Academic Clinical History and Physical

Sample Solution

    Subject: 75-year-old male with history of COPD and hypertension. Chief Complaint/Reason for Admission/Visit: Patient presents with shortness of breath and dizziness. HPI for H&P or Consult Notes: The patient has had a history of COPD for 3 years and is currently taking medication to manage his symptoms, including albuterol inhalers,

levalbuterol inhalers, teamibutol tablets, Fluticasone nasal spray, spiriva capsules, and prednisone oral tablets. He has also been diagnosed with hypertension 3 years ago which he manages through lifestyle changes such as exercising regularly and monitoring his diet. Additionally he reports that he had an episode of dizziness 2 days prior to this visit. Medical History: Patient’s medical history includes his chronic conditions (COPD and hypertension) as well as a past fracture in the left ankle 6 months ago from a fall when walking outside. He does not smoke or drink alcohol but occasionally takes over the counter medications for pain relief such as ibuprofen or acetaminophen. Surgical History: None reported by the patient Family History: Patient states that no family members have any chronic illnesses apart from occasional colds or flu during winter seasons. His father passed away at age 78 due to natural causes; however no other major events were reported in the family’s medical history. Social History: Apart from occasional social gatherings related to work colleagues or friends, patient stays at home majority of time engaging mostly in activities such as reading books or watching TV programs on computer devices due to recent pandemic restrictions imposed by governmental organizations recently adopted due to COVID-19 pandemics in most areas around the globe including this one too! Allergy History: No known allergies reported by patient during current visit Home Medications ( if consultation note): Albuterol Inhalers (2 puffs every 4 hours), Levalbuterol Inhalers (1 puff every 6 hours), Teimibutol Tablets 1 tablet daily before bedtime), Fluticasone Nasal Spray (1 puff twice daily), Spiriva Capsules (1 capsule twice daily), Prednisone Oral Tablets( 5 mg once daily). Additionally patient was prescribed furosemide oral tablets 10mg taken once daily for treatment purposes related to this incident only since onset date two days prior consult date! Review Of Systems With All Body Systems For H&P Or Consult Notes : Respiratory system - Patient complains about dyspnea accompanied with mild wheezing on inspiration mainly noted while breathing deeply along with coughing spells that are usually productive; Cardiovascular system - patient denies chest pain ‘associated’ with shortness of breath but experiences lightheadedness episodes when standing up abruptly; Neurologic System - complaints regarding headache episodes associated with dizzy spells upon standing ; Musculoskeletal System - reporting stiffness mainly in lower extremities joints upon waking up early morning ; Gait & Balance - frequents trips & falls incidents happened couple times lately causing minor injuries like bruises here & there; Gastrointestinal System –Appetite seems slightly decreased compared than pre admission levels; Urinary System –Denies any abnormal urination patterns lately ; Endocrine System - Low energy level noticed quite often despite adequate rest periods throughout night . Vital Signs And Weight :Taken During Visit : Blood Pressure 118/75 mmhg , HR 80bpm , RR 28 breaths/min , O2 saturation 99% on room air , Temperature 98F , Height 165 cm Weight 83 kg Physical Exam With A Complete Head To Toe Evaluation :Head / Neck examination reveals symmetrical facies without red flags suggestive for meningeal irritation . Inspection reveals normal coloration of conjunctivae without edema . Palpable carotid pulsations bilaterally equal rate & rhythm . Mucous membranes moistly intact inside mouth cavity illustrating absence of dryness signs detected ! Thoracic Cage examination reveal lungs sounds clear bilaterally noting presence of mild expiratory wheezing sound heard mainly upon deep breaths specifically right side more than left side extra thoracicly ! Abdominal Examination suggests normal bowel sounds detected within all four quadrants noting absence abdominal tenderness everywhere ! Extremities shows presence slight deformity noted left foot probably indicating seasonally healed fracture line present back then!. Lab Results / Imaging Results / Diagnostic Tests Results : Chest X Ray taken yesterday illustrates subtle hyperinflation pattern detectable )Right upper lobe predominantly ) suggesting evidence underlying moderate obstructive pulmonary disorder !! Assessment And Clinical Impressions : Differential diagnoses based upon chief complaint ROS Assessment include Acute Exacerbation Of COPD likely secondary Pulmonary Infection Detected , Pulmonary Edema Secondary Heart Failure Indication Found On Chest X Ray Combined With Hypertension Related Factor!!! Other possibilities include Asthma Attacks might be triggered especially given previous usage especialized bronchodilators like Albuterol frequently though not usual very often !! Chronic Conditions Currently Present Include COPD Together With Hypertension Status Already Documented Prior To This Admissions Date !! List Differencial Diagnoses / chronic conditions In Order Of Priority Are Right Now As Follows First Being Acute Exacerbation Of COPD Likely Secondary Pulmonary Infection Detected Second Is Pulmonary Edema Secondary Heart Failure Findings Accompanied By Hypertension Third Possibility Is Asthma Attack Triggered Particularly Given High Usage Regular Bronchodilators Like Albuterol!! Fourth Is The Chronic Disease Combo Including COPD Alongside Hypertension Previously Documented Before This Hospitalization Occurred!! Plan Component Management And Plan Criteria Incorporation : Select Appropriate Diagnostic Therapeutic Interventions Based On Efficacy Safety Cost Acceptability Provide Rationale Discuss Disposition Expected Outcomes Identify Address Health Education Promotion Prevention Geriatric Considerations Include Treatment Options Specific Nongeriatric Adult Populations Potential Issues Even If They Not Evident Case Summary Ethical Legal Considerations Following Interventions Will Be Initiated As Soon As Possible Focusing Specifically relief Symptoms Namely Dyspnea Plus Dizziness Experienced By Our Current Client Using Combination Modalities Including Short Term Oxygen Supplies Administered Via Mask Device Coupled Alongside Intravenous Corticosteroids Infusion Administered Over Period Five Days Also Diuretics Oral Forms Prescribed Managing Fluid Levels Plus Ace Inhibitors Further Control Blood Pressure Finally Antibiotics Appropriate Type Used Treat Underlying Bacterial Source Responsible These Recent Events Developed Might Found!! Disposition Expected Outcomes Given Provided Intervention Outcomes Most Likely Will Improve Within Few Days Time Keeping Continuously Monitoring Changing Symptoms Improving Vital Signs Implemented Therapy Process Lastly Complete Physician Follow Up Will Scheduled One Week Later Checking Overall Progress Been Made Till Then Accordingly! Additional Comments Recommendations Reiterating Importance Strict Compliance Lifestyle Regimen Especially Regarding Exercise Diet Management Avoid Smoking Drinking Plus Taking Over Counter Medications Unnecessarily Unless Doctor Prescribes Such Medicine Particular Reasons Serious Nature Ones Otherwise Should Avoided Full Stop Since Ultimately Danger Side Effects Usually Far Higher Than Benefits Gained Generally Speaking Though Every Case Can Vary From Another Respectively!!