Chronic obstructive pulmonary disease, unspecified

J44.9

Clinical Vignette:

Patient Profile:

* Age: 67 years old

* Sex: Female

* Name: Iris

History of Present Illness:

Meet Iris, a 67-year-old retired school librarian, whose love for stories is only rivaled by her love for her five cats. Over the past few months, Iris noticed that her daily routine became increasingly challenging. Her breathless treks up the stairs to her beloved library on the second floor of her home began to feel like scaling a mountain, and her words got interrupted more frequently by bouts of coughing.

These symptoms didn't occur in a vacuum. Iris had been a smoker for many years but had quit about a decade ago. But she noticed that her breathing trouble didn't completely resolve with cessation. It was on a particularly bad day when she couldn't even complete a sentence without gasping for air that she decided it was time to visit her doctor.

Physical Examination:

Upon examination, Iris' lungs exhibited prolonged expiratory phase and wheezes. She was tachypneic and used her accessory muscles to breathe, suggesting her struggle for oxygen.

Investigations and Diagnosis:

Given Iris' history of smoking and her symptoms, the doctor ordered a pulmonary function test. The test revealed a reduced FEV1/FVC ratio, indicating an obstructive lung disease. A chest X-ray and CT scan further confirmed the chronic obstruction in her airways.

With a heavy heart, Iris was diagnosed with Chronic Obstructive Pulmonary Disease (COPD). Although she was aware of her past smoking's potential repercussions, the diagnosis was a tough pill to swallow. But in true librarian fashion, Iris decided to learn more about her condition and take control, just like the heroines in her favorite stories.

Diagnosis and ICD-10-CM Code:

Chronic obstructive pulmonary disease, unspecified (J44.9)