Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of Ankylosing Spondylitis (ICD-10: M45.9_2) with known apical pulmonary fibrosis. Reports progressive exertional dyspnea, non-productive cough, and occasional pleuritic chest pain. Denies hemoptysis, fever, or night sweats. Symptoms are stable/worsening compared to previous visit.
Clinical Examination Findings
Respiratory exam: Auscultation reveals bilateral apical crackles, more pronounced on the right. Decreased chest wall expansion noted due to ankylosing spondylitis. Percussion is resonant. No signs of peripheral edema or cyanosis. O2 saturation on room air is [X]%.
Treatment Protocol
Management plan: Continue current DMARDs/biologic therapy for AS. Pulmonary referral for high-resolution CT (HRCT) and pulmonary function tests (PFTs). Consider supplemental oxygen if hypoxemia is present. Smoking cessation counseling provided. Annual influenza and pneumococcal vaccination recommended.