1. Primary Diagnosis
Considering the patient’s Pre and Post Bronchodilator Spirometry results along with his negative
CXR, it is evident that this patient has chronic obstructive pulmonary disease (COPD)
Pertinent Positive Findings
- Pre-Bronchodilator FEV1/FV = 52%
- Post Bronchodilator FEV1/FV = 52%
Pertinent Negative Findings
- CXR Negative for infiltrates or consolidations
- Cardiac and mediastinal silhouettes normal
- No hilar enlargements are evident
- Osseous Thorax intact
- Based on information, COPD (ICD J44.9) is my primary diagnosis for this patient, and
with the FEV1 on the spirometry being 47%, he has stage 3 COPD because if the FEV1
is between 30-50%, the classification is stage 3 (Gentry & Gentry, 2017).
2. ICD – 10 Code
COPD (Unspecified) ICD-10 J44.9.
3. Treatment Plan
Medication
o Based on the severity of this patient’s COPD and the FEV1/FV ratio post use of a
bronchodilator, it is imperative that a bronchodilator along with a long acting
musinaric (LAMA) is prescribed. The GOLD recommended start treatment is
(GOLD, 2019). It is recommended to start monotherapy with an inhaled
bronchodilator and anticholinergic treatment.
Tiotropium dry powder inhaler 18mcg
Sig: Take two puffs from 1 capsule 1x daily
Dispense: 30 capsules
Refills 1
Albuterol/ipratropium inhaler
Sig: Take 1 puff four times day as needed
Dispense: 1 canister 120 metered doses
Refills 3
Additional testing
o I do not believe any additional testing is necessary.
Patient education
o When using the inhaler for the first time, it is important to prime the inhaler/
shake the inhaler for five seconds, press down the canister with the index finger
with the inhaler away from face, wait a few seconds, shake the inhaler, press the
canister down again, and repeat the last step two more times (DePietro, et al.,
2018).
o Getting all recommended vaccinations such as pneumococcal, flu, and pertussis
vaccine, is an important part of managing COPD because getting sick with a
This study source was downloaded by 100000842670546 from CourseHero.com on 03-01-2022 12:23:34 GMT -06:00
https://www.coursehero.com/file/73994054/NR601-Week-2-Case-Study-Part-2docx/
Considering the patient’s Pre and Post Bronchodilator Spirometry results along with his negative
CXR, it is evident that this patient has chronic obstructive pulmonary disease (COPD)
Pertinent Positive Findings
- Pre-Bronchodilator FEV1/FV = 52%
- Post Bronchodilator FEV1/FV = 52%
Pertinent Negative Findings
- CXR Negative for infiltrates or consolidations
- Cardiac and mediastinal silhouettes normal
- No hilar enlargements are evident
- Osseous Thorax intact
- Based on information, COPD (ICD J44.9) is my primary diagnosis for this patient, and
with the FEV1 on the spirometry being 47%, he has stage 3 COPD because if the FEV1
is between 30-50%, the classification is stage 3 (Gentry & Gentry, 2017).
2. ICD – 10 Code
COPD (Unspecified) ICD-10 J44.9.
3. Treatment Plan
Medication
o Based on the severity of this patient’s COPD and the FEV1/FV ratio post use of a
bronchodilator, it is imperative that a bronchodilator along with a long acting
musinaric (LAMA) is prescribed. The GOLD recommended start treatment is
(GOLD, 2019). It is recommended to start monotherapy with an inhaled
bronchodilator and anticholinergic treatment.
Tiotropium dry powder inhaler 18mcg
Sig: Take two puffs from 1 capsule 1x daily
Dispense: 30 capsules
Refills 1
Albuterol/ipratropium inhaler
Sig: Take 1 puff four times day as needed
Dispense: 1 canister 120 metered doses
Refills 3
Additional testing
o I do not believe any additional testing is necessary.
Patient education
o When using the inhaler for the first time, it is important to prime the inhaler/
shake the inhaler for five seconds, press down the canister with the index finger
with the inhaler away from face, wait a few seconds, shake the inhaler, press the
canister down again, and repeat the last step two more times (DePietro, et al.,
2018).
o Getting all recommended vaccinations such as pneumococcal, flu, and pertussis
vaccine, is an important part of managing COPD because getting sick with a
This study source was downloaded by 100000842670546 from CourseHero.com on 03-01-2022 12:23:34 GMT -06:00
https://www.coursehero.com/file/73994054/NR601-Week-2-Case-Study-Part-2docx/
