tags:
  - type/patient/clinical_case
ccid: 102-1
name: cc102-1
counter: 1
hpi: |-
  Introduction
  The patient, 62 years old, former smoker, was admitted to the hospital with primary symptoms of difficulty breathing, chronic cough, and increased sputum production, which began worsening over the past six months.

  Initial Symptoms and Course
  The initial symptoms appeared approximately ten years ago with occasional shortness of breath and mild cough. The patient reported that the symptoms gradually worsened, especially in the mornings and during physical activity. Over the last six months, the shortness of breath became more severe and was accompanied by productive cough with yellow sputum.

  Risk Factors
  The patient has a history of smoking (20 years) and worked for many years in an environment with high levels of dust and chemical substances. There is no family history of pulmonary diseases.
referral: ""
notes: |-
  The patient visited the pulmonologist three months ago, where the following diagnostic tests were performed:

  Blood tests: Elevated white blood cell count, normal hemoglobin levels.

  Spirometry: Reduction of FEV1/FVC (Forced Expiratory Volume in 1 second / Forced Vital Capacity) to 60% of the predicted value.

  Chest X-ray: Signs of lung hyperinflation and flattened diaphragms.

  Chest CT scan: Revealed chronic bronchitis and signs of emphysema.
assess_date: 2017-06-15
assess_descr: |-
  Treatment Plan

  Smoking cessation

  Bronchodilator therapy:
  a) Tiotropium (Spiriva): 18 mcg inhalation capsule, once daily
  b) Salmeterol/Fluticasone (Seretide): 50/500 mcg dry powder inhaler, twice daily

  Pulmonary rehabilitation

  Vaccination against influenza and pneumococcus

  Regular monitoring and reassessment every month
patient: pat102
patient_link: "[[pat102.patient]]"
attendant: phys20240622120000
attendant_link: "[[phys20240622120000.physician]]"
referring: 
diag_date: 2017-05-15
diag_icd10: J44
diag_descr: Chronic Obstructive Pulmonary Disease (COPD)
diag_notes: The patient's diagnosis was confirmed as Chronic Obstructive Pulmonary Disease (COPD) with predominant chronic bronchitis.
created_at: 2024-07-28T19:17:41+03:00
updated_at: 2025-07-18T15:29:42+03:00
banner: "![[_System/Banners/patient_medical_case_800x400.jpg]]"