“Exacerbation of COPD in a 67-Year-Old Male: A Case Study”

Situation:
The patient is Vincent Brody, a 67-year-old male admitted directly from the provider’s office several hours ago for exacerbation of COPD.
Background:
Mr. Brody has a 50-year history of smoking 2 packs a day. During the past year, he has had two exacerbations of COPD. He has no known allergies.
Assessment:
His vital signs at 1100 are: Respiratory rate 18/min. He is maintaining O2 saturations at 92% on oxygen 2 L per nasal cannula. Heart rate is 90 and regular. Blood pressure at 134/82 measured at the right arm. He is alert and oriented times 4. Temperature is 99 °F (37.2 °C) tympanic.
His respiratory status has responded well to nebulizer treatments with albuterol and ipratropium, last administered at 1200. Lung auscultation findings are still wheezing bilaterally, but much improved since admission. He continues to have a productive cough with nonpurulent sputum. He has no pain complaints. Other physical findings include a barrel chest and clubbed fingers. An IV of D5 ½ normal saline with 20 mEq KCl is infusing at 50 mL/hr in his left hand. Labs were drawn at 1100: ABG, BMP, CBC, BNP, and troponin.
Recommendation:
Please continue to monitor vital signs and respiratory assessment every 4 hours. Provider’s orders and labs can be viewed in the chart.
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