Analyzing a Diagnosis and Analysis of a Patient's Condition

This patient is a 62-year-old Caucasian male. He presents to the office today with an intermitted cough and recent onset of shortness of breath. The cough has been present for the last 6 months, is productive in nature, with whitish-yellow phlegm. The cough is intermittent in nature but does occurs frequently and is worse in the AM. Activity makes the cough worse, while rest improves it. The patient is unable to walk > 20 feet without having to stop and catch his breath. One year ago, the patient noted that he was able to walk about a mile without any difficulties noted. He states that he has tried taking Robitussin, but it did not help the symptoms.

ROS: Pt denies fever, chills, weight loss, otalgia and otorrhea, rhinorrhea, nasal congestion, sneezing or postnasal drip, ST and redness in the throat. No lymph node tenderness or swelling, denies chest pain and no lower extremity edema. However, pt reports a persistent productive cough upon wakening for the last 6 months with SOB with activity.

History: Pt has primary HTN and takes Metoprolol succinate ER (Toprol-XL) 50mg PO daily and a MVI daily. He has had a cholecystectomy, appendectomy and allergic to PCN causing hives. Pt. is a senior accountant, married with 3 children. He denies alcohol or drug use. He is a former smoker (20 pack-year), he quiet when his father died of MI and CHF at age 59. His father also had a hx of diabetes and was a smoker. His mother is alive with osteoporosis and his siblings are healthy.

Physical Exam: Adult male in NAD is alert and oriented and able to speak in full sentences.

VS: Temp-98.1, P-66, RR-20, BP 156/94, Height 68.9in, Weight 258 pounds, O2sat 94% on RA.

Head: Normocephalic. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nose: Nares patent. Nasal turbinates clear without redness or edema. Nasal drainage is clear. Throat: Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck: Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. No JVD. Cardiopulmonary: Heart S1 and S2 with no murmurs, noted. Lungs clear to auscultation bilaterally with faint forced expiratory wheezes in bilateral bases. Respirations unlabored. Legs without edema. Abdomen: Soft, non-tender. No organomegaly

Differential Diagnoses: Listed below in order from most likely to least likely

Diagnosis #1 Chronic obstructive pulmonary disease (COPD)

COPD is a common treatable disease that includes respiratory symptoms including dyspnea, cough and or sputum production (GOLD, 2021). It commonly affects adults > 40-year-old who smoke or have smoked and seems to affect males more often than females (DynaMed, 2021). According to Boucherat (2016) COPD encompasses two main conditions, chronic bronchitis, and emphysema, and influenced by genetic and environmental factors.

Diagnosis #2 Congestive heart failure (CHF)

CHF is a condition caused by functional and structural defects or cardiac abnormalities which results with a reduced cardiac output. (Roversi, 2016). Patients with CHF presents symptoms such as chest pain, SOB, high blood pressure, weakness, edema in the legs, and rapid weight gain, persistent cough, and wheezing.

Diagnosis #3 Asthma

According GINA, (2021), asthma is a chronic inflammatory disorder of airways characterized by chronic airway inflammation. A patient that presents with suspected asthma may present with symptoms such as a wheeze, shortness of breath, chest tightness, or even a cough.

Analysis of differential diagnosis

Diagnosis #1 COPD

COPD is the most likely diagnosis because of the pertinent positives: SOB, wheezing, productive cough with white yellowish sputum, unable to work for > 20ft without stopping to catch his breath. The pt. also has an allergy of penicillin (hives), former smoker, age-more than 62 years, and is male.Pertinent negatives: no weight loss, no chest pain and lower extremity edema and no coughing blood.

Diagnosis #2 CHF

CHF is the second likely diagnosis. Pertinent positives: primary hypertension, SOB, wheezing persistent cough, primary HPN, legs without edema, allergic reactions, no fever, chills, or wheezing. Pertinent negatives: no weight gain, no chest pain, presence of productive cough and legs without edema.

Diagnosis #3 Asthma

Asthma is the least likely diagnosis.
Pertinent positives: wheezing, persistent cough, SOB, no fever, or chills. Pertinent negatives: productive cough with white yellowish sputum phlegm

Additional Testing

To diagnose COPD, perform spirometry to assess forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC).

Evaluating a patient with clinical symptoms of CHF, echocardiography, and ECG, added with a natriuretic peptide (Roversi, 2016). Additionally, blood tests, such as CBC,