Chronic Obstructive Pulmonary Disease ( COPD)

1. Demographic Information of The Patient ( NAME, GENDER, AGE, RACE)
2. Chief Complaint:
3. History Of Present Illness: Onset/Location/Duration/Character/Alleviating-Aggravating factors/Temporal pattern/Severity. Additional symptoms and previous treatment if known.

4.Past Medical History

5.“Family Medical history:

6.“Surgical Medical history:

7.Review of systems and Physical Examination : HHENT, NEURO, CARDIO RESP, GI, GU, MUSCULOSKELETAL.

8. As part the objective component include: Vital signs, body measurements.

9.Diagnostic Test:

10.Main Diagnosis with explanation of what it is:

11.Mention 3 Differentials Diagnosis each one with citation:

1.

2.

3.

12.Treatment: If medication include route, dose and frequency ( Describe the goals, priorities and education provided. Include a citation per therapeutic option and education.)

13. New orders for diagnostic testing. Include rationale and one citation per order.

14.Follow up and Referrals

15. Rational Paragraph justifying a theoretical perspective supporting your management approach.

Sample Solution.