MDM - COPD Exacerbation (Discharge)

[##]-year-old [male/female] with history and exam consistent with acute exacerbation of COPD.

Initial consideration in this patient included exacerbation of COPD, acute decompensated heart failure, acute coronary syndrome (ACS), acute bronchitis, pneumonia, influenza, asthma exacerbation, allergic rhinitis, upper respiratory infections (URI), foreign body airway obstruction, pulmonary embolism (PE) among others. 

Patient presented for [cough/shortness of breath/wheezing] with a known history of COPD consistent with acute exacerbation.  Patient’s lung sounds were [notable for expiratory wheezing/noted to be normal].  Patient noted to [have/have no] evidence of fever [or other systemic infectious symptoms].  A chest x-ray was obtained [and noted to have no evidence of consolidations suggestive of pneumonia or other acute abnormality/specify findings].  An EKG was obtained and [noted to have no evidence of acute abnormalities/notable for atrial fibrillation without rapid ventricular rate/multifocal atrial tachycardia/notable for chronic findings consistent with COPD].

Treatment was initiated with nebulized bronchodilators (albuterol and ipratropium) and [oral/intravenous] corticosteroids.  Patient was noted to have [significant improvement with this treatment/persistent symptoms which prompted further treatment with intravenous magnesium sulfate.  The patient was ultimately noted to have significant respiratory distress requiring initiation of non-invasive positive pressure ventilation (NIPPV).]  [The patient was noted to have a measured peak expiratory flow rate (PEFR) of [##]% predicted after treatment in the ED consistent with mild/moderate/severe/very severe COPD.]  Acute decompensated heart failure was felt to be a less likely cause of the patient’s symptoms given [absence of evidence of significant pulmonary congestion, peripheral edema, or other findings suggestive of volume overload and an unremarkable brain natriuretic peptide (BNP)].  Patient was felt to be appropriate for outpatient management based on [Ottawa COPD Score as noted above/significant improvement with treatment in the ED].  Antibiotics were [felt to be indicated given the presence of all three cardinal symptoms (increased dyspnea, increased sputum volume, and increased sputum purulence)/presence of two cardinal symptoms if increased sputum purulence is present/given severe exacerbation requiring non-invasive mechanical ventilation].

The patient [reported/denied] current tobacco use [and we discussed smoking cessation prior to discharge with the patient noted to be pre-contemplative/contemplative/expressing desire to quit at this time].

We discussed return precautions, specifically for evidence of worsening or persistent asthma symptoms or difficulty breathing, treatment with [bronchodilators/steroids/antibiotics], and close follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.  Prior to discharge we ensured that the patient had refills of all asthma control and rescue medications.

https://www.mdcalc.com/ottawa-copd-risk-scale#evidence
https://rebelem.com/rebel-core-cast-3-0-asthma-copd-pna/
https://www.mdcalc.com/global-initiative-obstructive-lung-disease-gold-criteria-copd
https://litfl.com/ecg-in-chronic-obstructive-pulmonary-disease/