Case Study – Part 2

You ordered a CXR and spirometry at the previous visit and he returns today to review the results. Physical exam and symptoms are … since last visit. Vital signs at this visit are: Temp-98.3, P-68, RR-20, BP 152/90, Height 68.9in., Weight 258 pounds, O2sat 94% on RA

CXR Result: No acute infiltrates or consolidations are seen. Cardiac and mediastinal silhouettes are normal. No hilar enlargement is evident. Osseous thorax is intact.

Spirometry Results:

Requirements/Questions:

• What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)
• Identify the corresponding ICD-10 code.
• Provide a treatment plan for this patient’s primary … which includes:
  • Medication*
  • Any additional testing necessary for this particular … *
  • Patient education
  • Referral
  • Follow up

• Provide an active problem list for this patient based on the information given in the case.
• Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBP argument for each treatment or testing decision.

SOLUTION 

1. What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case)

COPD with severe exacerbations, and dyspnea.

According to (Neumeier & Keith, 2020) GOLD and NICE guidelines:

Diagnosis for COPD, post-bronchodilator FEV1/FVC ratio of < 0.7 (p. 240). The patient’s FEV1/FVC ratio is 0.52.

Assessment of severity of airflow obstruction, reduction in the post-bronchodilator FEV1, GOLD 3: Severe FEV1 = 30%-49%. The patient’s FEV1 is 47%.

Medical Research Council dyspnea scale mMRC Grade 2. CAT score of patient > 10.

According to the ABCD assessment tool (GOLD, 2020), the patient is group …please click the purchase button below to access the entire solution at $15