tags:
  - type/patient/encounter
encid: 100-1-2
name: enc100-1-2
counter: 2
status: 1
reason: The patient visited us for a follow-up and evaluation of his clinical course of Chronic Obstructive Pulmonary Disease (COPD)
patient: pat100
patient_link: "[[pat100.patient]]"
consultation_link: 
clinical_case_link: "[[cc100-1.clincase]]"
banner: "![[_System/Banners/patient_encounter_banner.jpg]]"
created_at: 2024-08-13T22:26:33+03:00
updated_at: 2025-07-18T16:53:42+03:00
banner_y: 0.26255
weight: 80
weight_unit: kgr
height: 175
height_unit: cm
posture_gait: The patient exhibits a somewhat kyphotic posture, likely due to chronic dyspnea and the effort to breathe more easily.
iscooperative: true
mood: ANXIOUS
skin: Dryness and redness of the cheeks.
head: 
breast: 
resp: Dyspnea on exertion, chronic productive cough, wheezing.
cardio: Feeling of fatigue, occasional chest tightness, no history of angina or lower limb edema.
gastro: 
urin: 
genital: 
periph: Mild ankle edema, without other abnormalities.
musc: 
neuro: 
hemo: 
endo: 
systolic: 139
diastolic: 85
pulse_rate: 78
resp_rate: 18
temp: 36.8
temp_unit: °C
spo2: 94
vitals_notes: ""
chief_complaint: Dyspnea on exertion
other_symptoms: |-
  Cough with sputum production (primarily in the morning)
  Wheezing
  Fatigue
  Occasional chest tightness
disease_course: The patient reports slight improvement in symptoms after starting treatment, although dyspnea on exertion persists. The cough is less severe but productive sputum remains in the morning. The patient quit smoking three months ago.
instructions: |-
  Continue the current therapeutic regimen as prescribed
  Maintain pulmonary rehabilitation sessions
  Schedule influenza and pneumococcal vaccinations as soon as possible
  Avoid exposure to irritants (smoke, pollutants)
cssclasses:
  - table-color
  - table-lines
medication:
  - end_date: ""
    start_date: ""
    drug: Tiotropium (Spiriva)
    dosage: 18mcg inhalation capsule
    other: Once daily
  - drug: Salmeterol/Fluticasone (Seretide)
    dosage: 50/500 mcg inhalation powder, blister
    other: Twice daily, morning and evening
    start_date: ""
    end_date: ""
communication: The patient reports difficulty speaking, especially during episodes of dyspnea. This worsens when attempting to speak for prolonged periods or during physical exertion.