COPD flare, respiratory failure considered and excluded

EXAM: Chest radiograph, portable AP INDICATION: Dyspnea, wheezing. FINDINGS: Hyperinflated lungs with flattened hemidiaphragms. No focal consolidation, pleural effusion or pneumothorax. Heart size normal. IMPRESSION: Hyperinflation consistent with COPD. No acute cardiopulmonary process.

CC: Shortness of breath, wheezing. HPI: 69M with COPD, current smoker, presents with 3 days of worsening SOB, wheeze and increased sputum, now yellow. Using albuterol q2h at home without relief. No fever, chest pain or leg swelling. Not on home O2. Vitals: T 37.3, HR 108, BP 148/90, RR 26, SpO2 87% RA on arrival. Exam: Tripoding on arrival, diffuse expiratory wheezes, prolonged expiration, mild accessory muscle use. Labs: WBC 10.8, Hgb 15.9, BMP unremarkable. Troponin <0.01. CXR: hyperinflation, no infiltrate or effusion. Course: DuoNeb x3, methylprednisolone 125 mg IV, azithromycin 500 mg. On 2 L NC SpO2 93%; RR 22. Assessment/Plan: 1. COPD exacerbation. 2. Acute hypoxic respiratory failure? ABG pending. Dispo: Admit to medicine.

HISTORY AND PHYSICAL HPI: See ED. Feels much better after nebs. Two exacerbations in the past year treated as outpatient. PMH: COPD (FEV1 52% predicted, 2025). HTN. HLD. Depression. Meds: fluticasone/vilanterol 200/25 1 inh daily, tiotropium 18 mcg daily, albuterol PRN, amlodipine 5 mg daily, atorvastatin 20 mg daily, sertraline 50 mg daily. Social: Smokes 1 ppd cigarettes, 45 pack-years. Retired roofer. Exam: T 37.0, HR 94, BP 136/82, RR 20, SpO2 92% on room air at rest. Speaking full sentences, no accessory muscle use, scattered expiratory wheezes, fair air movement. ABG (RA, 08:40): pH 7.39 / pCO2 45 / pO2 66 / HCO3 27. Assessment/Plan: 1. COPD with acute exacerbation - prednisone 40 mg daily x5 days, DuoNeb q4h + albuterol q2h PRN, azithromycin x3 days. Titrate O2 to SpO2 88-92% only if needed. Not in respiratory failure: SpO2 92% RA, no increased work of breathing, ABG without hypoxemia or hypercapnia requiring support. 2. Tobacco use - cigarette dependence; nicotine patch 21 mg, cessation counseling >3 min. 3. HTN - continue amlodipine. 4. HLD - atorvastatin. 5. Depression - stable on sertraline. VTE ppx: enoxaparin.

Arrived to unit on 2 L NC. Per order weaned to room air at 11:00; SpO2 92-93% RA at rest, RR 20, speaking in full sentences, no accessory muscle use. DuoNeb given at 10:00 and 14:00 per RT. Pt requesting to go outside to smoke; nicotine patch applied, smoking cessation pamphlet given. Steady gait, independent in room.

HOSPITAL DAY 3 S: Breathing near baseline, walked hallway without stopping. O: HR 84, RR 18, SpO2 93% RA, ambulatory SpO2 90% RA. Faint end-expiratory wheeze. Assessment/Plan: 1. COPD exacerbation - improving. Space DuoNeb to q6h. Prednisone day 3/5. No home O2 need on ambulatory testing. 2. Tobacco dependence - on patch, wants to try varenicline. 3. HTN, HLD, depression - stable.

DISCHARGE SUMMARY Admit: 09/16/2026 Discharge: 09/19/2026 Disposition: Home DISCHARGE DIAGNOSES: 1. COPD with acute exacerbation 2. Nicotine dependence, cigarettes 3. Hypertension 4. Hyperlipidemia 5. Depression HOSPITAL COURSE: Admitted with COPD exacerbation. Acute respiratory failure was questioned in the ED; on admission he was not in respiratory failure (SpO2 92% RA, normal work of breathing, reassuring ABG). Improved with steroids, bronchodilators and azithromycin. Room air throughout after the ED. Started varenicline. DISCHARGE MEDICATIONS: prednisone 40 mg x2 more days; varenicline starter pack; nicotine patch 21 mg; home inhalers (fluticasone/vilanterol, tiotropium, albuterol), amlodipine, atorvastatin, sertraline unchanged. FOLLOW-UP: PCP 1 week; pulmonary rehab referral.