Adult with Worsening Cough

Case Description

A 57-year-old male presents to a primary care clinic with a worsening cough over the past month. Learners need to identify and manage the acute COPD exacerbation and advance the treatment of the patient’s chronic condition according to GOLD criteria. The scenario includes an option for the student to present the patient to a collaborating provider.

Learning Objectives

– Learner will collect pertinent patient history, including past medical history, history of present illness, review of systems, social history, and family history via chart review and patient interview
a. Chart will include one past visit note with VS including O2 saturation, pulmonary function tests, and diagnosis of COPD. Chart will also include VS from this visit (but O2 saturation is missing), a symptom assessment tool (filled out by the patient), recent lab results, and current outpatient meds for the Learner to review. The Learner will be expected to review the chart and interview the patient to confirm history, meds, allergies, immunizations, and to obtain HPI and ROS

– Learner will perform physical assessment and request any further data as appropriate for this encounter
a. Learner will be expected to auscultate heart and lungs anteriorly and posteriorly (reveals scattered wheezes bilaterally), palpate pulses, inspect skin, and perform abdominal exam if chosen. Patient will not be in obvious distress. The Learner will be expected to obtain O2 saturation level (90%). Learner will be able to ask for POCT. Normal EKG will be available if requested

– Learner will accurately identify the cause of acute illness
a. The Learner will be expected to ascertain that the patient is having a COPD exacerbation. The tablet for the EMR should include reference charts from GOLD criteria (mMRC scoring sheet, CAT scoring sheet completed by patient, and ABE categories from GOLD standards). Based on the GOLD criteria, the Learner will be expected to recalculate the patient’s current GOLD category which is a B (was A at time of initial diagnosis of COPD one month ago)

– Learner will devise a plan and order appropriate outpatient medications and diagnostic tests
a. The Learner will have the option of presenting to a collaborating provider. The Learner will be expected to order oral systemic steroids, an antibiotic, additional inhaler(s) for COPD as indicated by GOLD criteria, and an option for smoking cessation if desired. The tablet should contain several choices of meds and labs so that the Learner can choose the correct orders from a list of several correct and several incorrect choices

– Learner will educate the patient
a. Patient education will include diagnosis, plan of care, immunizations needed, smoking cessation, pulmonary rehabilitation, and resources available to help with affordability of medications