Medical Record of COPD
Name：Liang Ya jun Occupation: driver
Sex：male Date of admission: Jan ,17,2011 Age: 70 years old Date of record: Jan,17,2011 Nationality: Han Narrator of history: Himself
Birth place: Beijing Level of history: reliable
Chief complaint: Cough with productive of sputum for 30 years, wheeze for 10 years, and got worse for 3 days.
History of present illness: 30 years ago after exposure to cold weather, the patient suffered from a cough, with purulent sputum, without fever、fatigue、night sweats、hemoptysis. With the anti-infection therapy, He was cured. Since then he was often recurrent 2-3 times every year after catching a cold or having pulmonary infection. 20 years ago, he was diagnosed the chronic bronchitis, and he had to be admitted 1-2 times 1 year for the therapy. 10 years ago, he felt shortness of breath, particularly after sports ,and 5 years ago, he began edema in his legs and feet.
3 days ago, he felt worse without any reson. He coughed all night, couldn’t lie down during sleep, sometimes with dyspnea. The sputa was sticky and purulent. But no fever. He took the oral ampicillin and aminophylline by himself ,but they didn’t work. Then he came to emergency department of TianTan Hospital. The results of blood routine was: WBC:12500/mm3, N:82.3%. The X-ray of lung: The veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial trunk >15mmHg, cardiac apex being globular appearance and more elevated and emphysema. He was given some drugs of anti-infection, but the effect is not good. To be well treated, he was incharged of acute episode of COPD.
These days, he felt weakness, poor of appetite, the urine and stool are normal, his weight did not change.
Past history:He has had Hypertension for 30 years, DM for 4-5 years . 1986: myocardial infarction, full recovery / No subsequent investigation.
Social History: Smoking for 50 years ,the amount is about half a cigarette case per day. Never drink. Born and lives in Beijing, Never been to area of pestilence. Married for 45 years with 2 children and both of them are healthy.
Family history: No family history of chronic disease and genetic disease.
Review of Systems
Respiratory system: Same as the history of present illness.
Gastrointestinal tract: No current indigestion. No vomiting/ dysphagia/ diarrhea/ constipation/ abdominal pain.
Cardiovascular system: No current chest pain. No palpitation/loss of consciousness.
Genitourinary system: No urinary systems.
Nervous System: No headache/ syncope/ vertigo/ balance problem. No dizziness/ limb weakness/ sensory loss. No disturbance of vision/ hearing/ smell/ speech.
Musculoskeletal system: No joint pain/ stiffness/ extremity pain/ decreased range of motion. No disability.
Allergies History: penicillin-skin rash
Physical examination
T: 37.2℃ R: 24bpm P: 101bpm BP: 110/60mmHg
General: well. No anemic looking. consciousness is clear. His action is free .
Skin: No petechiae, purpura, Anlcteric. No cutaneas Lesions or rashes. His feet is Ⅱdegree edema .
Nodes: Surface nodes unpalpable.
Eyes: conjunctive normal.No icterus, hemorrhage. Lids without lesions. Pupils equal, round and react to light and accommodation.
Neck: Supple, Trachea midline. Thyroid not enlarged and without nodules. Jugular veins flat. Venous pulses normal.
Chest: Tubbish chest contour. No catfale, pain.
Lungs: Inspection:respiration equal,24bpm,rhythm regular.
Palpation:with symmetrical full expansion.No thrills.
Percussion:No percussion dullness.
Auscultation: coarse. Sometimes there are moist and dry rales in both lungs. There is no sounds of pleural friction.
Heart: Inspection: No visible lifts.
Palpation:rate:101bpm. Rhythm is regular. No lifts thrills,heaves.
Percussion: Heart border normal as follows:
Right(cm) Rib Left(cm)
2 Ⅱ 2
2 Ⅲ 4.5
3 Ⅳ 6
Ⅴ 8
MCL=8cm
Auscultation: rate:101bpm,rhythm is irregular, P 2> A 2. No splitting of heart sound.No cardiac murmurs or pericardial sound.
Abdomen: Inspection:No scars or visible masses.Venous pattern normal.
Palpation: Soft, no pain, mass, thill or fluid wave. Liver and spleen not palpable.
Percussion:Liver sonant normal.
Auscultation:Bowel sound 3bpm.No bruit.
Nerve: Higher function normal.
Cranial nervesⅰ-Ⅻ: normal.
Upper and lower limbs: power, tone, coordination, sensation all normal.
Laboratory and diagnostic tests
Blood routing: WBC 12500/mm3, N 82.2%.
Arterial blood-gas : PH 7.35 PO2 58mmHg PCO2 70mmHg BE 5mmol/L.
X-RAY: The veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial
trunk >15mmHg, cardiac apex being globular appearance and more elevated and emphysema. Summary
70-year-old male smoker with a family history and previous history of chronic bronchitis, presents with 20-year history of cough, sputum, wheeze and got worse for 3-day, which is unrelieved by ampicillin and aminophylline. On examination, there are moist and dry rales in both lungs.Blood routing: WBC 12500/mm3, N 82.2%.X-RAY: The veins of 2 pumonarys are coarse and irregular, right-lower pulmonary arterial trunk >15mmHg, cardiac apex being globular appearance and more
elevated and emphysema.The most likely diagnosis is an acute episode of COPD(chronic obstructive pulmonary disease).
Diagnosis: Acute episode stage of COPD(chronic obstructive pulmonary disease) Chronic bronchitis
Obstructive emphysema
Chronic pulmonary heart disease
Decompensation stage of cardiac and lung functions
Type 2 respiratory failure
Coronary heart disease
Old myocardial infarction
Sinus heart rate
Heart border normal
Cardiac function 2 classic
Hypertension 3 classic
2 type Diabetes mellitus
Dr. XX