Chronic Obstructive Pulmonary Disease
Age: years old
Gender:
HISTORY:
Returns for a follow-up
Last visit was ago
Progress since last visit:
Current symptoms:
, of phlegm
, over ,
, up to °, over
Exacerbations in the past year: , , , ,
Impact on daily activities:
Overall quality of life:
Comorbidities: , , , ,
Medications:
, , , , , , ,
Adherence:
Action plan available: ,
Use of rescue inhaler:
Inhaler technique:
Smoking: , pack-years
Physical activity:
Pulmonary rehabilitation program:
Pulmonary function tests:
Chest X-ray:
AGB:
Vaccinations:
Pneumococcal:
Influenza:
Covid:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
,
DDx: COPD exacerbation, asthma, acute bronchitis, respiratory infection, pulmonary embolism, pneumonia, heart failure, lung cancer, tuberculosis, interstitial lung disease, pulmonary hypertension, sleep apnea, occupational lung diseases, anemia
PLAN:
Investigations:
- Chest X-ray
- Pulmonary function tests
Treatments:
-
-
-
-
-
- COPD action plan: +
- Oxygen therapy if SpO2 < 88%
- Ensure proper inhalation technique and spacer use if necessary
- Smoking cessation counseling
- Immunization: pneumococcal, annual influenza, covid
Further care:
- Pulmonary rehabilitation program referral
- Referral to pulmonologist
- Follow-up in
- Return sooner if symptoms worsen
HISTORY: EXAM: ASSESSMENT: PLAN: