Comprehensive COPD (Chronic Obstructive Pulmonary Disease) Case Study

This is not a real patient chart. The names and data have been created.

Patient Chart

Patient Name: Robert Michael Adams
Date of Birth: 04/25/1957
Age: 67
Gender: Male
Medical Record Number: 20250313
Date of Admission: 03/13/2025
Primary Care Provider: Dr. Linda Carter

Chief Complaint (CC)

"I’ve been coughing a lot more lately, and it’s hard to breathe, especially when I’m trying to do anything physical."

History of Present Illness (HPI)

Robert Adams is a 67-year-old male with a long-standing history of smoking, chronic cough, and shortness of breath, who presents with increased coughing, wheezing, and difficulty breathing over the past two weeks. He reports a gradual increase in his baseline shortness of breath, which now occurs even at rest. He describes his cough as productive, with thick yellowish sputum. He has also noticed a decrease in his exercise tolerance and increased fatigue. No fevers, chills, or weight loss are reported.

He has a history of COPD for over 10 years, with previous exacerbations managed with antibiotics and steroids. He denies any recent travel or exposure to sick contacts but reports more frequent use of his albuterol inhaler over the past few weeks due to increased symptoms.

Past Medical History (PMH)

  • Chronic Obstructive Pulmonary Disease (COPD) – diagnosed 10 years ago, history of smoking
  • Hypertension – diagnosed 15 years ago, controlled with Lisinopril
  • Hyperlipidemia – diagnosed 12 years ago, managed with Atorvastatin
  • Gastroesophageal Reflux Disease (GERD) – diagnosed 8 years ago, managed with Omeprazole
  • Sleep Apnea – diagnosed 5 years ago, uses CPAP at night

Surgeries & Procedures

  • Tonsillectomy (childhood)
  • Left knee arthroscopy (5 years ago)

Allergies

  • No known drug allergies (NKDA)

Medications

  • Albuterol inhaler as needed
  • Fluticasone/Salmeterol inhaler 250/50 mcg twice daily
  • Lisinopril 10 mg daily
  • Atorvastatin 40 mg nightly
  • Omeprazole 20 mg daily (for GERD)
  • CPAP at night

Family History (FH)

  • Father: Deceased, 72, with a history of smoking and COPD
  • Mother: Alive, 88, with a history of hypertension and osteoporosis
  • Brother: Alive, 65, with hypertension and type 2 diabetes

Social History (SH)

  • Smoking: 40 pack-years, quit 5 years ago
  • Alcohol: Occasional drinker (1-2 drinks per week)
  • Drug Use: Denies illicit drug use
  • Occupation: Retired construction worker
  • Living Situation: Lives alone, independent in activities of daily living

Review of Systems (ROS)

  • General: Fatigue, no fever or weight loss
  • Respiratory: Chronic cough with yellowish sputum, shortness of breath, wheezing
  • Cardiovascular: No chest pain or palpitations
  • Gastrointestinal: No nausea, vomiting, or abdominal pain
  • Neurological: No headaches, dizziness, or syncope
  • Musculoskeletal: No joint pain or swelling

Physical Assessment Findings

Vital Signs:

  • Temperature: 98.6°F (37.0°C)
  • Heart Rate: 92 bpm, regular
  • Respiratory Rate: 22 breaths/min
  • Blood Pressure: 145/90 mmHg
  • Oxygen Saturation: 88% on room air
  • Height: 6'1"
  • Weight: 218 lbs.

General Appearance: Overweight male, alert, mild respiratory distress with increased work of breathing
Cardiovascular: Regular rate and rhythm, no peripheral edema, no jugular venous distention
Respiratory: Decreased breath sounds bilaterally, expiratory wheezes, prolonged expiratory phase, use of accessory muscles
Abdomen: Soft, non-tender, no hepatomegaly
Neurological: Alert and oriented, no focal deficits

Laboratory Results

Basic Metabolic Panel (BMP)

Test Result Reference Range
Sodium (Na) 138 mEq/L 135-145 mEq/L
Potassium (K) 4.1 mEq/L 3.5-5.1 mEq/L
Chloride (Cl) 102 mEq/L 98-107 mEq/L
Bicarbonate (HCO₃) 24 mEq/L 22-28 mEq/L
Blood Urea Nitrogen (BUN) 18 mg/dL 7-20 mg/dL
Creatinine (Cr) 1.0 mg/dL 0.6-1.2 mg/dL
Glucose (fasting) 100 mg/dL 70-99 mg/dL

Complete Blood Count (CBC)

Test Result Reference Range
White Blood Cell Count (WBC) 8.0 x10³/µL 4.0-11.0 x10³/µL
Hemoglobin (Hgb) 14.0 g/dL 12.0-16.0 g/dL
Hematocrit (Hct) 42% 36-46%
Platelets (Plt) 250 x10³/µL 150-450 x10³/µL

Liver Function Tests (LFTs)

Test Result Reference Range
Alanine Aminotransferase (ALT) 30 U/L 10-40 U/L
Aspartate Aminotransferase (AST) 32 U/L 10-40 U/L
Alkaline Phosphatase (ALP) 110 U/L 45-115 U/L
Bilirubin, Total 0.6 mg/dL 0.1-1.2 mg/dL

Arterial Blood Gas (ABG)

Test Result Reference Range
pH 7.40 7.35-7.45
PaO₂ 70 mmHg 75-100 mmHg
PaCO₂ 45 mmHg 35-45 mmHg
HCO₃ 24 mEq/L 22-28 mEq/L
Oxygen Saturation (SaO₂) 88% 95-100%

Chest X-Ray

Findings:

  • Hyperinflated lungs with flattened diaphragm, consistent with emphysema (a subtype of COPD)
  • No acute infiltrates or consolidation
  • Mild right heart enlargement

Pulmonary Function Tests (PFTs)

Findings:

  • FEV₁ (Forced Expiratory Volume in 1 second): 52% of predicted
  • FVC (Forced Vital Capacity): 72% of predicted
  • FEV₁/FVC ratio: 0.55, indicating obstructive airway disease
  • TLC (Total Lung Capacity): Increased, consistent with air trapping