COPD follow-up

HISTORY:

‍COPD follow-up

Progress since last visit: ‍unchangedimprovedworsenedvariable in intensityresolved

Current symptoms:

‍shortness of breath

‍wheezing

‍chest tightness

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍increased sputum production

‍change in sputum color

‍hemoptysis

‍decreased exercise tolerance

‍fatigue

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍fever, up to ‍°, over ‍ ‍hoursdays



Exacerbations in the past year: ‍ ‍none123, ‍self-treated, ‍PCP visits, ‍ER visits, ‍hospitalizations

Impact on daily activities: ‍minimalmoderateseveredebilitating

Overall quality of life: ‍goodaveragepoor ‍

Comorbidities: ‍congestive heart disease, ‍CAD, ‍diabetes, ‍anxiety, ‍depression



Medications:

‍LABAs, ‍LAMAs, ‍corticosteroids (ICS), ‍SABAs, ‍SAMAs, ‍Oxygen therapy, ‍LABA+ICS, ‍LABA+LAMA combinations

Adherence: ‍goodaveragepoor

Action plan available: ‍no ‍antibiotics, ‍prednisone

Use of rescue inhaler: ‍neverrarelyfew times weeklydailymultiple times a day

Inhaler technique: ‍correctincorrectnot reviewed



Smoking: ‍neversmokerformer smoker, ‍ pack-years

Physical activity: ‍adequateaveragesedentary

Pulmonary rehabilitation program: ‍completedenrolledabandonednot interested ‍



Pulmonary function tests: ‍

Chest X-ray: ‍ ‍normalunchanged

AGB: ‍ ‍normal



Vaccinations:

Pneumococcal: ‍up-to-dateincompleteunvaccinated

Influenza: ‍up-to-dateincompleteunvaccinated

Covid: ‍up-to-dateincompleteunvaccinated



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍COPD ‍likelysuspectedpossible, ‍well-controlled

DDx: ‍



PLAN:

- Chest X-ray

- Pulmonary function tests

- ‍Short-acting bronchodilators (SABAs)

- ‍Long-acting bronchodilators (LABAs)

- ‍Long-acting muscarinic antagonists (LAMAs)

- ‍Inhaled corticosteroids (ICS)

- ‍Combination inhalers

- COPD action plan: ‍Antibiotics + ‍Steroids

- Oxygen therapy if SpO2 < 88%

- Ensure proper inhalation technique and spacer use

- Smoking cessation counseling

- Immunization: pneumococcal, annual influenza, covid

- Pulmonary rehabilitation program referral

- Referral to pulmonologist

- Follow-up in ‍ ‍monthsyears

- Return sooner if symptoms worse