Subjective: Ongoing challenges with â€œbelchingâ€ but feels pretty good. Reports a cough in the morning with thick clear/white sputum. Getting SOB more easily than in past. Quit smoking at age 78.
Objective: No current medications. Utilizing pursed lip breathing. Faint â€˜whistlingâ€™ sound with respiratory effort. Breath sounds are course and diminished in lower lobes bilaterally.
Assessment: Pt. is a 89-year-old male who has a history of smoking 2 packs a day for past 69 years. Pt. experiencing â€˜belchingâ€™ symptoms and morning cough. Appears to be utilizing pursed lip breathing with a â€˜whistlingâ€™ sound present.
- Therapeutics: pharmacologic interventions, if any â€“ new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional – any other therapies in lieu of pharmacologic intervention]
- Would want to start patient on bronchodilator in chance that patient is experiencing symptoms of COPD. Pt. should also be started on rescue inhaler or short acting beta agonist to use during periods of SOB and wheezing.
- Educational: health information clients need to address their presenting problem(s); health information in support of any of the â€˜therapeuticsâ€™ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit
- Smoking is the number one cause of COPD. Given that the patient has smoked for 69 years, it is likely that this is an appropriate tentative diagnosis. It is important that the patient remain compliant with medication to further exacerbate COPD symptoms. The pt. needs to understand that long term use of bronchodilators can cause increased risk of infection and immunosuppression (Wang et. al., 2020). Because of the increased of infection, the pt. needs to be educated on importance of receiving vaccines on schedule and continuing to see healthcare provider on a regular basis.
- Consultation/Collaboration: if appropriate – collaborative â€˜Advanced Care Planningâ€™ with the patient/patientâ€™s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate â€“ consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making
- Further testing would include spirometer to determine if obstruction is present. Arterial blood gases would help determine if there is respiratory failure. Chest x-ray would determine if infection is present.