Skip to content
MedicalCoreCoding

Try a topic like assisted living, critical care or a code like 99214.

AboutContact

National Colony, Aurangabad, 431001 · Mon - Fri: 9am - 5pm

Report #23 · Office & outpatient

Worsening shortness of breath and cough

5 questionsCOPADataRiskMDMCode

From the lesson Office & Outpatient

Jump to the questions

Clinical note · #23

Office & outpatient

Patient: Mr. X

Age: 65

Presenting Complaint: Worsening shortness of breath and cough

History of Present Illness (HPI):

The patient has been diagnosed with COPD for the past five years. He has been experiencing a worsening of his symptoms over the past month. The patient has a 30 pack-year history of smoking.

Review of Systems (ROS):

  • Cardiovascular: No chest pain or palpitations.
  • Respiratory: As per HPI.
  • Gastrointestinal: No nausea, vomiting, or abdominal pain.

Past Medical History (PMH):

  • COPD
  • Hypertension
  • Type 2 Diabetes Mellitus

Physical Examination:

  • General: Alert, oriented, in no apparent distress.
  • Respiratory: Decreased breath sounds bilaterally. Wheezing present.
  • Cardiovascular: Regular rate and rhythm. No murmurs.

Assessment:

The patient's symptoms are consistent with an exacerbation of his COPD.

Plan:

  • Increase dose of inhaled corticosteroids
  • Prescribe a course of antibiotics due to risk of infection
  • Follow-up appointment in one week to assess response to treatment.