REASON FOR CONSULTATION: COPD exacerbation.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with end-stage COPD with a history of hypoxic, hypercapnic respiratory failure, who was admitted to the hospital with a history of worsening dyspnea and coughing up grayish-colored phlegm. Pulmonary was consulted as the patient had difficulty coughing out the phlegm and has had minimal improvement of his dyspnea in the past 24-48 hours. The patient denies any high-grade fever or chills. Complains of having upper respiratory tract infection prior to admission. He has had a history of tracheostomy and PEG tube placement in the past, which was subsequently removed. The patient is on chronic oxygen use at home and uses 2.5 liters on a continuous basis. The patient is also on BiPAP at night with settings of 20/5.
PAST MEDICAL HISTORY: End-stage COPD; chronic hypoxemia; history of hypercapnic respiratory failure; chronic smoker, quit a few months ago; history of tracheostomy and G tube placement in the past, which was removed.
MEDICATIONS:
1. Advair.
2. DuoNeb 4 times daily.
3. Protonix.
4. Theophylline nebs.
5. Moxifloxacin.
6. Diamox.
7. Glyburide.
8. Prednisone 40 mg IV every 6 hours.
9. Mucinex 600 mg twice daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is an ex-smoker. No asbestos exposure. No pets at home.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: A detailed review of systems was obtained and is negative, except as outlined in the history of present illness.
PHYSICAL EXAMINATION:
GENERAL: This is a pleasant gentleman, thin build, cachectic looking, able to converse in complete sentences.
VITAL SIGNS: Blood pressure 172/82 mmHg, pulse rate 114, respiratory rate 18-20, afebrile, sats are 94% on 2.5 liters of oxygen.
HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Sclerae anicteric. Head is normocephalic, atraumatic.
NECK: Supple. No JVD or carotid bruit.
CHEST: Distant breath sounds, no rales or rhonchi. Mildly prolonged expiration.
HEART: S1 and S2 heard. No murmurs, rubs or gallops. Tachycardic.
ABDOMEN: Soft, nontender. Bowel sounds heard. No palpable masses.
EXTREMITIES: No cyanosis, clubbing, or edema.
PSYCHIATRIC: Appropriate affect, good eye contact.
LABORATORY DATA: On admission, white count 8.4, hemoglobin 12.4, hematocrit 38.6, platelet count 314,000. Sodium 136, potassium 4.5, chloride 98, bicarb 36, BUN 18, creatinine 0.9, glucose 150. Troponin negative x2. LFTs are within normal limits. INR 0.9.
DIAGNOSTIC DATA: Chest x-ray shows hyperinflation, old granulomatous disease, no new infiltrates.
IMPRESSION:
1. End-stage chronic obstructive pulmonary disease with exacerbation.
2. Chronic hypoxemia.
3. Sinus tachycardia.
4. New chest congestion.
5. Hypertension.
6. History of respiratory failure, status post percutaneous endoscopic gastrostomy and tracheostomy in the past.
PLAN:
1. Aggressive pulmonary toilet.
2. Increase the dose of Mucinex to 1200 mg twice daily.
3. Add Mucomyst every 12 hours for the next 48 hours.
4. Add Pulmicort hand-held nebs.
5. Continue IV steroids.
6. Continue nebs, change to q. 4 hours and q. 2 hours p.r.n.
7. Continue BiPAP at night.
8. Obtain arterial blood gases.
9. Titrate oxygen to saturation between 90-92%.
10. If there is no significant improvement in the next 24-48 hours, will consider bronchoscopy for pulmonary toilet. I discussed with the patient the risks and benefits of bronchoscopy, and the patient verbalized agreement and understanding and consented for the bronchoscopy as needed.
Thank you for this consultation. We will follow along with you.
