A 19-year-old female with a history of tobacco smoking for 2 years.
Presenting Complaint: The patient presented to the clinic with a chief complaint of persistent cough and shortness of breath on exertion, which had been worsening over the past few months. She also reported experiencing occasional chest tightness and wheezing.
History of Present Illness: The patient began smoking cigarettes at the age of 17 with friends. She initially smoked socially but reported progressing to daily use within a few months. She typically smoked 10 cigarettes per day. She denied any history of respiratory infections or allergies.
Past Medical History: Unremarkable.
Social History: Lives with parents. Denies illicit drug use. Drinks alcohol occasionally.
Family History: Father has a history of chronic obstructive pulmonary disease (COPD).
Medications: None
Allergies: No known allergies
Physical Examination: Vital signs within normal limits. Respiratory examination revealed mild wheezing on expiration. No other significant abnormalities were noted on physical exam.
Laboratory Findings: Complete blood count (CBC) and basic metabolic panel (BMP) were within normal limits.
Pulmonary Function Tests (PFTs): Spirometry showed mild airflow obstruction, consistent with early-stage chronic obstructive pulmonary disease (COPD).
Diagnosis: Tobacco dependence, early-stage chronic obstructive pulmonary disease (COPD)
Treatment Plan:
Smoking cessation counseling and support: The patient was counseled on the dangers of tobacco use and the importance of quitting smoking. She was provided with resources and support options to help her quit, such as nicotine replacement therapy or prescription medications.
Bronchodilator therapy: An inhaler with a short-acting bronchodilator was prescribed to help relieve wheezing and shortness of breath.
Education: The patient was educated on the importance of avoiding secondhand smoke exposure and on the benefits of a healthy lifestyle, including regular exercise and a balanced diet.
Prognosis: The prognosis for this patient depends on her ability to quit smoking. Early intervention and smoking cessation can help prevent further progression of COPD and improve her quality of life.
Continued tobacco use will lead to worsening symptoms, increased risk of respiratory infections, and premature death.
Discussion: This case report highlights the negative health consequences of tobacco use, even in young individuals. Smoking can lead to a variety of health problems, including COPD, lung cancer, heart disease, and stroke. Early diagnosis and intervention are crucial to minimize the damage caused by smoking.
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