89 YO Male, general health eval, former smoker, 2PPD x69 years, no home medications, patient reports productive cough, mostly in the mornings, thick clear to white sputum and gets SOB easier than before. Reports issues with “belching”. Overall, feeling well.


            Patient using pursed lip breathing in the office today. Faint whistling sound associated with respiratory effort noted. Course breath sounds, diminished in bilateral lower lobes.

ASSESSMENT: Chronic Obstructive Pulmonary Disease (COPD)

PLAN: Based on the patients presenting characteristics, confirming a COPD diagnosis is appropriate. Perform a thorough assessment of the patient’s history including childhood factors, occupational history, and family history. Obtain diagnostic labs to establish a baseline. Assess patient’s current oxygen status to determine oxygen needs. Perform spirometry testing to diagnose COPD. Forced vital capacity maneuver during spirometry showing the presence of a post-bronchodilator FEV1/FVC ratio < 0.7 is needed to establish the diagnosis of COPD (Agusti et al., 2023). Severity of airflow obstruction (GOLD grade 1-4) and the questionaries (COPD assessment test- CAT and modified medical research council- MMRC) should also be completed. Assessment of COPD exacerbation history and risk should be completed.

  • Therapeutics:
    • Depending on the patients MMRC, CAT scores, and number of exacerbations per year, pharmacologic management will be determined. Recommendations for COPD management focus on reducing existing symptoms, decreasing the risk of future exacerbations, and improving health status. GOLD endorses long-acting bronchodilator combinations with differing mechanisms of action including long-acting muscarinic antagonists (LAMA) and long-acting beta2-agonists (LABA) in patients with COPD insufficiently controlled on mono-bronchodilator therapy. Inhaled corticosteroid (ICS)-containing medications, added to bronchodilator therapy, should be reserved for patients with moderate-to-very severe COPD (Palli et al., 2021).
  • Education:
    • Educate the patient on importance of follow up appointments and the need to avoid air pollution and smoke. Meals should be 4-6 smaller meals compared to the regular 3 large meals a day. Eat slowly to catch your breath between bites and eat food that does not require a lot of chewing (energy consumption). Instruct the patient to weigh once and notify the provider if they have any weight loss or gain, yellow or green mucous, or if their breathing gets worse. The annual influenza, pneumococcal, and TDAP vaccines are recommended for patients with COPD. Patient should exercise regularly. Continuing with smoking cessation is key.
  • Collaboration/ Consults: 
    • Depending on the patient, collaboration from several professionals could be indicated: pulmonologist, pharmacist, mental health therapist, and pulmonary rehab therapist.
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