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The patient symptoms that concern me on today’s visit are the increase in shortness of breath with ADL’sover the past few months, and the chronic cough. L. J.’s history of hypertension and 65 pack year smoking history is concerning to me.ROS:CONSTITUITIONAL: Do you have any recent weight loss, fever, chills, weakness, or fatique?HEENT: Do you have any visual loss, blurred vision, double vision, or yellow sclerae? Are you experiencing any hearing loss, sneezing, congestion, runny nose of sore throat?CARDIOVASCULAR: Do you have any chest pain, chest pressure or chest discomfort? Are you having any palpitations or edema?RESPIRATORY: Do you have any shortness of breath, cough, or sputum?Differential diagnosisCOPD (ICD-10: J44.9) Chronic obstructive pulmonary disease (COPD) is a debilitating and potentially life-threatening disease and is characterized by persistent airflow limitation that is usually progressive and associated with enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases (Beddoe & Schub, 2016). The course of COPD is invariably marked by exacerbation characterized by dyspnea, cough, and/or increased mucus production (Beddoe & Schub, 2016). Patients can experience severe breathlessness with activity (Beddoe & Schub, 2016). Smoking is the primary risk factor for COPD; 80–90% of COPD in the U.S. is related to cigarette smoking (Beddoe & Schub, 2016). Signs and symptoms of COPD include dyspnea, fatigue, cough, increased sputum production, and weight loss (Beddoe & Schub, 2016). The rationale for this diagnosis is LJ’s symptoms of cough, shortness of breath, and his 65 pack year smoking history which put him at risk for this disease.
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Chronic obstructive pulmonary disease, Pneumothorax, Schub, Smith & Rushton