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

The primary diagnosis for the presenting client is moderate to severe chronic obstructive pulmonary disease (COPD) (ICD-10-J44.9). A COPD diagnosis is given if the FEV1/FVC predicted is less than 0.7 percent (Haynes, 2018). The client reports an FEV1/FVC of 0.52, which is indicative of diagnostic airflow obstruction. The FEV1/FVC ratio of <0.7 percent and the respiratory symptoms reported in the subjective interview including dyspnea, shortness of breath, wheezing, and excess mucus or phlegm production (all classical symptoms of COPD) point to COPD. Further, the predicted value of FEV1 is less than the normal 80%, pointing to potential airflow obstruction (Haynes, 2018). The chest x-ray shows the lungs to be of normal size and not hyper-inflated as is characteristic of COPD (Hurst, 2018). However, hyper-inflated lungs are indicative of advanced COPD and are more likely to occur in severe cases.

Treatment Plan for the Primary Diagnosis

The goal of treatment in COPD is to reduce the severity and frequency of exacerbations, thus improving exercise tolerance and health status (Global Initiative for COPD, 2018). Bronchodilators (beta2- agonists, Antimuscarinic drugs, and Methylxanthines) are the recommended first-line treatments for COPD (Global Initiative for COPD, 2018). They work by increasing the FEV1, thus increasing the FEV1/FVC ratio (Global Initiative for COPD, 2018). The Global Guidelines for COPD treatment express that initial COPD treatment should begin with a Short-acting beta2-agonist (SABA), a short-acting muscarinic antagonist (SAMA), a long-acting beta2-agonist (LABA) or a long-acting muscarinic antagonist (LAMA) (Global Initiative for COPD, 2018). For patients with moderate to severe COPD...

Clinical trials have shown LABA/ICS combination therapy to be more effective than either medication alone in improving lung function, reducing exacerbations and improving health status in patients moderate to severe COPD (Global Initiative for COPD, 2018). The clinician thus initiates therapy as follows:

Medication #1

Rx: Formoterol 12mcg capsule (LABA)

Sig: 2 puffs daily, 12 hours apart, inhaled via nebulizer

Disp: #90

Refills: 3

Rationale: Formoterol is a LABA with extended duration of action maintained 12 hours after installation of a single dose (Global Initiative for COPD, 2018). Its speed of action and potency make it effective for both quick relief and prolonged effect (Global Initiative for COPD, 2018).

Medication #2

Rx: Budesonide 180mcg inhaler (ICS)

Sig: 2 puffs daily

Disp: #90

Refills: 3

Rationale: Anti-inflammatory agents help to reduce inflammatory biomarkers during exacerbations and to improve symptoms of phlegm and cough (Putcha, 2018). Budesonide is preferred to other ICS because it is less lipophilic and hence, more soluble in airway mucus and more rapidly absorbed into the tissues of the airways (Putcha, 2018).

Influenza vaccine, which decrease the risk of lower respiratory tract infection, once annually

Pneumococcal polysaccharide vaccine (PPSV23), which is recommended for adults aged between 19 and 65 and helps to reduce the incidence of community-acquired pneumonia in COPD patients (Global Initiative for COPD, 2018).

Any Additional Testing Necessary for this Diagnosis

Spirometry testing is the classical diagnostic test for COPD. The classical diagnostic…