Further History

his sputum has changed from white to green in color

increase the frequency with which he uses his albuterol inhaler. He denies having a fever, chest pain, peripheral edema, or other symptoms. His medical history is significant for hypertension, peripheral vascular disease, and two hospitalizations for pneumonia in the past 5 years. He has a 60-pack-year history of smoking and continues to smoke two packs of cigarettes a day.

On examination, he is in moderate respiratory distress. His temperature is 98.4°F, his blood pressure is 152/95 mm Hg, his pulse is 98 beats/min, his respiratory rate is 24 breaths/min, and he has an oxygen saturation of 94% on room air. His lung examination is significant for diffuse expiratory wheezing and a prolonged expiratory phase of respiration. There are no signs of cyanosis. The remainder of his examination is normal. A chest x-ray done in your office shows an increased anteroposterior (AP) diameter and a flattened diaphragm, but otherwise he has clear lung fields.

wheezing.

• Most likely cause of current symptoms: Acute exacerbation of chronic obstructive pulmonary disease (COPD)

• Appropriate treatment of exacerbation: Antibiotic, bronchodilators, systemic corticosteroids

• Interventions to reduce exacerbations: Smoking cessation, long-acting bronchodilator, inhaled corticosteroid, influenza and pneumococcal polysaccharide vaccination

Analysis