Evaluating Primary Diagnosis with COPD

What is your primary (one) diagnosis for this patient at this time? (Support the decision for your diagnosis with pertinent positives and negatives from the case)

The primary diagnosis for this patient is chronic obstructive pulmonary disorder (COPD). This patient presents with all the signs and suggestive features of COPD. Pertinent positive indications that suggest the diagnosis for COPD in this patient are shortness of breath, chronic cough, dyspnea, and sputum production. Dyspnea is a cardinal symptom associated with COPD (GOLD, 2021). This patient is also a former smoker which is a known risk factor during the assessment of COPD (GOLD, 2021). The patient has a persistent and productive cough that has been present for 6 months. According to GOLD (2021) a chronic cough that may or may not be productive is often the first symptom of COPD. Classification of severity of airflow limitation as determined by spirometry was GOLD 3 (Severe). The chest x-ray was negative which was useful to rule out other differentials. According to GOLD (2021) using the results of a chest x-ray is not useful during the diagnosis process but valuable when looking for the presence of a comorbidity. 

1. Identify the corresponding ICD-10 code.

J44.9

2. Provide a treatment plan for this patient's primary diagnosis which includes:

Medication

The use of medication in the maintenance of COPD helps to reduce symptoms, helps to reduce the severity and frequency of exacerbations, as well they can improve tolerance of exercise (GOLD, 2021). Currently, choosing which medication to prescribe is dependent on each individual patient, severity of symptoms, cost of medication, airflow limitations, and the balance of possible side effects (GOLD, 2021).

Tiotropium inhaled HandiHaler DPI: 18mcg per capsule

Dose: 2 puffs (1 capsule) inhaled Daily

Disp #30 Refills: 2

According to GOLD (2021), tiotropium helps to improve symptoms, reduce exacerbations rates versus treatment with an LABA, as well as improve the effectiveness of pulmonary rehabilitation

ProAir HFA MDI: 90 mcg per actuation

Dose: 2 puffs inhaled q4-6 hrs prn SOB or Wheezing

Disp #1 Refills: 2

Patients that are diagnosed with COPD should also be prescribed a short-acting bronchodilator for immediate symptom relief (GOLD, 2021)

Any additional testing necessary for this diagnosis

Along with spirometry, obtaining the patients history and severity of his symptoms are also needed for the treatment as well as the maintenance of COPD. A standardized symptoms score should be assessed using the (mMRC) Modified British Medical Research Council questionnaire or the (CAT) the COPD Assessment Test (GOLD, 2021). I would order an ECG and a BNP because a common comorbidity of COPD is cardiovascular disease (GOLD, 2021). I would order a CBC to assess for the possibility of anemia related to the presentation of dyspnea (Hollier, 2018). I would also add an alpha-1 antitrypsin to the labs, The World Health Organization recommends that all patients should be screened once that have a diagnosis of COPD (GOLD, 2021).

Patient education
Proper inhaler use and technique and assessed regularly (GOLD, 2021). The importance of getting flu, pneumonia, and Tdap vaccines if he has not already had them to decrease the incidence of lower respiratory tract infections (GOLD, 2021). Education provided on the disease course and symptoms of acute exacerbations including information on having a written action plan in place (GOLD, 2021).

Referral
Pulmonologist for pulmonary rehabilitation.

According to the GOLD guidelines (2021) pulmonary rehabilitation for patients in groups B to D should be started early and is considered an important integrated aspect of patient management.

Follow up

A follow up appointment should be made monthly until the stabilization of symptoms, after stabilization follow up appointments should be made at six-month intervals (Hollier, 2018).

4. Provide an active problem list for this patient based on the information given in the case.

SOB; Dyspnea; Cough; Sputum production; Wheezing; Fatigue.

5. Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBP argument for each treatment or testing decision.

Since this is a new diagnosis of COPD, no changes should be, made at this time. Patient will need to be monitored for short- and long-term complications associated with COPD

References:

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2021 [internet publication]

Hollier, A. (2018). Clinical guidelines in primary care (3rd ed.). Advanced Practice Education Associates, Inc.