70-year old male 6’0” 180 poundsNo Known Drug Allergies (NKDA)Medications: AlbuterolChief Complaints: Cough and wheezingPatient states his cough and wheezing have been steadily getting worse for the past year. He was diagnosed with asthma when he was 9 and has had to use his inhaler more often in the past three months. He is a 40-pack year smoker and continues to smoke. Patient admits to more lung infections than “he can count” over the past 10 years. The cough and wheezing are worse in the morning (more frequent but non productive) but occurs throughout the day. He finds that breathing through pursed lips helps. You notice as he is speaking with you that he uses his SCM, scalene and trapezius to breathe. He admits he has lost 20 pounds over the last year. Patient states his symptoms are alleviated when he sits up and aggravated while lying down. He sees a pulmonary specialist who “wants to give him more medications but the patient just does not want to take them.” The pulmonary specialist’s findings are as follows:  Forced Expiratory Volume in 1 second (FEC1) < 80% predicted and the ratio between Forced Expiratory Volume 1 (FEC1) and Forced Vital Capacity (FVC) < 0.60.  Symptom severity is 8 out of 10.

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