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Rensselaer Polytechnic Institute, Troy ​hi my name is Tracy sugar and I'm here to present a patient today RT who is experiencing experiencing an acute exacerbation of COPD and has hypertension RT is a 57 year old Caucasian gentlemen presenting today with a chief complaint of I can't breathe due to an acute COPD exacerbation his sputum is greenish brown and smelly RT has been being treated for COPD for more than three years and has recently experienced three previous acute exacerbations within the last 90 days January 15th January 18th February 5th and today past medical history includes COPD dyslipidemia he had a myocardial infarction in 2015 depression family history of cardiovascular disease depression he has a history of smoking a pack a day for ten years but he did quit in 2019 he was married for 24 years but his wife passed away in 2016 he drinks occasionally alcohol he has an allergic reaction to adhesives and his current medications are metoprolol succinate 200 milligrams once daily albuterol 2 puffs every four hours as needed for shortness of breath the tour of Staten 80 milligrams once daily aspirin 325 milligrams once daily Volant are all umma clogged inium which I'm gonna say from now on anoro ellipta inhaler he takes one inhalation once daily he's also on be appropriate Excel 300 milligrams once daily to prioritize his problem list on the high end we have the fact that he's dealing right now with an acute exacerbation of COPD with altered Mental Status possible respiratory infection most likely bacterial chronic uncontrolled COPD hypertension he also in the middle of the range is a patient with CKD we don't know for sure if he's up to date on his vaccinations specifically pneumococcal and influenza and on the low end of the spectrum depression which is under seems to be under good control with his bupropion and also he is borderline overweight he's not really overweight when you look at his BMI of 24 3 3 however he does have him at a bollock syndrome to assess let's start with the COPD so to assess his disease Arty's COPD is currently uncontrolled as noted by his multiple recent acute exacerbations per the gold 2018 guidelines RT is an classification of gold 3 group B based on his fe v post value of 45 let's see gold 3 would be somewhere between 30 and 50 fev1 and that was the last reading he had was 45 on February the 19th he has had more than 2 exacerbations leading to hospital admission and his cat score is 26 which is greater than or equal to 10 which leads us to the D category diagnosis he is also in addition he has an altered mental mental status is experiencing increased its dyspnea increased speed and volume and perience indicating that this is a severe exacerbation smoking lack of exercise and a history of being overweight are contributing factors to RT COPD his history of mi did not lead to heart failure which his ejection fraction is still I believe 57 percent which is pretty good RT has a history of depression and cardiovascular disease and metabolic syndrome qualified by his triglycerides being greater than 150 his HDLs are less than 40 and his systolic blood pressure greater than 130 and his diastolic blood pressure being greater than 85 also his waist circumference is 37 inches so per that rec that is per Alberti at al and harmonizing the metabolic syndrome discusses metabolic syndrome and other disease states which often concomitant and necessary to treat with COPD and one of those is metabolic syndrome COPD in addition to artis other comorbidities is a contributor to cardiovascular risks such as myocardial infarction stroke cardiovascular events and gaining control of the COPD can lessen this chance of these risks the goal of therapy is to reduce symptoms and risk prevent progression of disease reduce mortality and improve quality of life and exercise tolerance the assessment of current therapy is RT is currently being treated with muscle methylprednisolone 500 milligrams every six hours IV mature below succinate p o 200 milligrams once daily atorvastatin 80 milligrams once daily aspirin 325 milligrams once daily let's see his volunteer all the club in iam inhaler once daily albuterol I perturb reom nebulizer solution every six hours heparin sub-q tid be appropriate XL 300 milligrams once daily since our tia is hypoxic glucocorticoids are appropriate to shorten recovery time and improve lung function which is gold evidence a however this is only indicated for up to five to seven days the current plan is to treat for 14 days with IV which is incorrect this could actually be changed to a Pio dosage form since this patient is non invasively ventilated and capable of pl also an antibiotic should be implemented per the gold guidelines Pio is preferred this is missing in the current therapy the use of his Brio ellipta inhaler is inappropriate because during an acute exacerbation short-acting inhaled beta-2 agonist either with or without anticholinergics are indicated and the long-term the long-acting bronchodilators are more for prevention of exacerbations and should be instituted after being discharged from the hospital so when we look at his plan recommendation all recommendations contribute to the goal of therapy of minimizing the negative impact of this acute exacerbation and preventing subsequent events also I would like to make a note before I start with recommendation one that I do not recommend roof limo last although it is a potential treatment for group D patients with FEV values of

less than 50% it is associated with depression so since RT has a history of depression and is currently under control I'm going to avoid that drug at this point although it's something that we may need to consider later if RT continues to have problems so recommendation one is that we're going to discontinue methylprednisolone 500 milligrams every six hours IV and per day jong-il therapy with oral prednisone is not inferior to IV treatment in the first 90 days after starting therapy and it has also suggested that RI that oral therapy is preferable to IV to treat COPD exacerbations so moving on to recommendation 2 I'd like to initiate prednisone 40 milligrams per day P o times 5 days the reduced trial by Olympia al concluded that five days of glucocorticoids was non-inferior to 14 days of therapy when looking at 6month Reax re exacerbation rates and plus this gives us the advantage of decreased Luca Cory's exposure and therefore decreasing the side-effects gold and gold guidelines and waters I have al states that oral glucocorticoids can reduce the rate of treatment failure and relapse and improve lung function and Brooklyn as' so let's monitor his blood pressure weight blood glucose electrolytes white blood cells for infection hemoglobin watch for the side effects of hypertension headache emotional lability mood swings diaphoresis decreased potassium abdominal upset and hypersensitivities recommendation 3 includes initiating amoxicillin clavulanic 500 over 125 milligrams PL every eight hours for five days my original statement that I turned in on the test I recommended a zipper Meissen 500 milligrams once daily for three days and I don't I I would rather go with the augment and at this time so rational being that gold guidelines in the systemic systematic review by poha at al recommends antibiotics reduced treatment failure and mortality rates and COPD patients with severe exacerbations and in the hospital like RT so let's monitor for science of rash and a whole axis at first dose and watch his renal function tests this medication may also upset his stomach so taking it with food may help we're going to be recommendation number four would be to discontinue the Brio Lifta inhaler recommendation five to continue his albuterol approach opium her nebulizer every six hours and the rationale for those two last recommendations or gold guidelines and the nice study that concludes that using short-acting beta-2 agonist rather than long act long-acting agents during an acute exacerbation is appropriate once RT is discharged from the hospital we can look at some recommendations to can not continue but to initiate a zipper mice and 250 milligrams P o once daily for a year the rationale being that Albert adults concluded that as if our mice and taken daily for one year when added to usual treatment decrease the frequency of exacerbations and improve the quality of life but however it can cause hearing decrements in a small percentage of patients so to monitor let's watch let's monitor his hearing look at his liver function tests CBC with differential and basically just follow up with him if he has any issues or side effects from long term azithromycin therapy recommendation to after discharge from the hospital we would be to reinitiate the Brio ellipta one inhalation once daily the rationale actually I keep seeing Bree o alikum but it's anoro ellipta let's see let me look at that yes I'm so sorry I've been saying Bree oh it's anoro ellipta okay so recommendation three consider an addition of an inhaled corticosteroid inhaler such as Bekele Methos own or qvar ready healer 40 micrograms per actuation - inhalations by mouth twice daily gold guideline recommendations consideration for group D patients states that you can add this to help maintain the controlled therapy patient education non pharmacotherapy would be to encourage exercise continued success with smoking cessation to stay up to date with his influenza and pneumococcal pneumococcal vaccines and instill the importance of compliance with pharmacotherapy maintenance meds to prevent further exacerbations also review the use appropriate use of all of his inhalers and make sure that he's using them correctly to move on to hypertension RT has uncontrolled hypertension with an average blood pressure of 140 over 90 according to the ACCA EJ 2017 guidelines this is categorized as stage 2 hypertension and contributing factors include his history of MI COPD chronic kidney disease being overweight in the past metabolic syndrome based on the rationale that I discussed earlier about his triglycerides his systolic and diastolic blood pressure waist circumference etc his lack of exercise in history of smoking are also contributors the goal of therapy includes trying to reach a blood pressure of less than 130 over 80 millimeters for my mercury per the 2017 guidelines and this would reduce his chance of than my stroke and cardiovascular events his AS CVD risk score is calculated to be 7.4 now just to mention the Sprint trial does suggest benefits of reducing blood pressure to less than 120 over 80 to help lessen cardiovascular and CKD risks associated with hypertension at this time I'm more comfortable sticking with the accha hypertension guidelines since he is not in great shape right now I don't want to cause any undue stress for him we need to address this hypertension to reduce all of this risks to assess his therapy currently he is taking monotherapy of metoprolol succinate 200 milligrams once daily to address this hypertension and the plan is to change this to carve a tall which is inappropriate metoprolol is actually more cardio selective than carve a Dalal and is less likely to aggravate bronco spastic Airways instead we should definitely need to continue the metoprolol but we need to add a second agent to this suboptimal regimen for the 2017 hypertension guidelines the second agent for patient with CKD is an ACE inhibitor this is a class 2a recommendation so recommendation one would be to continue the metoprolol succinate 200 milligrams once daily with the rationale being that he RT has a history of MI and per the 2013 heart

failure guidelines the NCL beta blocker should be used post mi titrated to a maximum dose of four metoprolol to 200 milligrams per day which RT is already there and a goal the goal would be to decrease cardiovascular risk and CKD events by lowering the blood pressure to get to under 130 over 80 we need to monitor his ECG his heart rate his blood pressure recommendation - would be to initiate lisinopril 10 milligrams once daily this is per 2017 accha hypertension guidelines the recommendation to treat first with an ACE inhibitor thiazide like diuretic calcium channel blocker as first-line however since he has the history of MIT already have metoprolol on board so let's add the ACE inhibitor let's monitor for a reduction in blood pressure look for adverse events such as angioedema that would be a worst case scenario hyperkalemia monitor has the UN serum creatinine potassium look at his baseline liver function test renal function tests and with one or two within one or two weeks after initiation and then periodically reassess his blood pressure to titrate to it his dose so that we can reach therapeutic goal of less than 130 over 80 and this would help us to avoid cardiovascular events which can increase morbidity and mortality patient education includes using proper diet the - diet low sodium high-fiber etc start to exercise start low and build up he is not currently exercising so don't go out and start exercising 30 minutes a day five days a week right off the bat and to contact the doctor if he has any signs or symptoms of angioedema or lightheadedness etc and that is it that is my that is what I really would have liked to have put on my test but that took me a couple more hours of work than what I turned in for the test so I will post that as my presentation and compared to what I turned in for the test it's quite a bit different so hopefully I'm going to get faster at this and be able to do that in two hours thank you so much I appreciate everything bye New York University of Architecture.