pO2 64
HPI: 67 yom reporting progressively worsening SOB with ambulation x 3months. He has been admitted for comprehensive rehabilitation to address diminishing functional status. Dx - COPD. Currently reports functional status is limited to a maximum of 2 blocks of ambulation and approximately 1 flight of stairs. Primary symptoms are SOB and mild chest tightness that occurs daily, during activity. Symptoms are relieved with cessation of activity and resting 2-3 minutes before resuming walking. Onset of symptoms are reported to occur after walking approximately 1 block and become severe after 2 blocks. The client can function (I) for most ADL/IADL but requires frequent rests and the time to complete functional activities has increased. SOB occurs daily. (+) driver. (-) reported pain. (-) SOB/dyspnea at rest.
ROS: (-) for any contributory hx.
PMH: no significant hx reported, (+) hx of smoking x 50 years - 1 PPD but recently quit with worsening of SOB
Family Hx: (+) for DM, Ca, HTN, CAD, COPD
Meds: Albuteral prn, O - 2 L via NC.
Avocational/Vocational Hx: Retired salesman whose avocational interest include fishing and camping. Lifestyle is primarily sedentary.
Social: Client lives wife in a 2 SH, 8 steps to enter, 13 steps to the second floor.
Musculoskeletal System:
ROM: WFL t/o (B) UEs & LEs
MMT: UE/LE - all muscle groups screen were strong and painless t/o
Posture: (+) for forward head, increased A-P diameter of the chest, (+) mild thoracic kyphosis; patient observed leaning forward on the UEs in sitting
Palpation: (-) pain with palpation of the accessory respiratory muscles.
Integumentary System: (-) cynanosis, skin dry and intact t/o, LE Pulses - DP/PT, popliteal were all palpable.
Neurological System: sensation - intact to lt. touch t/o UE/LE (B)
Cardiopulmonary System:
HR BP RR SaO2 Resting 70 140/86 16 96% Post-amb x 100' 86 150/88 22 92% Chest Expansion: Axilla = 2 cm, Nipple line = 2 cm, Xiphoid process = 3 cm
Breathing Pattern: primarily upper chest with decreased diaphragmatic excursion = 1.5 cm, (+) SCM hypertrophy.
Auscultation: diminished breath sounds t/o the (R) lower lobes, (+) for (click here for the breath sound) (L) & (R) lower lung fields. (click here to play the breath sound) also heard on expiration.
Finger Percussion: Hyper-resonance in the (R) lower lobes.
Breath Support for Phonation: 10/words
Cough/Secretion Management: non-functional and only partially productive for small amounts of thin clear secretions.
Functional Status: (S) ambulation on level surfaces s AD x 100'/trial, primary limitation is SOB, no LOB noted, ascend/descend 13 steps (S) s handrail with mild SOB reported. VCs are required for energy conservation. Bed mobility skills and transfers - (I).
