CC: SOB

HPI: 62 year old Caucasian male presents with SOB. He states he has been
increasingly short of breath over the past 3 days. He states today his SOB has become
so severe that he can barely walk to the bathroom without gasping for breath. He has
increased cough with sputum production which he states is white. He has history of
COPD and has been taking all of his medications as currently prescribed. He states he
has been admitted to the hospital in the past for breathing trouble and has more
difficulty breathing with the cold weather. He denies any recent fevers, chills or night
sweats. He has not had any chest pain, N/V/D. Denies any sick contacts, no recent
travel and no immobility.
PMHx: COPD, hypertension, GERD, NIDDM, Osteoarthritis
PSHx: Carpal tunnel release (R), appendectomy, cholecystectomy
Allergies: NKDA
Fam Hx: Father DMII, Mother Breast CA
Soc Hx: 80 pack year tobacco use, currently down to 10 cigarettes per day, denies
alcohol or recreational drug use
Medications:
ROS: (+) SOB, productive cough, nasal congestion, denies CP, N/V/D, fevers, chills,
hemoptysis, myalgias, visual changes all other systems have been reviewed and are
negative
PE: VS: T 98.2 BP 124/76 RR18 P 86 02sat 96% on 2L Nasal Cannula
Gen: AAO x 3, NAD, pleasant
Head: NCAT, no infestation or lesions
Eyes: PERRLA, EOMI, no scleral icterus
ENT: No erythema or discharge, MMM
Neck: Supple, no thyromegaly or lymphadenopathy
CV: RRR, no M/R/G +S1S2
Lungs: +Rhonchi BL, Expiratory wheezes BL, prolonged expiratory phase, no use of
accessory muscles
Abdomen: Soft, NT, ND, +BS
Extremities: No edema or cyanosis
Skin: Warm, dry, no lesions
Neuro: CNII-XII intact BL, strength 5/5 throughout upper and lower extremities
LABS: Na: 141 K: 4.7 Cl: 101 HCO3:24 BUN:11 Creatinine: 0.9 Glucose: 188
CBC: WBC: 7.0 Hgb: 14 Hct: 42.4 Plt: 290
Mg 1.9
Ekg: HR: 88, Normal Sinus Rhythm, no ST changes or T waves abnormalities
CXR: Chronic interstitial changes, no focal infiltrate or consolidation, no effusion or
cephalization
Weight 195
Height 510
BMI: 28

A/P:

1. AECOPD- Patient was given 125mg IV solumedrol in the ED, will start on
solumedrol 60mg IV Q8H, will start Duoneb treatments Q4H while awake with Q4H
PRN. Will place on supplemental O2 through nasal cannula, titrate to O2 sat >92.
Patient has deferred blood gas. Admit to medical step down.
2. Lisinopril 10mg daily for hypertension. Also, ACE inhibitors protect diabetes from
renal failure.
2. NIDDM: Patient is currently taking Metformin 500mg BID at home, states his blood
sugars typically run in the 130s to 140s but has had some readings in the 190s at
home recently. Will continue on Metformin but will add sliding scale insulin coverage as I
suspect the steroids will increase his BG. Placed on Carbohydrate constant diet
1800-2200 Cal/day. Accuchecks Q
3. GERD- continue home protonix 40mg PO daily
4. Osteoarthritis- continue home Acetaminophen 650mg PO Q4HP
5. VTE Prophylaxis will place on SubQ heparin 5000u Q12H
iabetes