What is your primary (one) diagnosis for this patient at this time? (Support the decision for your diagnosis with pertinent positives and negatives from the case

INSTRUCTIONS:
What is your primary (one) diagnosis for this patient at this time? (Support the decision for your diagnosis with pertinent positives and negatives from the case)
The primary diagnosis for this patient is chronic obstructive pulmonary disorder (COPD). This patient presents with all the signs and suggestive features of COPD. Pertinent positive indications that suggest the diagnosis for COPD in this patient are shortness of breath, chronic cough, dyspnea, and sputum production. Dyspnea is a cardinal symptom associated with COPD (GOLD, 2021). This patient is also a former smoker which is a known risk factor during the assessment of COPD (GOLD, 2021). The patient has a persistent and productive cough that has been present for 6 months. According to GOLD (2021) a chronic cough that may or may not be productive is often the first symptom of COPD. Classification of severity of airflow limitation as determined by spirometry was GOLD 3 (Severe). The chest x-ray was negative which was useful to rule out other differentials. According to GOLD (2021) using the results of a chest x-ray is not useful during the diagnosis process but valuable when looking for the presence of a comorbidity. 
1. Identify the corresponding ICD-10 code.
J44.9
 
2. Provide a treatment plan for this patient’s primary diagnosis which includes:
 
Medication
The use of medication in the maintenance of COPD helps to reduce symptoms, helps to reduce the severity and frequency of exacerbations, as well they can improve tolerance of exercise (GOLD, 2021). Currently, choosing which medication to prescribe is dependent on each individual patient, severity of symptoms, cost of medication, airflow limitations, and the balance of possible side effects (GOLD, 2021).
 
Tiotropium inhaled HandiHaler DPI: 18mcg per capsule
Dose: 2 puffs (1 capsule) inhaled Daily
Disp

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