Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a progressive, non-productive cough and exertional dyspnea of [Number] months' duration. Denies orthopnea, paroxysmal nocturnal dyspnea, or chest pain. No history of occupational dust exposure, domestic bird contact, or connective tissue disease symptoms (e.g., Raynaud’s, arthralgia). Symptoms are insidious in onset and have resulted in significant limitation of daily activities.
Clinical Examination Findings
General: Patient is in no acute distress, resting comfortably. Respiratory: Auscultation reveals bilateral, fine, end-inspiratory "Velcro-like" crackles at the lung bases. No wheezing or rhonchi. Cardiovascular: Regular rate and rhythm, S1/S2 normal, no murmurs, rubs, or gallops. Extremities: Digital clubbing present/absent. No peripheral edema. Oxygen saturation [Number]% on room air.
Treatment Protocol
Initiate antifibrotic therapy with [Nintedanib/Pirfenidone] 150mg [Frequency] to slow disease progression. Monitor liver function tests (LFTs) at baseline and monthly for the first 6 months. Recommend supplemental oxygen if resting SpO2 <88%. Refer to pulmonary rehabilitation program. Advise smoking cessation and annual influenza/pneumococcal vaccination.