Understanding COPD Case Management

question please tell me how do you want to take your further issue from this patient okay thank you so first i would like to greet james ask about chief complaint reassure confidentiality explore his ideas concerns and expectations and proceed with an open-ended question regarding this cough i would like to know when was the onset of it did it start suddenly or gradually if it goes on and off and if it's or if it's constant and if it is episodic or not Then I would like to know if there is any pattern to it, any diurnal or nocturnal, any weekdays or weekends, and if there is anything that makes it better or worse, such as change in the posture, eating, drinking, or exertion, or even resting. And if there were any triggers for it, any viral protome, any contact with sick person, any trauma, anything at all. And I would like to know if he had coughs like stick before. Then regarding this phlegm, I would like to know when did that start. and also regarding the color consistency and volume and by any chance any blood sting flame and if it has changed in volume and purulence recently then i'm going to ask about the effect of this cough on my patient's life from functionality to tolerance to physical activity and also stress and sleep and then i'm going to ask about some symptoms such as any fevers any shields or ashes any lumps or bumps any weight loss any night sweats any headache any nasal congestion. or discharge any red watery eyes also any mouth problems any sore throat or sneezing any problems swallowing or drinking any change in the voice or any horses of the voice also any ear problem any pain or discharge or fullness any chest pain any shortness of breath any palpitation or chest tightness also regarding any bad taste in the mouth and any abdominal pain especially a heartburn and any abdominal distension i also like to ask about any calf tenderness any lean edema or swelling, and also any joint stiffness, especially morning stiffness. Then I'm going to ask about the situation at home, any other person with the same condition, any new pet, new plant, or new carpet. And regarding the job, I can see that my patient is a manager. Has he ever had a job that included exposure to smoke, gases, or fumes? And regarding the travel, any history of travel to TB endemic areas or even contact with refugee. I like to know about my patient's past medical history, any medical condition regarding lungs, any history of asthma, any history of lung condition during the childhood. And I also like to know about my patient's level of physical activity, if there is any change to the tolerance of physical activity and regarding sleep, any problems regarding that, any snoring, any weakness apnea and any problems regarding duration, quality, and quantity of sleep. I also like to dig in more about the stressful family situation, if there is anything that we could offer help with. And after that, I'm going to ask about my patient's diet, if there is any diet, and if my patient takes any medications. Okay, thank you. Thank you so much. So your patient's saying that I had this cough from six months ago. It's worse in the morning. I feel that every day. And I feel that recently I increased in the sputum. There was no fever. I didn't feel that I lost anyway. There was no nasal congestion and no specific triggers, no pads or new carpets. So, doctor, could you please tell me what would be your physical examination? Thank you very much. So, about the physical examination, I would like to follow the standard protocol and gain consent from my patient. Then I'm going to start with... the general appearance i would like to look for any cachexia any cyanosis increased work offering or any paler then i would like to measure my patient's vital sign especially temperature auto saturation and respiratory rate i'm also going to measure my patient's bmi and waist and neck circumference my focus examination would be complete chest examination in addition to the ent examinations and my relevant would be abdomen upper abdomen mostly and also lower limbs for any edema or calf tenderness. My office test in this case would be ECG also spirometry and I would like to also consider blood glucose levels. Then after that I'm going regarding the examination I'm going to start with the regarding the chest examination I'm going to start with the upper extremity check for an innate clubbing check capillary fill time and after that move to the chest check for any asymmetries in the air entry and increase in the breathing work also in use of accessory muscles then i'm going to palpate and percuss for any hyper or high porousness or any dullness. or even tender points. After that I'm going to ascultate for any decreased or increased brief sounds or any added sounds. I'm also gonna check heart for any murmurs and check JVP if it's raised or not and also after that I'm going to move to the ENT examination check for any red watery eyes also check any tenderness on facial bones and check mouth for any problems such as post nasal dripping and large tonsils and also consider malampity score checking and after that i'm going to move to the neck check for any lymphadenopaties and for the more checking ears okay thank you thank you so much doctor so the vital signs in stable you feel some hyperresonancy in in percussion of your chest. There's some reduced chest expansion. And I've sent the spirometry results for you. So with the status, please tell me what would be a provisional differential and what investigations do you need for this patient? Okay, thank you very much. So in this case, as I have a 64-year-old James with cough from six months ago, who also smoked for a very long time and has increased sputum and... hyperresonancy and reduced checks expansion, my provisional diagnosis would be COPD also regarding the spirometry result which indicates a lowered FE1 and also which is less than 70% and which is a diagnostic for COPD. So my provisional diagnosis would be in this case chronic obstructive pulmonary disease. My referential diagnosis would be some other lung causes such as interstitial lung disease, even asthma, it was nephelic bronchitis, bronchiectasis, and then the thing that I should not miss in this case would be the chance of malignancy, also some other less likely causes such as rheumatology causes, even TB which is very rare and also sarcoidosis and some other causes such as GOULD. even post-viral cough or chronic rhinosinusitis or allergic rhinosinusitis, which are really not much relevant in this case. My investigations in this case would be absolutely, I would like to order chest x-ray, PA and lateral, and also I would like to consider full blood examination for any peripheral eosinophilia and also sputum culture. I would like to consider that also sputum. culture and microscopy for mycobacterium specifically and this would be it okay thank you thank you so much so let me give you the investigation results okay so you found some hyperinflation in chest x-ray otherwise it's normal espiton culture is negative tb is negative and all of three investigations is normal so please tell me what would be your management? Thank you very much. About the management, I would like to thank my patient first for his cooperation. Then I'm going to consult with my supervisor. And after that, I'm going to explain to my patient that this cough and this sputum that you're experiencing is most likely due to a condition called chronic obstructive pulmonary disease, which is a condition that due to prolonged inflammation and irritation, there are some changes in the airwaves. And there is some obstruction to the airflow. In your case, it is most likely due to smoking. So I'm going to address my patient's concerns and questions and double check his understanding. After that, I'm going to start my management with non-pharmacological management. After careful consideration with my supervisor regarding any need for further assessment. So first, I would like to emphasize on a SMAP protocol. In this regard, I would like to mostly emphasize on smoking cessation. our life to pinpoint. that this is the single most good action, beneficial action that we could take to prevent further lung deterioration and even alleviate symptoms. I'm going to educate my patient about methods of cessation and also benefits of smoking cessation. And if my patient agrees, we're going to arrange another session in a few days for smoking cessation. After that, I'm going to They encourage my patient regarding the physical activity to remain active and in this regard I'm going to refer my patient to the pulmonary rehabilitative center. patient unit and also to encourage my patient to remain within the healthy BMI and other as my patient has a stressful life I'm going to teach her some stress relaxation techniques. Then regarding the also regarding the vaccination to be up to date especially with some flu and pneumococcal vaccinations. Regarding the pharmacological management I like to approach my patient based on a stepwise approach which is based on the severity of the condition. In this case, we most likely have some mild conditions. So I'm going to start my patient on a PRN, a short-acting beta-agonist, such as salvatamol. Also educate my patient on how to use it regarding the correct technique and use of the spacer. And using a teach-back technique, then I'm going to provide my patient with some reading materials from lung foundation. Also prepare my patient's COPD action plan and educate him on how to use it. I'm going to arrange a review session in six weeks for the COPD, but we're going to have another session soon for a smoking cessation if possible and educate about some red flags such as any chest pain, any shortness of breath or any bloody cough, also any worsening in the conditions, and also consider referral to the pulmonary specialist. if there is any doubt regarding the diagnosis or if we suspect any underlying cause. And I'm going to also activate my patient's GP management plan. Okay, thank you. Thank you. Thank you. So for the last question, could you please explain to me what's the COPD action plan? The COPD action plan is actually a plan which is implemented when my patient experiences an increased symptoms such as increasing the cough increasing the sputum and sometimes even infectious symptoms such as fever so it has steps that teaches my patient such as first start pregnancy and if you have symptoms of infection also start antibiotics and if you've become unwell call your doctor or go to the doctor it has several charts based on the severity of the symptoms and tells my patient what to do in each step. That's great, thank you. Thank you, Dr. Armin. That was really brilliant. Thank you for stepping up to presenting this case. You were the path to this case and it shows that you were so much ready to present this case. It was perfect. I don't have anything to add to your presentation actually. Just I think that if you want to ask about FLIM, you can add that in the character part. But overall it was good, really I don't mind. And the reporting associated symptom was so good, it was comprehensive. And let me see, if you have it right, you mentioned about, okay. Regarding the differential diagnosis, I just wanna add something. And whenever you're saying that it's COPD, it's with it would be better that if you just mention about the severity of that, that okay, I think the COPD and based on the symptoms of my patients, it could be a more to moderate COPD. In that way, panel knows your provisional diagnosis more better. And you should, did you mention the lung cancer in your differential diagnosis? Yes, I mentioned that I shouldn't. Oh, yes, I didn't hear that. Okay, thank you. So you covered all the parts properly. And at the first of your initiation, did you mention about wearing masks? Because I didn't hear the first of your presentation. Mentioned about what? Sorry, I didn't catch you. Wearing masks or wear the personal protective equipment. Oh, no, I didn't mention that. Okay, it's okay. Actually, you mentioned about... Althus, I don't have anything to add. Thank you. Thank you so much for stepping up for this case. Do you have any questions? No, thank you very much. I'm excited to enjoy your class and learn from you. Thank you. Thank you. Thank you so much. Okay, so let's wrap up this new case. Okay, we actually had this case previously as a hematosis case, and this week they showed up as a new version of that. which with this data we found out that we are facing we can the case which is so they can give us actually He gave us the asthma case because the spirometry can interpret to different ways. So we're speaking regarding all of scenarios, all probable scenarios together. Actually, I don't have anything to add to Dr. Armin's presentation. If you want to add a reference, you can have the recording of Dr. Armin's voice to know that how you should go and how you should present well. But as maybe it's challenging for you guys in some steps, so I want to explain regarding each and every step. Okay, let's go and see which cases we are. So first of all, as we can see, our patient is here for a cost. We don't know about the duration. We don't know that at the first stage it was dry. or chesty cough. So we need to ask so many questions in our history take. Before we start our history taking, like the normal thing that we do in our practices, we should wear our mask, or even we can wear our personal protective equipment, because it can seem that it could be a respiratory infection. So after that, we start our initiate. After introducing, greeting, and be sure to be patient about confidentiality, and check the stability, we should think more about this cuff. So regarding this cuff, we should know when did it start. It's gradual or suddenly, at any specific pattern, like any seasonal pattern, or it's more in days or nights. If it's constant or on and off, if any specific other patterns, like a weekday or weekends, then regard. think the character of that first we should determine that our patient has dry or chest cough and regarding phlegm regarding phlegm that they mentioned in the first stem so we should know that how's the consistency other volume of this phlegm and any specific pattern like cough cough turning into blue or cough vomiting or any whooping cough regarding elevating aggravating factor we should know what condition make our patients better or worse, like using any inhaler, any medication. If our patients facing with cold weather, physical activity, resting will make this condition better or worse. For example, we should be specified regarding that, that how many stairs can our patients walk or how our patient doing in physical activity. Regarding triggers, we have so many triggers and we have six or seven cough cases. So it's so easy for the guys to know about triggers, like any contact with sick persons, any home condition, and any new pet, new carpet, or new sense of life, travel, or based on my patient's opinion, if this smoking can be a trigger for this cough or not. and the contact fields. where's any bush firing and we have other we have so many triggers after that we should ask about effects that how this condition affected on my patient's daily routine sleep job and how was the sequences of the cough and the flame for my patient if this cough leads to my patient for any work absence lead to any sleep disturbance? So we can make two or three questions regarding that. So we can ask that when and how you realize that it's smoker class. Which actions did you take regarding that? Did you visit any GP or any specialist for that? So it's necessary because they give you this smoking cough and you should think more about that. After that, that's the time for associated symptoms. So if you want to follow the top-to-toe approach, you should ask about any fever, choose rations or any red eye, water or ear pain or ear discharge. You should ask any runny nose or facial bone pain, any secreting behind the shorts, any dental problems. You should ask if your patient has a coughed up blood. It's hemoptysia, so it's a red flag. There's a must for ask this question. Any bad smell from the mouse? Any difficulty in swallowing? It's another red flag for your patients. Any hoarseness of voice. Any lumps and bumps, unintended weight loss. With this cough, I want to know if my patient had any noisy breathing and difficulty in breathing. Any increasing in pillows. We're asking this for dyspnea, which could be another red flag. Any worsening condition when a patient's laying down. Any chest palpitation, calf tenderness. leg swelling or recent surgery and water brush or any diarrhea. So actually, you asked 90% of your questions. Now it's the time to ask about the job of the patient. Because it's so important that if your patient was any exposure to any other smokes or any specific jobs, any specific gases to make this condition worse. You should ask that if your patients change their job, because now you can see that your patient's job is a manager. Just you should know that each part of industry he works, for example, or is facing with any chemical material. Then we go and pass medical history, because we know that maybe we have some overlap with COPD, which could be an asthma. So we should ask some questions regarding past medical history. If our patient had any asthma, if our patient had any panic disorders. As you can see, our patient has some stressful family situation. But we didn't ask about this matter. So it's the time to ask, what makes my condition to be stressful? Any specific stressful family situation? If my patient's roaring is affecting my... my patient's mood and after that your time is finished if you want to add anything you should ask about home condition of your patient so at this stage they give you these data that this cough started from six months ago it's worse in the morning it's every day the sputum is increasing and there is no any fever weight loss or hemoptasia and no specific triggers So how do you want to perform your physical examination? So like always, we follow standard protocols, explain every step of examination. In general appearance, we should look for any signs of work of breathing, excessive work of breathing. If our patient can speak a full sentence and say noses, any protective posture. Regarding vital signs, we should check respiratory temperature, O2, BMI, and compare with previous one. And we know and we mentioned about BMI because there's a chance for a patient to have long cancer, right? So our focus examination, as Dr. Orman said perfectly, is the complete hip examination, special lung examination, head and neck, special end examination, and as relevant examination, you can mention about abdomen examination. It's not important if you miss the abdominal examination because they ask us about the whole hip examination. focus examination like all of our cost cases could be the chest examination and int examination and that's it so regarding office tests you need ekg and for the first time in this new version pesky exam we need a spirometer and as your questioner we have a questioner named copd assessment test we have this questioner to ask the patient that how the severity of this condition and how this affected on our patient condition. So I will send you this test and the questionnaire to be more familiar with that. So just let me to send this questionnaire having this history of our group. Okay, after that... Can I have a question, Dr. Poulin? Sorry to interrupt you. Please put the question for the last of our... Actually, I know that what would be your question, because this test. But let us just finish the presentation and we are going to discuss. Okay, so after that, we should elaborate our physical examination, as Dr. Armin started. For a long examination, you should do the same because the inter-examination can be irritating even for adults. So you should. start and we have so many data in long examination as you noticed so you start from from checking along by clubbing you should have some inspection and what's important is that in your exploitation you should say about decreasing an air entry any crackle or any reasons and then should finish your examination for percash as you notice that they gave us hyper-resonancy data, right? So let's go and have a chat regarding spirometry interpretation. Please open the spirometry data sent. Let me send the update version. Okay, yeah, the recall. As I spoke to the candidates who had this case in the real exam, they didn't ask about interperation of spirometry. But just let's have a quick chat regarding this spirometry. So as you can see it's a typical spirometry of a COPD condition. So when we are going to interpret our spirometry, first we should look at FEV1 or FEVC ratio. So firstly, as you can see, the first we have the predicted amounts. So what's the predicted? So for every age, for any condition, or for every weight based on age or weight or other factors, we have a predicted amount for each person. So for this person is 0.73. So we do the spirometry and we write the results. So as you can see, the prebronchodilator results is 0.54. So it shows that we have the less amount, the amount of prebronchodilator is less than the predicted amount. After that, we should look for FEV1 amounts. So as you can see, the predicted one is 2.55 liter, but our patient's prebronchodilator our patient's actual amount is 1.21. So we have a reduced FVC ratio here. So maybe they're going to give the asthma case for spirometry next time. So we should know how we should deal with that. So until here, we found out that our patients' FVC ratio is decreased and it's less than 70%. be either asthma or COPD because we are facing with the obstructive disease. So how should we differentiate between asthma and COPD? So we should look at post-bronchodilator, which we give out to our patient's salivary gland, our patient in here, and then we spiromide our patient again. So let's see that how our patients change as we can see the predict. the predicted percentage is 47, but our post-bronchodilator is 1.5, and the change percent is minus 5. If this was an asthma case, you should have more than 12 percent change after administering the bronchodilator. So your patient's ratio was not changed, even reduced after post-bronchodilator. So it can't be an asthma case. So you're definitely here facing with a COPD case. So that's why they tell us in exam that your FEV1 to FVC is less than 0.5 because it's crucial to diagnose the COPD, right? So let's proceed. with the stuff case. Okay, so for your physical examination findings, they show the page with lots of dates. They show that vitals are stable. You had some high-resonance in chest examination and reduced chest expansion. Pyrometry shows FPU1 to FVC ratio less than 70%, and they ask about provisional and differential diagnosis. And actually, they ask investigation. together. So, okay, as we have the live men with 64 years old, with complaining of cough from six months ago, which has phlegm every day. So our patients was smoking. Our patients had heavy smoking. And based on spirometry, I think about some obstructive diseases. And at the top of my list, I can think about COPD, chronic obstructive pulmonary diseases. Then I can think also about asthma, but my patient has flame and had dry cough, so it's not likely. And now we can go for our other differential diagnosis, right? So you set your clinical judgments, your provisional diagnosis. Now is the time for your differential diagnosis. So after that, you can have doubt about bronchiectasis. You can have the asthma, CFPD, overlap syndrome. You can have chronic bronchitis. But you should not miss your, actually, your diagnosis of lung cancer. because the age and being a heavy smoker of patients can be consistent with this diagnosis. But your patient doesn't have red flags like hemoptasia or intended weight loss or night sweets, so this condition can be unlikely, but you can't miss this diagnosis. After that, you can think about post-nasal drip or upper epic cough syndrome. You can think about gastroesophageal reflux diseases, interstitial lung diseases. You can even think about TB, which we know that is rare in Australia. You can think about sarcoidosis or medication-induced cough. And you can see the rest of benign conditions. What's important? You should say why you choose this diagnosis. You choose that based on your patient's symptom, your patient being an heavy smoker. and your patient's barometric. And first you say that, yes, I found out that I'm facing with an obstructive disease. So for that, I think about COPD and asthma, but because my patient had weight loss. So because of that, I think more about COPD. And you don't miss lung cancer, and that's all. After that, they ask about investigation. So I really enjoyed that Dr. Armin didn't forget to mention about investigation, because most of the time candidates, as I saw in my students or in classes, they forget about mentioning investigation when these two questions are asked together. So here we should divide our test into two categories of imaging and lab tests. So you definitely need a chest x-ray to rule out other diagnoses. And if you found any abnormality, you should ask for CT scan after consulting with your supervisor. Regarding blood tests, you need full blood examination to assess infection and inflammation information. You need a sputoculture or serology to rule out other infections. And you need an ESR and CRP. And that's it. Don't go through all of your investigations. I mean all of us know that we need more other investigation but you should be more focused and that's enough because they give us the data that okay after that the chair six-way is normal the CT scan is normal just in chair six-way you found out some hyperinflation and the sputum culture is normal as well so please proceed with your math okay we should do all of our structure and don't lose our structure. So if we want to work like that, first of all, we should thank our patients for coming and cooperation. We show all of our funds to our supervisor, and we should say and explain this condition to our patients and how we should explain that. It's so important to notice that at the first step, they mentioned about some family issues, some family situation. So your patient is worried, right? So it's important to address this at the first of your management. Okay, you start. I want to explain to James that James, you cough and increase phlegm or likely due to a condition named COPD, a lung condition that often linked to smoke. The good news is that we can work together to manage this. We should focus on three key areas, quitting smoking, easing your coughs, and preventing filler ops. Then I want to check the understanding. I want to address the concerns. I want to Address if there is any fear of inhaler dependency, any weight gain after quitting smoking. I want to address if there is any family situation. And I want to make sure of the patient that based on your CT scan, based on your chest x-ray, it's the probability of lung cancer is low. And I want to offer, if need, involvement of a support person. Okay, so your explanation is good. That's enough. actually is more than enough. After that you say about your explanations. I want to just send some slides from references to have more discussion together. Just let me find the slides and we'll speak together. Those are all from the combination of RCGP and ETG. So it's so useful for the guys and it's a reference for exam. So please look at them at least once. Okay. Please open it away. Okay, I think it could be enough. Okay, so as you can see in the management of COPD, we should focus on some areas. First, we should look for optimizing function of our patient, preventing deterioration. developing support networks and self-management skills and we should manage the following exacerbations. So we don't want to lose our structure, right? So we're gonna speak about lifestyle advice, SNAP protocol. So I should explain to my patient regarding SNAP protocol, I will do a motivational counseling based on five-way approach for them and the most important one is the smoking cessation. I'll speak to my patients as I mentioned regarding motivational interviewing. I want to emphasize that James quitting smoking is the most effective way to slow your COPD progression. In this regard, I want to offer my patients some pharmacotherapies, for example, a varnicoline or nicotine replacement therapies. And I want to refer my patients for counseling regarding cessation to quit life. After that regarding nutrition, I want to say that you should consider high calorie supplements. You should have some advice using of alcohol. You should have less than two standard drinks per week and you should continue your daily exercise for three minutes per walk and I have some concentration for this physical activity and I will refer my patient to pulmonary rehabilitation for an eight-week program. So after that, I will explain to my patients that it's a multidisciplinary team approach. As you noticed in the slide from ETG, they mentioned all multidisciplinary care for COPD, but we don't have enough time to mention about all of them. So we just mentioned about some of them, and as you can see at the first line, they mentioned about GP. So the GP is the main coordinator for this process. The GP should follow regularly, the GP should prescribe medications, and the GP should write the proper action plan for the patient. So I want to tell that me as a GP, I should prescribe medication, have a coordinated care, and I want to give you CFP the action plan, and I want to educate my and we know that the sources is a main comorbidity. within COPD. So please don't forget to mention that because they told this at the first of your step. So you need to refer your patient to a psychologist to address any stress or anxiety related to family situation. You should give your patient and educate your patient regarding some relaxation techniques. You need to refer your patient to a dietician to provide the tailored nutritional advices and you can give your patients some general advices. As I mentioned, we can have general advice in the physical activity of our patients. So, for infection prevention, your patients should have hand hygiene, avoid going to crowded places, especially during flu season. Your patients should administer the vaccination, especially flu and pneumococcal vaccination. And you should tell your patients some daily living strategies. For example, your patient should maintain good hydration. Home air purifier consideration is good. Your patient should do his daily activity step by step. And you can divide to little by little activities. Okay. After that, we are going to excellent regarding pharmacological management. So just let's look at the ATG or actually the guideline for COPD. So we have three categories for CFP, right? Mild, moderate, and severe. Here we are facing with a mild category. And as you can see in the previous slide, we can see that which symptoms belongs to which category. So here our patients have cough and sputum, and everyone is between 60 to 80. And our patient's few symptoms, we don't have any breathless for our patient, maybe in some moderate exertion. So this patient definitely could be a mild COPD. So what we have in mild COPD, yes, we should reduce risk factors, which we discussed. We should have an optimized function of our patient, which we did. We should optimize the treatment of comorbidities, and we did, because we addressed the anxiety and depression of our patients. refer symptomatic patients for pulmonary rehabilitation. We did that, we refer our patients. And after that, we should have a stepwise drug management. So attention that it's a stepwise drug management. Like asthma, here we have a stepwise drug management either. So for all patients, as you can see, we should start as needed short-acting bronchodilator therapy. like Ventolin. Let me see. No, let me just send a proper. Okay. So as you can read for patients with mild and infrequent symptoms, like our patient, a combination of general measures, which we mentioned, and short-acting beta-2 agonists, which we named as SAVA. is adequate and it should be salbutamol 100 to 200 micrograms by inhalation we have a spacer or butolin you prefer to just name one of them which we are easier with salbutam okay so how we should say this pharmacological management in our presentation okay just give me times two. For pharmacological management, after consulting with my supervisor, I want to consider the established drug trop as I'm here facing with a multi-OPD management. I want to prescribe for my patients as needed short-acting betagonist, which could be salbutamol, via spacer. And if needed, if needed, I can consider a lab offer for the patient, but as my patient now doesn't have any exacerbation, maybe there is no need, but I want to consult with my supervisor. I want to review the COPD assessment test. If it's more than 10 or the symptoms persist, I want to prescribe them. After that, I want to read, write. a precise COPD action plan. I'm going to educate my patient in details regarding green zone or amber zone. Let me send the COPD action plan for you guys. Okay, so it's the COPD action plan. As you can see, we have different colors and it's for different severities. So our patient is small so we can think about the green area and also we can think about amber area. which our patient could be more breathless than normal or more cough and increase the care flip as you can know as you know the COPD is a progressive disease so maybe your patient have uh should be in amber area amber area for example in three months later so you should explain to your patient these two areas so the green zone is In the green zone, they mentioned that you should continue Saba as needed, plus daily exercise. And if your patient is amber zone, so maybe there is a need to double Saba and start prednisone for five days. We don't have enough time to go through the details of that. If panel wants, as I asked from Dr. Army, they will ask us to tell them in details. So after that, we should actually activate the GP management plan for my patients as we need a coordinated care. So whenever we need a coordinated care, we need to involve other light health. So there is a need to activate GP management plan to review and follow up the patients mostly. Now it's time that you say about your. review sessions and how do you want to check the safety netting of your patient. So after checking check the safety netting of my patient, I want to arrange a review session for after four weeks. Why you want to do that after four weeks? Okay we're gonna do that for checking our patient smoking cessation. It's important for you. You will check the inhaler techniques and you will assess regarding the severity of symptoms. You have another annual assessment for the patient to check the spirometry, BMI check, vaccination status, and medication review. And if there was any red flags like breathlessness or shortness of breath at rest or any fever, any high fever, any hemoptasia. any weight loss, any nitrates, your patient should come back to you as soon as possible. And you will tell your patients, you provide your patient with material from Long Foundation of Australia. And actually everything that I said to you guys, it's from Long Foundation, ETG and RSCG. So my presentation is over and I think that's enough for covering the PET-STY exam. So guys, if you have any questions. I remember that Dr. Armin had some questions. Let's tackle this. Thank you, Dr. Puria, for your great wrap-up. Regarding the questionnaire in the examination part, at that point in the consultation, we are not sure. We don't know if this is a COPD case. So maybe a COPD questionnaire might be a little suspicious on our part. Yes, you're right. Yes, you're right. While I'm mentioning the COPD assessment test, I was thinking about that, yes, it could be obvious that we have recalls. But it's vital to mention that, right? If you don't want to mention here, you must mention that in your management, because it's access to stability of your patient, and the practice nurse has a job to review this annually. But as I consider this patient to have phlegm and don't have any red flags, I was just, and because this case is new to us, I was just thinking that maybe we think about COPD at some points as a GP, as some normal GPs. But as you're mentioning, actually, I agree with you. For this stage, we should wait for recalls, for more recalls. But there's no need to mention the COPD assessment test here. But there's a must to mention that in your manual. Okay, the next question. hi dr hi hi i have a question should we uh offer spirometry in the office test in physical examination part thank you yes we should offer the spirometry because if you don't do that so panel doesn't give you the data regarding spirometry and you can definitely say that it's a copd or any infectious disease And actually we have five office tests. Urine pregnancy test, urine dipestic test, blood sugar, and this spirometry. I think I forgot one of them, but the spirometry is one of the office tests. And especially in this case, we didn't have that in our previous cases, but here we need a spirometry. Okay, thank you very much. Thank you very much. Okay. So, yes, yes. And it means that could we add spirometry to the office test in other cough case or just for this case? No, no, because in other cough cases, our most suspected suspicion is for infectious diseases. Whenever you're suspected mostly due to infectious diseases, so there is no need to aspirin. Here, because we need to have a diagnosis of COPD, so there is a mask for doing spirometry. Okay. Thank you very much. Okay. Yes, ETG, I forgot about ETG, Dr.

or discharge any red watery eyes also any mouth problems any sore throat or sneezing any problems swallowing or drinking any change in the voice or any horses of the voice also any ear problem any pain or discharge or fullness any chest pain any shortness of breath any palpitation or chest tightness also regarding any bad taste in the mouth and any abdominal pain especially a heartburn and any abdominal distension i also like to ask about any calf tenderness any lean edema or swelling, and also any joint stiffness, especially morning stiffness. Then I'm going to ask about the situation at home, any other person with the same condition, any new pet, new plant, or new carpet. And regarding the job, I can see that my patient is a manager. Has he ever had a job that included exposure to smoke, gases, or fumes? And regarding the travel, any history of travel to TB endemic areas or even contact with refugee.

I like to know about my patient's past medical history, any medical condition regarding lungs, any history of asthma, any history of lung condition during the childhood. And I also like to know about my patient's level of physical activity, if there is any change to the tolerance of physical activity and regarding sleep, any problems regarding that, any snoring, any weakness apnea and any problems regarding duration, quality, and quantity of sleep. I also like to dig in more about the stressful family situation, if there is anything that we could offer help with. And after that, I'm going to ask about my patient's diet, if there is any diet, and if my patient takes any medications.

Okay, thank you. Thank you so much. So your patient's saying that I had this cough from six months ago. It's worse in the morning.

I feel that every day. And I feel that recently I increased in the sputum. There was no fever. I didn't feel that I lost anyway. There was no nasal congestion and no specific triggers, no pads or new carpets.

So, doctor, could you please tell me what would be your physical examination? Thank you very much. So, about the physical examination, I would like to follow the standard protocol and gain consent from my patient.

Then I'm going to start with... the general appearance i would like to look for any cachexia any cyanosis increased work offering or any paler then i would like to measure my patient's vital sign especially temperature auto saturation and respiratory rate i'm also going to measure my patient's bmi and waist and neck circumference my focus examination would be complete chest examination in addition to the ent examinations and my relevant would be abdomen upper abdomen mostly and also lower limbs for any edema or calf tenderness. My office test in this case would be ECG also spirometry and I would like to also consider blood glucose levels. Then after that I'm going regarding the examination I'm going to start with the regarding the chest examination I'm going to start with the upper extremity check for an innate clubbing check capillary fill time and after that move to the chest check for any asymmetries in the air entry and increase in the breathing work also in use of accessory muscles then i'm going to palpate and percuss for any hyper or high porousness or any dullness.

or even tender points. After that I'm going to ascultate for any decreased or increased brief sounds or any added sounds. I'm also gonna check heart for any murmurs and check JVP if it's raised or not and also after that I'm going to move to the ENT examination check for any red watery eyes also check any tenderness on facial bones and check mouth for any problems such as post nasal dripping and large tonsils and also consider malampity score checking and after that i'm going to move to the neck check for any lymphadenopaties and for the more checking ears okay thank you thank you so much doctor so the vital signs in stable you feel some hyperresonancy in in percussion of your chest. There's some reduced chest expansion.

And I've sent the spirometry results for you. So with the status, please tell me what would be a provisional differential and what investigations do you need for this patient? Okay, thank you very much. So in this case, as I have a 64-year-old James with cough from six months ago, who also smoked for a very long time and has increased sputum and...

hyperresonancy and reduced checks expansion, my provisional diagnosis would be COPD also regarding the spirometry result which indicates a lowered FE1 and also which is less than 70% and which is a diagnostic for COPD. So my provisional diagnosis would be in this case chronic obstructive pulmonary disease. My referential diagnosis would be some other lung causes such as interstitial lung disease, even asthma, it was nephelic bronchitis, bronchiectasis, and then the thing that I should not miss in this case would be the chance of malignancy, also some other less likely causes such as rheumatology causes, even TB which is very rare and also sarcoidosis and some other causes such as GOULD. even post-viral cough or chronic rhinosinusitis or allergic rhinosinusitis, which are really not much relevant in this case. My investigations in this case would be absolutely, I would like to order chest x-ray, PA and lateral, and also I would like to consider full blood examination for any peripheral eosinophilia and also sputum culture.

I would like to consider that also sputum. culture and microscopy for mycobacterium specifically and this would be it okay thank you thank you so much so let me give you the investigation results okay so you found some hyperinflation in chest x-ray otherwise it's normal espiton culture is negative tb is negative and all of three investigations is normal so please tell me what would be your management? Thank you very much.

About the management, I would like to thank my patient first for his cooperation. Then I'm going to consult with my supervisor. And after that, I'm going to explain to my patient that this cough and this sputum that you're experiencing is most likely due to a condition called chronic obstructive pulmonary disease, which is a condition that due to prolonged inflammation and irritation, there are some changes in the airwaves. And there is some obstruction to the airflow.

In your case, it is most likely due to smoking. So I'm going to address my patient's concerns and questions and double check his understanding. After that, I'm going to start my management with non-pharmacological management.

After careful consideration with my supervisor regarding any need for further assessment. So first, I would like to emphasize on a SMAP protocol. In this regard, I would like to mostly emphasize on smoking cessation. our life to pinpoint.

that this is the single most good action, beneficial action that we could take to prevent further lung deterioration and even alleviate symptoms. I'm going to educate my patient about methods of cessation and also benefits of smoking cessation. And if my patient agrees, we're going to arrange another session in a few days for smoking cessation. After that, I'm going to They encourage my patient regarding the physical activity to remain active and in this regard I'm going to refer my patient to the pulmonary rehabilitative center. patient unit and also to encourage my patient to remain within the healthy BMI and other as my patient has a stressful life I'm going to teach her some stress relaxation techniques.

Then regarding the also regarding the vaccination to be up to date especially with some flu and pneumococcal vaccinations. Regarding the pharmacological management I like to approach my patient based on a stepwise approach which is based on the severity of the condition. In this case, we most likely have some mild conditions. So I'm going to start my patient on a PRN, a short-acting beta-agonist, such as salvatamol. Also educate my patient on how to use it regarding the correct technique and use of the spacer.

And using a teach-back technique, then I'm going to provide my patient with some reading materials from lung foundation. Also prepare my patient's COPD action plan and educate him on how to use it. I'm going to arrange a review session in six weeks for the COPD, but we're going to have another session soon for a smoking cessation if possible and educate about some red flags such as any chest pain, any shortness of breath or any bloody cough, also any worsening in the conditions, and also consider referral to the pulmonary specialist.

if there is any doubt regarding the diagnosis or if we suspect any underlying cause. And I'm going to also activate my patient's GP management plan. Okay, thank you. Thank you. Thank you.

So for the last question, could you please explain to me what's the COPD action plan? The COPD action plan is actually a plan which is implemented when my patient experiences an increased symptoms such as increasing the cough increasing the sputum and sometimes even infectious symptoms such as fever so it has steps that teaches my patient such as first start pregnancy and if you have symptoms of infection also start antibiotics and if you've become unwell call your doctor or go to the doctor it has several charts based on the severity of the symptoms and tells my patient what to do in each step. That's great, thank you.

Thank you, Dr. Armin. That was really brilliant. Thank you for stepping up to presenting this case.

You were the path to this case and it shows that you were so much ready to present this case. It was perfect. I don't have anything to add to your presentation actually. Just I think that if you want to ask about FLIM, you can add that in the character part. But overall it was good, really I don't mind.

And the reporting associated symptom was so good, it was comprehensive. And let me see, if you have it right, you mentioned about, okay. Regarding the differential diagnosis, I just wanna add something. And whenever you're saying that it's COPD, it's with it would be better that if you just mention about the severity of that, that okay, I think the COPD and based on the symptoms of my patients, it could be a more to moderate COPD.

In that way, panel knows your provisional diagnosis more better. And you should, did you mention the lung cancer in your differential diagnosis? Yes, I mentioned that I shouldn't.

Oh, yes, I didn't hear that. Okay, thank you. So you covered all the parts properly. And at the first of your initiation, did you mention about wearing masks? Because I didn't hear the first of your presentation.

Mentioned about what? Sorry, I didn't catch you. Wearing masks or wear the personal protective equipment.

Oh, no, I didn't mention that. Okay, it's okay. Actually, you mentioned about... Althus, I don't have anything to add.

Thank you. Thank you so much for stepping up for this case. Do you have any questions?

No, thank you very much. I'm excited to enjoy your class and learn from you. Thank you. Thank you. Thank you so much.

Okay, so let's wrap up this new case. Okay, we actually had this case previously as a hematosis case, and this week they showed up as a new version of that. which with this data we found out that we are facing we can the case which is so they can give us actually He gave us the asthma case because the spirometry can interpret to different ways.

So we're speaking regarding all of scenarios, all probable scenarios together. Actually, I don't have anything to add to Dr. Armin's presentation. If you want to add a reference, you can have the recording of Dr. Armin's voice to know that how you should go and how you should present well. But as maybe it's challenging for you guys in some steps, so I want to explain regarding each and every step. Okay, let's go and see which cases we are.

So first of all, as we can see, our patient is here for a cost. We don't know about the duration. We don't know that at the first stage it was dry.

or chesty cough. So we need to ask so many questions in our history take. Before we start our history taking, like the normal thing that we do in our practices, we should wear our mask, or even we can wear our personal protective equipment, because it can seem that it could be a respiratory infection. So after that, we start our initiate.

After introducing, greeting, and be sure to be patient about confidentiality, and check the stability, we should think more about this cuff. So regarding this cuff, we should know when did it start. It's gradual or suddenly, at any specific pattern, like any seasonal pattern, or it's more in days or nights.

If it's constant or on and off, if any specific other patterns, like a weekday or weekends, then regard. think the character of that first we should determine that our patient has dry or chest cough and regarding phlegm regarding phlegm that they mentioned in the first stem so we should know that how's the consistency other volume of this phlegm and any specific pattern like cough cough turning into blue or cough vomiting or any whooping cough regarding elevating aggravating factor we should know what condition make our patients better or worse, like using any inhaler, any medication. If our patients facing with cold weather, physical activity, resting will make this condition better or worse. For example, we should be specified regarding that, that how many stairs can our patients walk or how our patient doing in physical activity. Regarding triggers, we have so many triggers and we have six or seven cough cases.

So it's so easy for the guys to know about triggers, like any contact with sick persons, any home condition, and any new pet, new carpet, or new sense of life, travel, or based on my patient's opinion, if this smoking can be a trigger for this cough or not. and the contact fields. where's any bush firing and we have other we have so many triggers after that we should ask about effects that how this condition affected on my patient's daily routine sleep job and how was the sequences of the cough and the flame for my patient if this cough leads to my patient for any work absence lead to any sleep disturbance? So we can make two or three questions regarding that. So we can ask that when and how you realize that it's smoker class.

Which actions did you take regarding that? Did you visit any GP or any specialist for that? So it's necessary because they give you this smoking cough and you should think more about that.

After that, that's the time for associated symptoms. So if you want to follow the top-to-toe approach, you should ask about any fever, choose rations or any red eye, water or ear pain or ear discharge. You should ask any runny nose or facial bone pain, any secreting behind the shorts, any dental problems.

You should ask if your patient has a coughed up blood. It's hemoptysia, so it's a red flag. There's a must for ask this question.

Any bad smell from the mouse? Any difficulty in swallowing? It's another red flag for your patients.

Any hoarseness of voice. Any lumps and bumps, unintended weight loss. With this cough, I want to know if my patient had any noisy breathing and difficulty in breathing. Any increasing in pillows. We're asking this for dyspnea, which could be another red flag.

Any worsening condition when a patient's laying down. Any chest palpitation, calf tenderness. leg swelling or recent surgery and water brush or any diarrhea.

So actually, you asked 90% of your questions. Now it's the time to ask about the job of the patient. Because it's so important that if your patient was any exposure to any other smokes or any specific jobs, any specific gases to make this condition worse. You should ask that if your patients change their job, because now you can see that your patient's job is a manager.

Just you should know that each part of industry he works, for example, or is facing with any chemical material. Then we go and pass medical history, because we know that maybe we have some overlap with COPD, which could be an asthma. So we should ask some questions regarding past medical history.

If our patient had any asthma, if our patient had any panic disorders. As you can see, our patient has some stressful family situation. But we didn't ask about this matter.

So it's the time to ask, what makes my condition to be stressful? Any specific stressful family situation? If my patient's roaring is affecting my... my patient's mood and after that your time is finished if you want to add anything you should ask about home condition of your patient so at this stage they give you these data that this cough started from six months ago it's worse in the morning it's every day the sputum is increasing and there is no any fever weight loss or hemoptasia and no specific triggers So how do you want to perform your physical examination? So like always, we follow standard protocols, explain every step of examination.

In general appearance, we should look for any signs of work of breathing, excessive work of breathing. If our patient can speak a full sentence and say noses, any protective posture. Regarding vital signs, we should check respiratory temperature, O2, BMI, and compare with previous one.

And we know and we mentioned about BMI because there's a chance for a patient to have long cancer, right? So our focus examination, as Dr. Orman said perfectly, is the complete hip examination, special lung examination, head and neck, special end examination, and as relevant examination, you can mention about abdomen examination. It's not important if you miss the abdominal examination because they ask us about the whole hip examination.

focus examination like all of our cost cases could be the chest examination and int examination and that's it so regarding office tests you need ekg and for the first time in this new version pesky exam we need a spirometer and as your questioner we have a questioner named copd assessment test we have this questioner to ask the patient that how the severity of this condition and how this affected on our patient condition. So I will send you this test and the questionnaire to be more familiar with that. So just let me to send this questionnaire having this history of our group.

Okay, after that... Can I have a question, Dr. Poulin? Sorry to interrupt you.

Please put the question for the last of our... Actually, I know that what would be your question, because this test. But let us just finish the presentation and we are going to discuss. Okay, so after that, we should elaborate our physical examination, as Dr. Armin started.

For a long examination, you should do the same because the inter-examination can be irritating even for adults. So you should. start and we have so many data in long examination as you noticed so you start from from checking along by clubbing you should have some inspection and what's important is that in your exploitation you should say about decreasing an air entry any crackle or any reasons and then should finish your examination for percash as you notice that they gave us hyper-resonancy data, right? So let's go and have a chat regarding spirometry interpretation.

Please open the spirometry data sent. Let me send the update version. Okay, yeah, the recall. As I spoke to the candidates who had this case in the real exam, they didn't ask about interperation of spirometry. But just let's have a quick chat regarding this spirometry.

So as you can see it's a typical spirometry of a COPD condition. So when we are going to interpret our spirometry, first we should look at FEV1 or FEVC ratio. So firstly, as you can see, the first we have the predicted amounts. So what's the predicted? So for every age, for any condition, or for every weight based on age or weight or other factors, we have a predicted amount for each person.

So for this person is 0.73. So we do the spirometry and we write the results. So as you can see, the prebronchodilator results is 0.54.

So it shows that we have the less amount, the amount of prebronchodilator is less than the predicted amount. After that, we should look for FEV1 amounts. So as you can see, the predicted one is 2.55 liter, but our patient's prebronchodilator our patient's actual amount is 1.21.

So we have a reduced FVC ratio here. So maybe they're going to give the asthma case for spirometry next time. So we should know how we should deal with that.

So until here, we found out that our patients' FVC ratio is decreased and it's less than 70%. be either asthma or COPD because we are facing with the obstructive disease. So how should we differentiate between asthma and COPD? So we should look at post-bronchodilator, which we give out to our patient's salivary gland, our patient in here, and then we spiromide our patient again.

So let's see that how our patients change as we can see the predict. the predicted percentage is 47, but our post-bronchodilator is 1.5, and the change percent is minus 5. If this was an asthma case, you should have more than 12 percent change after administering the bronchodilator. So your patient's ratio was not changed, even reduced after post-bronchodilator.

So it can't be an asthma case. So you're definitely here facing with a COPD case. So that's why they tell us in exam that your FEV1 to FVC is less than 0.5 because it's crucial to diagnose the COPD, right? So let's proceed.

with the stuff case. Okay, so for your physical examination findings, they show the page with lots of dates. They show that vitals are stable.

You had some high-resonance in chest examination and reduced chest expansion. Pyrometry shows FPU1 to FVC ratio less than 70%, and they ask about provisional and differential diagnosis. And actually, they ask investigation.

together. So, okay, as we have the live men with 64 years old, with complaining of cough from six months ago, which has phlegm every day. So our patients was smoking. Our patients had heavy smoking.

And based on spirometry, I think about some obstructive diseases. And at the top of my list, I can think about COPD, chronic obstructive pulmonary diseases. Then I can think also about asthma, but my patient has flame and had dry cough, so it's not likely.

And now we can go for our other differential diagnosis, right? So you set your clinical judgments, your provisional diagnosis. Now is the time for your differential diagnosis.

So after that, you can have doubt about bronchiectasis. You can have the asthma, CFPD, overlap syndrome. You can have chronic bronchitis.

But you should not miss your, actually, your diagnosis of lung cancer. because the age and being a heavy smoker of patients can be consistent with this diagnosis. But your patient doesn't have red flags like hemoptasia or intended weight loss or night sweets, so this condition can be unlikely, but you can't miss this diagnosis. After that, you can think about post-nasal drip or upper epic cough syndrome. You can think about gastroesophageal reflux diseases, interstitial lung diseases.

You can even think about TB, which we know that is rare in Australia. You can think about sarcoidosis or medication-induced cough. And you can see the rest of benign conditions. What's important?

You should say why you choose this diagnosis. You choose that based on your patient's symptom, your patient being an heavy smoker. and your patient's barometric.

And first you say that, yes, I found out that I'm facing with an obstructive disease. So for that, I think about COPD and asthma, but because my patient had weight loss. So because of that, I think more about COPD. And you don't miss lung cancer, and that's all. After that, they ask about investigation.

So I really enjoyed that Dr. Armin didn't forget to mention about investigation, because most of the time candidates, as I saw in my students or in classes, they forget about mentioning investigation when these two questions are asked together. So here we should divide our test into two categories of imaging and lab tests. So you definitely need a chest x-ray to rule out other diagnoses.

And if you found any abnormality, you should ask for CT scan after consulting with your supervisor. Regarding blood tests, you need full blood examination to assess infection and inflammation information. You need a sputoculture or serology to rule out other infections. And you need an ESR and CRP.

And that's it. Don't go through all of your investigations. I mean all of us know that we need more other investigation but you should be more focused and that's enough because they give us the data that okay after that the chair six-way is normal the CT scan is normal just in chair six-way you found out some hyperinflation and the sputum culture is normal as well so please proceed with your math okay we should do all of our structure and don't lose our structure.

So if we want to work like that, first of all, we should thank our patients for coming and cooperation. We show all of our funds to our supervisor, and we should say and explain this condition to our patients and how we should explain that. It's so important to notice that at the first step, they mentioned about some family issues, some family situation. So your patient is worried, right?

So it's important to address this at the first of your management. Okay, you start. I want to explain to James that James, you cough and increase phlegm or likely due to a condition named COPD, a lung condition that often linked to smoke.

The good news is that we can work together to manage this. We should focus on three key areas, quitting smoking, easing your coughs, and preventing filler ops. Then I want to check the understanding. I want to address the concerns. I want to Address if there is any fear of inhaler dependency, any weight gain after quitting smoking.

I want to address if there is any family situation. And I want to make sure of the patient that based on your CT scan, based on your chest x-ray, it's the probability of lung cancer is low. And I want to offer, if need, involvement of a support person.

Okay, so your explanation is good. That's enough. actually is more than enough. After that you say about your explanations.

I want to just send some slides from references to have more discussion together. Just let me find the slides and we'll speak together. Those are all from the combination of RCGP and ETG.

So it's so useful for the guys and it's a reference for exam. So please look at them at least once. Okay. Please open it away. Okay, I think it could be enough.

Okay, so as you can see in the management of COPD, we should focus on some areas. First, we should look for optimizing function of our patient, preventing deterioration. developing support networks and self-management skills and we should manage the following exacerbations. So we don't want to lose our structure, right?

So we're gonna speak about lifestyle advice, SNAP protocol. So I should explain to my patient regarding SNAP protocol, I will do a motivational counseling based on five-way approach for them and the most important one is the smoking cessation. I'll speak to my patients as I mentioned regarding motivational interviewing.

I want to emphasize that James quitting smoking is the most effective way to slow your COPD progression. In this regard, I want to offer my patients some pharmacotherapies, for example, a varnicoline or nicotine replacement therapies. And I want to refer my patients for counseling regarding cessation to quit life.

After that regarding nutrition, I want to say that you should consider high calorie supplements. You should have some advice using of alcohol. You should have less than two standard drinks per week and you should continue your daily exercise for three minutes per walk and I have some concentration for this physical activity and I will refer my patient to pulmonary rehabilitation for an eight-week program. So after that, I will explain to my patients that it's a multidisciplinary team approach. As you noticed in the slide from ETG, they mentioned all multidisciplinary care for COPD, but we don't have enough time to mention about all of them.

So we just mentioned about some of them, and as you can see at the first line, they mentioned about GP. So the GP is the main coordinator for this process. The GP should follow regularly, the GP should prescribe medications, and the GP should write the proper action plan for the patient. So I want to tell that me as a GP, I should prescribe medication, have a coordinated care, and I want to give you CFP the action plan, and I want to educate my and we know that the sources is a main comorbidity. within COPD.

So please don't forget to mention that because they told this at the first of your step. So you need to refer your patient to a psychologist to address any stress or anxiety related to family situation. You should give your patient and educate your patient regarding some relaxation techniques.

You need to refer your patient to a dietician to provide the tailored nutritional advices and you can give your patients some general advices. As I mentioned, we can have general advice in the physical activity of our patients. So, for infection prevention, your patients should have hand hygiene, avoid going to crowded places, especially during flu season. Your patients should administer the vaccination, especially flu and pneumococcal vaccination.

And you should tell your patients some daily living strategies. For example, your patient should maintain good hydration. Home air purifier consideration is good. Your patient should do his daily activity step by step.

And you can divide to little by little activities. Okay. After that, we are going to excellent regarding pharmacological management. So just let's look at the ATG or actually the guideline for COPD.

So we have three categories for CFP, right? Mild, moderate, and severe. Here we are facing with a mild category. And as you can see in the previous slide, we can see that which symptoms belongs to which category. So here our patients have cough and sputum, and everyone is between 60 to 80. And our patient's few symptoms, we don't have any breathless for our patient, maybe in some moderate exertion.

So this patient definitely could be a mild COPD. So what we have in mild COPD, yes, we should reduce risk factors, which we discussed. We should have an optimized function of our patient, which we did.

We should optimize the treatment of comorbidities, and we did, because we addressed the anxiety and depression of our patients. refer symptomatic patients for pulmonary rehabilitation. We did that, we refer our patients. And after that, we should have a stepwise drug management. So attention that it's a stepwise drug management.

Like asthma, here we have a stepwise drug management either. So for all patients, as you can see, we should start as needed short-acting bronchodilator therapy. like Ventolin. Let me see.

No, let me just send a proper. Okay. So as you can read for patients with mild and infrequent symptoms, like our patient, a combination of general measures, which we mentioned, and short-acting beta-2 agonists, which we named as SAVA. is adequate and it should be salbutamol 100 to 200 micrograms by inhalation we have a spacer or butolin you prefer to just name one of them which we are easier with salbutam okay so how we should say this pharmacological management in our presentation okay just give me times two. For pharmacological management, after consulting with my supervisor, I want to consider the established drug trop as I'm here facing with a multi-OPD management.

I want to prescribe for my patients as needed short-acting betagonist, which could be salbutamol, via spacer. And if needed, if needed, I can consider a lab offer for the patient, but as my patient now doesn't have any exacerbation, maybe there is no need, but I want to consult with my supervisor. I want to review the COPD assessment test.

If it's more than 10 or the symptoms persist, I want to prescribe them. After that, I want to read, write. a precise COPD action plan. I'm going to educate my patient in details regarding green zone or amber zone. Let me send the COPD action plan for you guys.

Okay, so it's the COPD action plan. As you can see, we have different colors and it's for different severities. So our patient is small so we can think about the green area and also we can think about amber area. which our patient could be more breathless than normal or more cough and increase the care flip as you can know as you know the COPD is a progressive disease so maybe your patient have uh should be in amber area amber area for example in three months later so you should explain to your patient these two areas so the green zone is In the green zone, they mentioned that you should continue Saba as needed, plus daily exercise. And if your patient is amber zone, so maybe there is a need to double Saba and start prednisone for five days.

We don't have enough time to go through the details of that. If panel wants, as I asked from Dr. Army, they will ask us to tell them in details. So after that, we should actually activate the GP management plan for my patients as we need a coordinated care.

So whenever we need a coordinated care, we need to involve other light health. So there is a need to activate GP management plan to review and follow up the patients mostly. Now it's time that you say about your.

review sessions and how do you want to check the safety netting of your patient. So after checking check the safety netting of my patient, I want to arrange a review session for after four weeks. Why you want to do that after four weeks? Okay we're gonna do that for checking our patient smoking cessation.

It's important for you. You will check the inhaler techniques and you will assess regarding the severity of symptoms. You have another annual assessment for the patient to check the spirometry, BMI check, vaccination status, and medication review. And if there was any red flags like breathlessness or shortness of breath at rest or any fever, any high fever, any hemoptasia.

any weight loss, any nitrates, your patient should come back to you as soon as possible. And you will tell your patients, you provide your patient with material from Long Foundation of Australia. And actually everything that I said to you guys, it's from Long Foundation, ETG and RSCG. So my presentation is over and I think that's enough for covering the PET-STY exam. So guys, if you have any questions.

I remember that Dr. Armin had some questions. Let's tackle this. Thank you, Dr. Puria, for your great wrap-up. Regarding the questionnaire in the examination part, at that point in the consultation, we are not sure.

We don't know if this is a COPD case. So maybe a COPD questionnaire might be a little suspicious on our part. Yes, you're right. Yes, you're right. While I'm mentioning the COPD assessment test, I was thinking about that, yes, it could be obvious that we have recalls.

But it's vital to mention that, right? If you don't want to mention here, you must mention that in your management, because it's access to stability of your patient, and the practice nurse has a job to review this annually. But as I consider this patient to have phlegm and don't have any red flags, I was just, and because this case is new to us, I was just thinking that maybe we think about COPD at some points as a GP, as some normal GPs.

But as you're mentioning, actually, I agree with you. For this stage, we should wait for recalls, for more recalls. But there's no need to mention the COPD assessment test here. But there's a must to mention that in your manual. Okay, the next question.

hi dr hi hi i have a question should we uh offer spirometry in the office test in physical examination part thank you yes we should offer the spirometry because if you don't do that so panel doesn't give you the data regarding spirometry and you can definitely say that it's a copd or any infectious disease And actually we have five office tests. Urine pregnancy test, urine dipestic test, blood sugar, and this spirometry. I think I forgot one of them, but the spirometry is one of the office tests. And especially in this case, we didn't have that in our previous cases, but here we need a spirometry.

Okay, thank you very much. Thank you very much. Okay.

So, yes, yes. And it means that could we add spirometry to the office test in other cough case or just for this case? No, no, because in other cough cases, our most suspected suspicion is for infectious diseases. Whenever you're suspected mostly due to infectious diseases, so there is no need to aspirin.

Here, because we need to have a diagnosis of COPD, so there is a mask for doing spirometry. Okay. Thank you very much.

Okay. Yes, ETG, I forgot about ETG, Dr.

Transcript for:Understanding COPD Case Management

Transcript for:
Understanding COPD Case Management