MDM - Pneumonia (Admit)

[##]-year-old [male/female] with history and exam consistent with [viral/atypical/community-acquired] pneumonia.

Initial consideration in this patient included pneumonia, bronchitis, influenza, upper respiratory infections (URI), malignancy, atelectasis, tuberculosis, pulmonary embolism (PE), diffuse alveolar hemorrhage, and cardiac etiologies among others. 

Patient presented with [fever, productive cough, abnormal lung sounds] concerning for pneumonia.  A chest x-ray was obtained in the evaluation of this patient and was notable for [right/left/upper/middle/bilateral/multifocal consolidation(s) with/without associated effusion].  Labs were obtained and were notable for [leukocytosis with a leftward shift/etc.].  Patient was noted to have evidence of [fever/tachycardia/tachypnea/etc.] on presentation [with/without significant improvement] after treatment with [IV fluids/anti-pyretics/antibiotics].  Patient felt to [not] have evidence of [sepsis/septic shock] based on [relevant abnormalities].  Blood cultures were obtained due to planned admission for pneumonia. 

Patient felt to be low risk for PE based on history, exam, and absence of significant risk factors.  No significant risk factors to suggest cardiac etiology for symptoms.

Patient noted to have [no] recent antibiotic use.  Patient noted to have [no] recent admission to a hospital or residence in a nursing home.  Hospital-acquired pneumonia felt to be [likely/unlikely] in this patient.

Patient felt to not be appropriate for outpatient treatment of pneumonia based on [evidence of sepsis, absence of good social support and moderate/high risk CURB-65 score as noted above].  Antibiotics were selected based on [facility antibiogram/professional guidelines/to cover for community-acquired/healthcare-associated and atypical pathogens] and initiated in the ED.

We discussed planned admission with the patient who demonstrates understanding and agreement with this plan.  We discussed case with Dr. [NAME] who evaluated the patient and agrees with need for admission to [general floor/telemetry unit/step-down unit/ICU].

https://www.mdcalc.com/curb-65-score-pneumonia-severity
https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap

https://wikem.org/wiki/Pneumonia_(main)

MDM - Pneumonia (Discharge)

[##]-year-old [male/female] with history and exam consistent with [viral/atypical/community-acquired] pneumonia.

Initial consideration in this patient included pneumonia, bronchitis, influenza, upper respiratory infections (URI), malignancy, atelectasis, tuberculosis, pulmonary embolism (PE), diffuse alveolar hemorrhage, and cardiac etiologies among others. 

Patient presented with [fever, productive cough, abnormal lung sounds] concerning for pneumonia.  A chest x-ray was obtained in the evaluation of this patient and was notable for [right/left/upper/middle/bilateral/multifocal consolidation(s) with/without associated effusion].  Patient was noted to have evidence of [fever/tachycardia/tachypnea/etc.] on presentation with noted [improvement/resolution] after treatment with [IV fluids/anti-pyretics/antibiotics].  Doubt sepsis or significant systemic infection at this time.  Patient felt to be low risk for PE based on history, exam, and absence of significant risk factors.  No significant risk factors to suggest cardiac etiology for symptoms.

Patient noted to have [no] recent antibiotic use.  Patient noted to have [no] recent admission to a hospital or residence in a nursing home.  Hospital-acquired pneumonia felt to be [likely/unlikely] in this patient.  Patient reported good social support, and access to follow up medical care.  Patient felt to be appropriate for outpatient treatment based on [overall stable appearance, response to treatment, and low risk CURB-65 score as noted above].  Antibiotics were selected based on [facility antibiogram/professional guidelines/to cover for community-acquired/healthcare-associated and atypical pathogens].

Prior to discharge, we discussed return precautions, specifically for evidence of persistent or worsening infection, treatment with appropriate antibiotics [0bronchodilators/anti-pyretics], and 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.

https://www.mdcalc.com/curb-65-score-pneumonia-severity
https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap
https://wikem.org/wiki/Pneumonia_(main)

Decision Rule - CURB-65 Score

CURB-65 Score for Pneumonia:

-Confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

-BUN >19 mg/dL (>7 mmol/L) . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

-Respiratory rate >30 bpm . . . . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

-Systolic BP <90 mmHg or diastolic BP ≤60 mmHg  . .  [No (+0 points)/Yes (+1 point)]

-Age ≥65  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

TOTAL = [## points]

Patient is determined to be low risk (0-1 points) with a 1.5% mortality, and recommendation for close outpatient care.

Patient is determined to be moderate risk (2 points) with a mortality of 9.2%, and recommendation for inpatient versus observation admission.

Patient is determined to be high risk (≥3 points) with a mortality of 22% and inpatient treatment and consideration of ICU admission is recommended for a score of 4-5.

https://www.mdcalc.com/curb-65-score-pneumonia-severity

MDM - COPD Exacerbation (Admit)

[##]-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 noted to be high risk for failure of outpatient management based on [Ottawa COPD Score as noted above/failure to significantly improve with treatment in the ED].  Antibiotics were felt to be indicated in the setting of [moderate/severe] exacerbation requiring admission.

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 planned admission with the patient who demonstrates understanding and agreement with this plan.  We discussed case with Dr. [NAME] who evaluated the patient and agrees with need for admission to [general floor/telemetry unit/step-down unit/ICU].

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/

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/

Decision Rule - Ottawa COPD Score

Ottawa COPD Score

History

-Coronary bypass graft . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]

-Intervention for peripheral vascular disease  . . . . . . .  [No (0 points)/Yes (+1 point)]

-Any history of intubation for respiratory distress  . . .  [No (0 points)/Yes (+2 points)]

Examination

-Heart rate ≥110 beats/minute on arrival  . . . . . . . . . . .  [No (0 points)/Yes (+2 points)]

-To ill to do walk test after treatment in ED   . . . . . . . .  [No (0 points)/Yes (+2 points)]

(Saturation <90% or HR ≥120/min after 3 minute walk test)

Investigations

-Acute ischemic changes on EKG . . . . . . . . . . . . . . . . . .   [No (0 points)/Yes (+2 points)]

-Pulmonary congestion on chest x-ray  . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]

-Hemoglobin <10 g/dL (100 g/L)  . . . . . . . . . . . . . . . . . .  [No (0 points)/Yes (+3 points)]

-BUN ≥34 mg/dL (Urea ≥12 mmol/L) . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]

-Serum ≥CO₂ 35 mEq/L (35 mmol/L)  . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]

TOTAL Score = [## points]

[Score 0] Patient deemed to be low risk for adverse events in the next 30 days based on the Ottawa COPD Risk scale consistent with a 2.2% risk.

[Score 1-2] Patient deemed to be medium risk for adverse events in the next 30 days based on the Ottawa COPD Risk scale consistent with a 4.0-7.2% risk.  We discussed this risk with the patient after noting significant improvement in symptoms prior to discharge.  Admission was considered and discussed with the patient, who preferred discharge home with close follow up.  Patient noted to have access to close follow up care, and demonstrated understanding of risk, return precautions, and follow up care.

[Score 3-7] Patient deemed to be high risk for adverse events in the next 30 days based on the Ottawa COPD Risk scale consistent with a [12.5/20.9/32.9/47.5/62.6]% risk.  We discussed this risk with the patient and recommended admission for further treatment.

MDM - Asthma Exacerbation (Discharge)

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

Initial consideration in this patient included exacerbation of asthma, acute bronchitis, pneumonia, influenza, COPD 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 asthma 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/was not] obtained [and noted to have no evidence of consolidations suggestive of pneumonia or other acute abnormality/due to absence of abnormal lung sounds or other evidence suggestive of pneumonia or other acute intrathoracic pathology]. 

[A peak expiratory flow rate (PEFR) was measured in this patient at presentation, and was noted to be [##]% of predicted.]  Treatment was initiated with nebulized bronchodilators (albuterol and ipratropium) and [oral/intravenous] corticostreroids.  Patient was noted to have [significant improvement with this treatment/persistent symptoms which prompted further treatment with intravenous magnesium sulfate/terbutaline/epinephrine/heliox.  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 high likelihood of successful outpatient management].

We discussed return precautions, specifically for evidence of worsening or persistent asthma symptoms or difficulty breathing, treatment with [bronchodilators/steroids], 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/estimated-expected-peak-expiratory-flow-peak-flow#next-steps

https://emcrit.org/emcrit/severe-asthmatic/

https://emcrit.org/ibcc/asthma/

MDM - Acute Bronchitis

[##]-year-old [male/female] with history and exam consistent with acute bronchitis of likely [viral/bacterial] etiology.

Initial consideration in this patient included bronchitis, pneumonia, influenza, allergic rhinitis, upper respiratory infections (URI), pulmonary embolism (PE), and reactive airway diseases (asthma, chronic bronchitis) among others. 

Patient presented with cough [productive of sputum] and [reported/evidence of] wheezing consistent with bronchitis.  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/was not] obtained [and noted to have no evidence of consolidations suggestive of pneumonia or other acute abnormality/due to absence of abnormal lung sounds or other evidence suggestive of pneumonia or other acute intrathoracic pathology].  The patient [reported/denied] a history of obstructive lung disease (asthma or COPD).  Patient [reported/denied] a history of 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].  Patient noted to have [mild/some/significant] improvement after treatment with [specify] in the ED prior to discharge.

We discussed return precautions, specifically for evidence of worsening difficulty breathing, treatment with [bronchodilators/steroids], and 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.