Nursing Homework week 3 Clinical

68-year-old Hispanic male with a 3-year history of COPD presents for follow-up. Reports progressive shortness of breath over the last month, especially with exertion (walking short distances). Cough is productive with white sputum. Denies fever, hemoptysis, or chest pain. Admits to continued smoking (½ pack per day). Uses albuterol inhaler PRN but not consistently. States difficulty affording long-acting inhaler prescribed previously. No recent hospitalizations.

Past Medical History

· COPD (diagnosed 3 years ago)

· Hypertension

· Hyperlipidemia

Medications

· Albuterol inhaler PRN

· Lisinopril 10 mg daily

· Atorvastatin 20 mg daily

Allergies

· NKDA

Social History

· Current smoker (½ pack/day, 40 pack-year history)

· Denies alcohol or illicit drugs

· Retired construction worker

Review of Systems (ROS)

·

· Dyspnea on exertion, chronic cough with sputum

· Denies chest pain, fever, chills, hemoptysis, or edema

Physical Exam

· Vitals: BP 138/82, HR 88, RR 20, SpO₂ 93% on room air

· General: Appears mildly dyspneic with exertion

· Lungs: Decreased breath sounds bilaterally, scattered wheezes, prolonged expiratory phase

· Heart: Regular rate and rhythm, no murmurs

· Extremities: No edema, no cyanosis

Assessment

· COPD, moderate, with recent increase in dyspnea

· Hypertension, stable

· Hyperlipidemia, controlled

Plan

· Start tiotropium inhaler daily (long-acting anticholinergic)

· Continue albuterol inhaler PRN, educate on proper use

· Smoking cessation counseling provided; offered nicotine patch

· Order spirometry, CBC, CMP, chest X-ray

· Continue lisinopril and atorvastatin

· Follow-up in 6 weeks or sooner if symptoms worsen

Coding

ICD-10 Codes

· J44.9 – Chronic obstructive pulmonary disease, unspecified

· I10 – Essential hypertension

· E78.5 – Hyperlipidemia, unspecified

· Z72.0 – Tobacco use

CPT Codes

· 99214 – Office or other outpatient visit, established patient, moderate complexity

· 94010 – Spirometry, including graphic record

· 71046 – Chest X-ray, 2 views

· 80053 – Comprehensive metabolic panel (CMP)

Clinical Notes (Summary for Typhon): 68-year-old Hispanic male with COPD (diagnosed 3 years ago), HTN, and hyperlipidemia presented with increased dyspnea on exertion and chronic productive cough. Exam revealed decreased breath sounds, wheezing, SpO₂ 93%. Started tiotropium inhaler, continued albuterol PRN, and provided smoking cessation counseling. Spirometry, CMP, and chest X-ray ordered. Will follow up in 6 weeks.