Hispanic male presents with an accelerated decline in lung function. Last year you ordered an albuterol inhaler PRN, and that seemed sufficient. Today he is dyspneic, pale, and seems almost listless. He continues to smoke, and his pack-year history is 40 years.

CC: “I have to sleep in my recliner because I can’t lie in bed, and I have no energy to do anything – I don’t even have energy to eat.”

Vital signs: Blood pressure is 132/94. His heart rate is 120 beats/minute. Respiratory rate is 36 breaths per minute. Height is 5’9”. Weight is 160 pounds.

AP to lateral diameter: 1:1. Cough with clear mucoid sputum. Diminished breath sounds. Hyper-resonance over lung fields on percussion and use of accessory muscles during respiration.