Clinical Pharmacy & therapeutics II lab

2nd semester 2023.2024

COPD Case

Chief Complaint
“Why can’t I just take prednisone every day? It always works when I get admitted to the hospital.”

HPI
Thomas Jones is a 66-year-old man with COPD who is presenting to the family medicine clinic today to
have a 1-month follow-up appointment from his last hospital admission for an acute exacerbation of
COPD. This last COPD exacerbation is the second hospital admission in the last 6 months related to TJ’s
COPD instability.

After TJ’s hospitalization, his discharge COPD regimen was changed to include tiotropium, 1 inhalation
daily in addition to salmeterol 50 mcg, 1 inhalation Q 12 h, and an albuterol MDI as needed. TJ had
pulmonary function tests (PFTs) while he was in the hospital 1 month ago but has yet to have them
reassessed after the change in his COPD regimen. He wants to start taking prednisone every day because
he believes this would prevent him from being readmitted to the hospital. The patient states that his
respiratory symptoms are better than when he was admitted 1 month ago, but he still has shortness of
breath every day and a decreased exercise capacity (e.g., he becomes very short of breath after walking
a couple of blocks). He states that he is adherent to the new medication regimen that was changed on
discharge from the hospital. No other medications were changed at that time that he can recall. His
daughter, who is at the appointment today, states that she makes sure he uses his inhalers but often
wonders if he is using them correctly because he still has daily symptoms.

PMH
- COPD × 12 years.
- GERD × 5 years.
- HTN × 20 years
- CAD (MI 5 years ago)
- Chronic bronchitis × 14 years.

FH

Mother died from emphysema 4 years ago at the age of 82. Father has a history of coronary artery
disease.

SH

He lives with his daughter and her family. His wife died 10 years ago from breast cancer. He has a 35
pack-year history of smoking. He quit smoking approximately 3 months ago but has had occasional
relapses. He states he has not smoked for approximately a week. He drinks one to two beers every
evening.
Clinical Pharmacy & therapeutics II lab
2nd semester 2023.2024
COPD Case

Meds

- Metoprolol tartrate 50 mg po BID.

- Salmeterol (Serevent Diskus) 1 inhalation (50 mcg) BID.
- Tiotropium (Spiriva) 1 capsule (18 mcg) inhaled once daily.
- Lisinopril 20 mg po once daily.
- Esomeprazole (Nexium) 20 mg po once daily
- Albuterol MDI 1–2 puffs Q 6 h PRN.
- Aspirin 81 mg po once daily

All: NKDA

ROS: (+) Shortness of breath with chronic nonproductive cough; (+) fatigue; (+) exercise intolerance,
mMRC 2 (CAT 12), the patient reports taking PO prednisone by himself as his physician refused to
prescribe him one (5mg Q24)

Physical Examination

Gen: WDWN man appearing in mild respiratory distress after walking to the end of the hall to reach the
exam room.

VS: BP 138/88, P 85, RR 26, T 37.5°C; Wt 95 kg, Ht 5'11'' (180 cm)

Skin: Warm, dry; no rashes

HEENT: Normocephalic; PERRLA, EOMI; normal sclerae; mucous membranes are moist; TMs intact;
oropharynx clear

Neck/Lymph Nodes: Supple without lymphadenopathy

Lungs: Tachypnea with prolonged expiration; decreased breath sounds; no rales, rhonchi, or crackles

CV: RRR without murmur; normal S1 and S2

Abd: Soft, NT/ND; (+) bowel sounds; no organomegaly

Genit/Rect: No back or flank tenderness; normal male genitalia

MS/Ext: No clubbing, cyanosis, or edema; pulses 2+ throughout

Clinical Pharmacy & therapeutics II lab
2nd semester 2023.2024
COPD Case

Neuro: A & O× 3; CN II–XII intact; DTRs 2+; normal mood and affect

Labs

Pulmonary Function Tests (during Hospital Admission 1 Month Ago)

Prebronchodilator FEV1 = 1.1 L (predicted is 3.1 L)

Prebronchodilator FVC = 3.2 L

Postbronchodilator FEV1 = 1.6 L

Pulmonary Function Tests (during Clinic Visit Today)

Prebronchodilator FEV1 = 1.3 L (predicted is 3.1 L)

Prebronchodilator FVC = 3.2 L

Postbronchodilator FEV1= 1.47 L`

Assessment
Clinical Pharmacy & therapeutics II lab
2nd semester 2023.2024
COPD Case

This is a normal-appearing 66 yo man presenting to the clinic with mild respiratory distress for
follow-up on his COPD medication regimen that was changed 1 month ago on hospital
discharge. He also has a history of GERD, HTN, CAD, and a chronic bronchitis.