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Asked by ycarter2

 

Mrs. Nelson is a new patient to you. She is a 67-year-old female who complains of progressively worsening shortness of breath with exertion over the last year. 

She currently smokes half a pack of cigarettes daily and has accumulated 35 pack years. 

She uses Ventolin HFA MDI 90 mcgs/actuation 3-4 times a day with limited relief. 

She is no longer able to ride a bike with her grandchildren. Her last hospitalization was 4 months ago secondary to right lower lobe pneumonia; she was COVID negative at that time. 

She does not complain of weight loss or loss of appetite. 

She has a past medical history of dietary controlled Type II diabetes. 

On exam, her respiratory rate is 22 per minute; chest exam reveals mild end-expiratory wheezing without the use of accessory muscles of respiration and no retractions. No clubbing, cyanosis or lower extremity edema is noted. Spirometry reveals an FVC of 78% predicted, FEV1 of 62% predicted and FEV1/FVC of 68% post-bronchodilator administration.

 

Answer the following questions:

What additional questions would you ask your patient?
What additional diagnostic study results would you like to have?
From the information presented, what risk factors for COPD does your patient present with?
According to the GOLD Guidelines, what classification of COPD severity does your patient present with?
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