Acute Exacerbation of Chronic Obstructive Pulmonary Disease
Age: years old
Gender:
HISTORY:
Presents with a - history of
Symptoms include:
, of phlegm
, up to °, over
,
Alleviating factors: ,
Contributing factors:
no history of: , , ,
no use of: ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: COPD exacerbation, asthma exacerbation, pneumonia, acute bronchitis, viral URI, heart failure, pulmonary embolism, lung cancer, tuberculosis, interstitial lung disease, pulmonary hypertension, medication noncompliance, environmental triggers, anxiety
PLAN:
Investigations:
- Chest X-ray
- Blood work: , , , ,
- Sputum culture
- Pulmonary function tests
Treatments:
- Increase dose of rescue inhaler
- If mild increase shortness of breath, dougle dose of inhaled corticosteroids:
- If moderate increase shortness of breath, add oral corticosteroids:
- If change in sputum color, add antibiotics:
- Oxygen therapy if SpO2 < 90-92%
- Ensure proper inhalation technique and spacer use if necessary
- Smoking cessation counseling
- Immunization: pneumococcal, annual influenza, covid
Further care:
- Referral to pulmonologist
- Follow-up in
- Return sooner if symptoms not better in 72h or if symptoms worsen
- Referral to ER if severe shortness of breath, chest pain, or high fever
HISTORY: EXAM: ASSESSMENT: PLAN: