lOMoARcPSD|13111427
lOMoARcPSD|13111
Week 2 Case study part 2 COPD
Primary Care of the Maturing and Aged Family Practicum
(Chamberlain University)
Dr. Chapman and Class- Part 2 Case Study:
1. What is your primary (one) diagnosis for this patient at this time?
COPD with acute exacerbation. He is a CAT grade 2 level B according to GOLD, 2020. His
FeV1 is predicted at 46 % and actually a 47, with a FEV1/FVC ratio of 0.52 or 52 %. This
means that he is a moderate severity of COPD and because of symptoms is having an acute
exacerbation, + cough worsens in the morning, + productive persistent cough that does not get
better with Robitussin and has lasted for 6 months, + forced expiratory wheezes in bilateral
bases on auscultation, +White/Yellow Phlegm, +SHOB with exertion and not able to walk more
than 20 ft without stopping to catch his breath, - fever/chills, -rhinorrhea, nasal congestion,
sneezing or post nasal drip. Negative assessments with throat, neck- lymph nodes normal
without pain or swelling. No chest pain, CXR normal. O2 sats within normal limits of 94 % or
greater on RA.
2. Identify the corresponding ICD-10 code: J44.1
3. TREATMENT PLAN:
A. Medications:
There is an increased effectiveness of decreasing exacerbations using a combination therapy vs a
monotherapy (GOLD, 2020).
1. Breo Ellipta fluticasone furoate/vilanterol inhaled) 100 mcg/25 mcg 1 puff inhaled
daily. Dispense: one inhaler. No refills (GOLD, 2020).
2. Albuterol (Ventolin HFA) 90 mcg/puff. Take 2 puffs every 4-6 hours as needed
for bronchospasms. Dispense 1 inhaler. 0 refills (GOLD, 2020).
A LABA/LAMA combo is recommended for exercise intolerances to help with preventing acute
exacerbations long term (Nici et al., 2019).
Metoprolol ER (Toprol XL) 50 mg po daily. Dispense 30 tabs. 0 refills.
B. Tests:
• Office spirometer yearly to assess pulmonary function (Fenstermacher & Hudson, 2020).
• CAT/mMRC- questionnaire at each visit (Fenstermacher & Hudson, 2020).
C. EDU:
• Rinse mouth after using inhaler to decrease the risk of thrush (Hollier, 2018).
• COPD action plan (ALA, 2020)
• Take medications daily regardless of symptoms, it is for long term management
lOMoARcPSD|13111
Week 2 Case study part 2 COPD
Primary Care of the Maturing and Aged Family Practicum
(Chamberlain University)
Dr. Chapman and Class- Part 2 Case Study:
1. What is your primary (one) diagnosis for this patient at this time?
COPD with acute exacerbation. He is a CAT grade 2 level B according to GOLD, 2020. His
FeV1 is predicted at 46 % and actually a 47, with a FEV1/FVC ratio of 0.52 or 52 %. This
means that he is a moderate severity of COPD and because of symptoms is having an acute
exacerbation, + cough worsens in the morning, + productive persistent cough that does not get
better with Robitussin and has lasted for 6 months, + forced expiratory wheezes in bilateral
bases on auscultation, +White/Yellow Phlegm, +SHOB with exertion and not able to walk more
than 20 ft without stopping to catch his breath, - fever/chills, -rhinorrhea, nasal congestion,
sneezing or post nasal drip. Negative assessments with throat, neck- lymph nodes normal
without pain or swelling. No chest pain, CXR normal. O2 sats within normal limits of 94 % or
greater on RA.
2. Identify the corresponding ICD-10 code: J44.1
3. TREATMENT PLAN:
A. Medications:
There is an increased effectiveness of decreasing exacerbations using a combination therapy vs a
monotherapy (GOLD, 2020).
1. Breo Ellipta fluticasone furoate/vilanterol inhaled) 100 mcg/25 mcg 1 puff inhaled
daily. Dispense: one inhaler. No refills (GOLD, 2020).
2. Albuterol (Ventolin HFA) 90 mcg/puff. Take 2 puffs every 4-6 hours as needed
for bronchospasms. Dispense 1 inhaler. 0 refills (GOLD, 2020).
A LABA/LAMA combo is recommended for exercise intolerances to help with preventing acute
exacerbations long term (Nici et al., 2019).
Metoprolol ER (Toprol XL) 50 mg po daily. Dispense 30 tabs. 0 refills.
B. Tests:
• Office spirometer yearly to assess pulmonary function (Fenstermacher & Hudson, 2020).
• CAT/mMRC- questionnaire at each visit (Fenstermacher & Hudson, 2020).
C. EDU:
• Rinse mouth after using inhaler to decrease the risk of thrush (Hollier, 2018).
• COPD action plan (ALA, 2020)
• Take medications daily regardless of symptoms, it is for long term management
