Janis, a 59 year old female, here for yearly follow-up and refills on her medications and to review labs. She presents with complains of increasing shortness of breath. She has an 20 pack year history of smoking. She has decreased her number of cigarettes to 10 per day. The shortness of breath began a few months ago but seems to be worsening with activity. She is only able to walk around the block without shortness of breath. She also is no longer able to walk 18 holes when playing golf.
Past Medical History: Janis has COPD. In the past year, she has had 1 exacerbation of her COPD and no hospitalizations. She has attempted to stop smoking, using nicotine gum replacement unsuccessfully. She has decreased the number to 10 cigarettes per day and would like to quit. She has osteoarthritis in the hands and knees. She has HTN well controlled with Olmesartan. Hyperlipidemia, well controlled with Rosuvastatin. She has not had most recent COVID vaccination. She has had Shingrix vaccine. She has not had flu shot this year and she has not had pneumonia vaccine.
Surgical History
- Cholecystectomy
- Appendectomy
Family History: Noncontributory.
Social History: She lives with her husband who also smokes 1 packs of cigarettes per day and cares for her elderly mother, who lives with them and is frail but ambulatory.
Patient is allergic to penicillin.
Vital Signs: B/P 122/64; P 92 and regular; Respirations 24; Temp 98.2; SpO2 95;
Skin: Warm and dry
HEENT: Negative
Cardiovascular: RRR. S1/S2/ normal; no murmurs, clicks, rubs, or gallops. No evidence of peripheral edema. Posterior tibial and dorsalis pedis pulses 2+/4+.
Respiratory: Lungs have mild wheezing right upper lobe.
Abdomen: Soft with bowel sounds; tympanic to percussion. No organomegaly.
MSK/Neuro: Negative.
Today's diagnostics
Spirometry: FEV1/FVC <70; FEV1 79% predicted
Chest x-ray normal
ECG: normal sinus rhythm
mMRC score 2
Pt is on following meds:
28 ACTUAT salmeterol 0.05 MG/ACTUAT Dry Powder Inhaler [Serevent] -Dose:One inhalation twice daily
Albuterol 90 MCG/ACTUAT Metered Dose Inhaler, 200 ACTUAT
- Dose: 1 puff as needed
Naproxen 250 MG Oral Tablet
- Dose: 2 tablets as needed
Olmesartan medoxomil 20 MG Oral Tablet DAILY
Rosuvastatin calcium 10 MG Oral Tablet
- Dose: 1 tablet Daily
Following test done and immunization received by pt
Mammogram done on June 23, 2023- WNL
CT Scan done for preventive screening lung cancer on 01/2/22
Colonoscopy done on 2019- Normal
Received COVID dose initial vaccine and booster # 1, #2, #3
DTap received received on 2021
Shingrix, Shingrix booster received on 2020
a) What is the diagnosis?
