Solution for COPD Case Study Part 2

Patient Summary:

Pertinent Positives:

• Smoking History: Former smoker with a 20 pack-year history.
• Cough: Chronic intermittent cough for 6 months, worse in the morning, productive with white-yellowish phlegm.
• Shortness of Breath: Occurs with activity and is relieved by rest.
• Physical Exam Findings: Faint forced expiratory wheezes in bilateral bases on auscultation, oxygen saturation of 94% on room air.
• Spirometry Results: FVC predicted at 67%, FEV1 predicted at 46%.

Pertinent Negatives:

• No barrel chest, weakness, loss of appetite, nausea, coarse lung crackles, dizziness, lower extremity edema, neck vein distention, nail clubbing, normal chest x-ray, or use of accessory muscles.

Diagnosis:

• ICD-10 Code: J44.9 - Chronic obstructive pulmonary disease, unspecified.

Prescribed Medications:

1. Albuterol 2.5 mg Inhaler
   • Dosage: 1-2 puffs every 4-6 hours PRN for shortness of breath (SOB) or wheezing.
   • Dispense: #1 inhaler, no refills.
2. Spiriva 2.5 mcg Capsule Inhaler
   • Dosage: 2 puffs daily.
   • Dispense: #1 inhaler, no refills.

SOLUTION:

Solution for COPD Case Study

Patient Summary:

Pertinent Positives:

• Smoking History: Former smoker with a 20 pack-year history.
• Cough: Chronic intermittent cough for 6 months, worse in the morning, productive with white-yellowish phlegm.
• Shortness of Breath: Occurs with activity and is relieved by rest.
• Physical Exam Findings:
  • Faint forced expiratory wheezes in bilateral lung bases on auscultation.
  • Oxygen saturation of 94% on room air.
• Spirometry Results:
  • Forced Vital Capacity (FVC) predicted at 67%.
  • Forced Expiratory Volume in 1 second (FEV1) predicted at 46%.

Pertinent Negatives:

• No barrel chest, weakness, loss of appetite, nausea, coarse lung crackles, dizziness, lower extremity edema, neck vein distention, nail clubbing, normal chest x-ray, or use of accessory muscles.

Diagnosis:

• ICD-10 Code: J44.9 - Chronic obstructive pulmonary disease, unspecified.

Medication Plan:

1. Albuterol 2.5 mg Inhaler
   • Dosage: 1-2 puffs every 4-6 hours as needed for shortness of breath (SOB) or wheezing.
   • Dispense: #1 inhaler, no refills.
2. Spiriva (Tiotropium) 2.5 mcg Capsule Inhaler
   • Dosage: 2 puffs daily.
   • Dispense: #1 inhaler, no refills.

Rationale:

• Albuterol is a short-acting bronchodilator (beta-agonist) used for quick relief of acute bronchospasm or wheezing associated with COPD. It provides immediate relief by relaxing the muscles around the airways, making it easier to breathe.
• Spiriva (Tiotropium) is a long-acting anticholinergic (LAMA) that helps to prevent symptoms like wheezing and shortness of breath. It works by relaxing the muscles in the airways to improve airflow and reduce exacerbations in COPD.

Management Plan:

1. Continued Monitoring:
   • Follow-up with spirometry to monitor disease progression and treatment effectiveness.
   • Regular assessments to check for potential side effects of medications and to ensure the patient is adhering to the prescribed treatment.
2. Lifestyle Modifications:
   • Encourage smoking cessation if the patient has not already quit.
   • Recommend pulmonary rehabilitation to improve exercise tolerance and quality of life.
   • Discuss the importance of staying physically active within limits to maintain respiratory function.
3. Preventive Care:
   • Administer annual influenza vaccination and pneumococcal vaccine to reduce the risk of respiratory infections, which can exacerbate COPD symptoms.
4. Patient Education:
   • Educate the patient on the proper use of inhalers to ensure maximum efficacy.
   • Advise on recognizing signs of exacerbation and when to seek medical attention.
   • Discuss the importance of adhering to the medication regimen and attending regular follow-up appointments.

Conclusion:

This solution provides a comprehensive approach to managing the patient’s COPD, ensuring both immediate symptom relief and long-term control. The use of both short-acting and long-acting bronchodilators, along with appropriate follow-up and lifestyle recommendations, aligns with best practices for COPD management.