Analyzation of CXR and Spirometry Results

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Case Study – Part 2
Primary Diagnosis
           Based on the physical examination, clinical presentation, and ancillary procedures done, the patient has chronic obstructive pulmonary disease, specifically chronic bronchitis. 
           First, the vital signs of the patient already indicate that there is a respiratory problem because of the decreased oxygen saturation, at 94%. Second, the signs and symptoms of the patient align with the diagnosis. These are shortness of breath with activity, wheezing upon expiration, and persisting productive cough, with white-yellowish secretion, that is worse in the morning. In addition to these, the length of time that the patient is presenting with his complaints which is 6 months is also a characteristic of chronic bronchitis. Third, is the consideration of the patient’s lifestyle which involves the previous history of cigarette smoking with 20 pack-years (Lowe, et al., 2019). Upon examination, the patient shows pertinent negative findings to help rule out various conditions. Examples of these are findings are negative murmurs, chest pain, and edema in the lower extremities, ruling out cardiovascular affectation, and negative fever and weight loss, ruling out the presence of infection in the body. The ancillary procedures are done also help confirm the diagnosis. The spirometry results reveal an obstructive type of chronic obstructive pulmonary disease because of the FEV1 being below 80% of the predicted value, reduced FVC at 67%, and FEV1/FVC ratio below 0.7, without much changes even at the post-bronchodilator phase of the test (GOLD, 2017). The chest x-ray results reveal the following: No consolidations or infiltrations seen; Normal mediastinal and cardiac silhouettes; Intact osseous thorax; No hilar enlargement. These do not show any complications and also help in ruling out other conditions such as emphysema, and congestive heart failure. In addition to these, chronic bronchitis is also a condition that may appear normal on chest x-rays which explains the results. 
ICD-10 Code
           The possible ICD-10 Code appropriate for the primary diagnosis are: 
J41.0. - Chronic obstructive pulmonary disease with (acute) lower respiratory infection
J44.1 - Chronic obstructive pulmonary disease with (acute) exacerbation
Treatment plan
Medications
* Advair 2x/day
* Oxygen @ 2L/min as needed
The main medications for the patient who is suffering from chronic bronchitis are bronchodilators and corticosteroids. Advair is used as a maintenance medication and is composed of salmeterol, corticosteroid, and fluticasone (O’Dell, et al., 2018). The bronchodilator will aid in easing the difficulty in breathing by promoting relaxation in the air passages. The corticosteroids will prevent bronchospasm and inflammation to improve airflow. Salmeterol will be beneficial to the patient by improving lung function and having positive effects on the functional activities of the patient. Lastly, oxygen therapy will help the patient because he is experiencing low oxygen sat...