COPD follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for a ‍COPD follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimprovedworsenedvariable in intensityresolved



Current symptoms:

‍shortness of breath

‍wheezing

‍chest tightness

‍cough, ‍non-productiveproductive of ‍clearcolored phlegm

‍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, ‍apparent distress

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

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍COPD ‍likelysuspectedpossible, ‍well-controlled

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:

- ‍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 if necessary

- Smoking cessation counseling

- Immunization: pneumococcal, annual influenza, covid

Further care:

- Pulmonary rehabilitation program referral

- Referral to pulmonologist

- Follow-up in ‍ ‍monthsyears

- Return sooner if symptoms worsen