Review Test Submission: Chapter 10 Review – 2021 ...
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Review Test Submission: Chapter 10 Review
Review Test Submission: Chapter 10 Review
User
Course 2021 Certified Documentation Expert Inpatient (CDEI ) - #AAPC
Test Chapter 10 Review
Started 1/6/22 10:57 AM
Submitted 1/6/22 11:48 AM
Status Completed
Attempt Score 94.66666 out of 100 points
Time Elapsed 50 minutes out of 2 hours
Results Displayed Submitted Answers, Correct Answers, Feedback
Question 1 5 out of 5 points
Case 7:
History and Physical Examination
Albert Smith
DOB: 4/15/19XX
Admit Date: 07/04/20XX
CHIEF COMPLAINT: Progressive shortness of breath over the 1 week prior to admission in this patient with
known longstanding underlying COPD.
This patient was seen and examined in the emergency room. History was mainly obtained from the patient
himself and there is a friend at the bedside as well who helps, and the history is a little bit limited as he is
on BiPAP, so it is difficult to understand him through the mask.
HISTORY OF PRESENT ILLNESS: This patient is a 74-year-old male patient with known COPD with a
baseline FEV1 of 0.9 which was done in 20XX and on chronic oxygen who presents complaining of
progressive shortness of breath over the last week. On presentation to the ER, he was noted to be in
severe distress, tripoding, using all accessory muscles. He, however, did improve after being placed on
BiPAP with 2 continuous nebulized albuterol treatments. He is now able to talk in short sentences without
significant dyspnea. He remains on the BiPAP, however. He notes he does use his oxygen continuously at
2-4 L/minute. Sounds like he was overusing Ativan for anxiety and was going through prescriptions
quickly. He follows with Dr. Jones. He did not renew the last prescription since he felt he was overusing it
and he felt increased anxiety and difficulty sleeping. Felt like he had some withdrawal symptoms, became
progressively short of breath. Over the last couple of days, he has coughed up a few hard rubbery things
from the back of his throat but otherwise had no significant cough. He denies any pleuritic chest pain or
hemoptysis. He has no history of DVT or pulmonary embolism. He has had no fever or chills. No recent
sick contacts. No recent travel. No swelling of his legs recently.
ALLERGIES: He has no known drug allergies.
PRIMARY DOCTOR: Dr. Jones.
PAST MEDICAL HISTORY: Significant for longstanding tobacco use in the past. He also has history of
,Review Test Submission: Chapter 10 Review – 2021 ...
severe COPD. On his last FEV1, he had severe diffusion changes and FEV1 of 0.9. He required up to 6
L/minute with ambulation to maintain saturations around 87%. He did see Dr. Thompson a few times in
the past, his last was in 20XX. He has been maintained using oxygen regularly and has not gone back.
HOME MEDICATIONS: Ativan which he was overusing and was stopped about a week ago. He was placed
on citalopram 20 mg daily for anxiety symptoms; albuterol 2 puffs, he says he had been using it twice a
day but up to 4 times a day more recently; Spiriva 1 inhalation daily; and oxygen 4 L/minute. Denies other
over-the-counter herbal medicines.
SOCIAL HISTORIES: He lives alone. He has lived locally for a long time. He has a brother in another state,
but no other local family. He is a retired business owner. He has had a couple of businesses in the past. He
does have a home nurse visiting twice a week. He did smoke on and off since age 13. He quit about 15
years ago.
FAMILY HISTORY: Significant for father who died of COPD at around age 100. His mother died at age 78
of unknown causes. Brother lives in another state, he is older. He denies other medical problems. No
family history of cancer, DVT, or pulmonary embolism.
REVIEW OF SYSTEMS: Constitutional: Denies unexplained fevers or sweats. His baseline ambulation, he has
about 60 feet at its best, had been down to about 30 feet over the last week or so. HEENT: Denies sore
throat, sinus pressure, postnasal drip. Respiratory: Again, please refer to the HPI. Cardiovascular: Denies
any chest pain with exertion, palpitations, heart racing, or syncope. GI: Denies any change in bowel
movements, GERD, or constipation. GU: Denies any dysuria, hematuria. Neurologic: He denies any
recurrent headaches, stroke, or seizure symptoms.
PHYSICAL EXAMINATION: Vital Signs: 02 92% on 4L; resp rate 20; blood pressure 127/76; pulse initially
122, since come down. Is saturating well. He is afebrile in the ER. General: This time, he is able to converse
with short sentences due to the BiPAP. He has mild accessory use. He has severe cachexia, has particularly
supraclavicular cachexia. Chest: No obvious axillary lymphadenopathy. Lung fields reveal diffusely
decreased breath sounds with very little air movement throughout, so I think this is his baseline, some
wheezing noted bilaterally. Cardiovascular: He is mildly tachycardic. He has a regular rate and rhythm.
Distant heart sounds. Abdomen: Soft, non-tender without guarding or rebound. GU: There are normal
femoral pulses without bruits. No inguinal lymphadenopathy. Extremities: No obvious peripheral edema.
Skin: No obvious findings.
PAST SURGICAL HISTORY: A prior appendectomy in the past and he had a skin graft to his left lower
extremity that he cannot remember the cause of.
LABORATORY EXAMINATION: Initial troponin of 0.043. BUN and creatinine are 16 and 1.0 respectively.
Sodium 137, potassium 4.3. His initial pH on the ABG was 7.24, CO2 of 73, bicarb of 30. White count of
15.5 with 83 segs, 11 lymphs, 6 monos. Hemoglobin 14.5, platelet count of 306. BNP of 59. Chest X-ray
does not show any acute infiltrates. EKG: Normal sinus rhythm. No ST/T changes.
Chest X-ray did not show any acute infiltrates or disease, just underlying chronic obstructive pulmonary
disease. Initial arterial blood gas showed a hydrogen ion concentration of 7.24 with a partial pressure of
carbon dioxide of 73, bicarbonate of 30.2. Urinalysis shows trace protein, some red blood cells, although
there was a traumatic Foley insertion and some white blood cells. Urine culture is pending.
IMPRESSION:
1- Chronic obstructive pulmonary disease exacerbation and acute respiratory failure in this patient with
severe underlying chronic obstructive pulmonary disease, markedly reduced FEV1. Again, the patient has
improved with BiPAP and continuous nebulizer treatments in the ER. We will admit to the intensive care
unit on albuterol and Atrovent nebs. We will use Solu-Medrol 60 mg q. 8 h. Start Rocephin and Zithromax,
he has received doses in the ER. Cachexic. We will continue to follow clinically. I did discuss the patient’s
code status. He does not wish to be intubated even if it means he does not leave the hospital, he is aware
of this and is competent to make his own wishes. A do not intubate order was written. In addition, we will
check a 2D Doppler to evaluate his right-sided heart pressures and check Doppler ultrasound of the
bilateral lower extremities.
2- Recent withdrawal from Ativan. We will give Ativan as needed here. Continue to monitor clinically for
further withdrawal symptoms.
3- History of longstanding tobacco use, quit. Continue to follow.
4- Borderline elevation of detectable troponin. We will check a repeat EKG and repeat troponin levels in the
morning as well. Again, continue to monitor in ICU.
Progress Notes
,Review Test Submission: Chapter 10 Review – 2021 ...
07/05/20XX @ 0400. Patient with chronic obstructive pulmonary disease exacerbation with acute
respiratory failure. Patient tolerating BiPAP overnight for 20 minutes at a time. SOB better with nebs, no
CP, no fever. Labored breathing, accessory muscle use noted. Cardio: RRR. Lungs: diffusely decreased
breath sounds with very little air movement throughout, wheezing bilaterally. BP 116/68, HR 84, RR 22, O2
94 with 4L, T 98.0
Follow-up blood gas after being on bi-level positive airway pressure for a period of time showed a
hydrogen ion concentration of 7.35, partial pressure of carbon dioxide of 59, partial pressure of oxygen of
91, bicarbonate of 31.7.
EKG: Normal sinus rhythm. No ST/T changes. Repeat troponin wnl. Bilat LE doppler negative for clots.
Echocardiogram:
1- Severely technically limited study
2- Grossly normal left ventricular size and function
3- Small hemodynamically insignificant pericardial effusion
4-Right ventricular enlargement with preserved function
5- Pulmonary hypertension
6-Right atrial enlargement
Plan: COPD exacerbation and acute respiratory failure - continue Solu-Medrol 60 mg q. 8 h., Rocephin
and Zithromax, albuterol and Atrovent nebs prn. Try to wean off BiPAP.
07/06/20XX @ 1230. Patient off BiPAP for respiratory distress. Only minimal SOB, which improves with
nebs, no CP, no fever. Somewhat labored breathing with accessory muscle use noted. Cardio: RRR. Lungs:
wheezing, diffusely decreased breath sounds with very little air movement throughout. Patient reports he
is feeling anxious and complains of poor sleep.
BP 108/66, HR 89, RR 20, O2 93 with 4L, T 98.1
Plan: COPD exacerbation - continue O2, albuterol and Atrovent nebulizers, Solu-Medrol 60 mg q. 8 h.,
Rocephin and Zithromax; Ativan prn for anxiety. Ambien prn for insomnia.
07/07/20XX. Mainly nodding yes or shaking head no in response to questions. Denies pain. Likes Ambien,
reports improved sleep. Does feel like Roxanol helps. Mouth feeling dry. No pain. Breathing feels better.
no CP, no fever. Cardio: RRR. Lungs: decreased breath sounds throughout, wheezing improved. Abdomen
soft and + bowel sounds. Cachectic.
BP 104/62, HR 85, RR 24, O2 94 with 4L, T 98
Plan: COPD exacerbation - continue O2, albuterol and Atrovent nebulizers prn. Solu-Medrol 60 mg q. 8 h.,
Rocephin and Zithromax; Ativan prn for anxiety. Ambien prn for insomnia. Roxanol prn for pain/air
hunger.
07/08/20XX @ 1120: Breathing feels better, able to verbalize this today. Negative CP, some wheezing, no
belly pain. Lying supine, access muscle use noted, tachypnea. Lungs: decreased breath sounds with some
wheezing. End-stage COPD admitted with exacerbation overall doing much better on 2L O2. Urine culture
shows no growth to date.
BP 98/59, HR 89, RR 22, O2 93 with 2L
Plan: COPD exacerbation - continue albuterol and Atrovent nebulizers as needed, Solu-Medrol, Rocephin,
and Zithromax; Ativan prn for anxiety. Ambien prn for insomnia. Roxanol prn for pain/air hunger. PT to
assess.
07/09/20XX @ 1030. Chart reviewed, patient seen by PT. Feeling better, eating more. Up to chair today,
wants to try walking this afternoon. Afebrile. Pursed lip breathing, access muscle use noted. Card: RRR,
distant. Lungs: decreased breath sounds with some wheezing. Abdomen non-tender. Significant CO2
retention.
BP 102/61, HR 81, RR 20, O2 94 with 2L
Plan: COPD exacerbation - continue O2, nebs, Solu-Medrol, Rocephin, and Zithromax; PT to work with
patient on mobility issues. Ativan prn for anxiety. Ambien prn for insomnia. Roxanol prn for pain/air
hunger.
07/10/20XX @ 0740. Patient remained stable/comfortable, no new problems. No edema. Up to chair
today but refused to work with PT any further. Afebrile. Card: RRR, distant. Lungs: decreased breath
sounds. Abdomen non-tender. Cachectic.
BP 100/60, HR 85, RR 20, O2 95 with 2L
, Review Test Submission: Chapter 10 Review – 2021 ...
Plan: COPD exacerbation - continue nebs, Solu-Medrol, Rocephin, and Zithromax; continue PT. Ativan prn
for anxiety. Ambien prn for insomnia. Plans for transfer later today.
07/11/20XX @ 0800. The patient’s friends and the patient himself were refusing to be discharged to
extended care facility yesterday. They were stating that he was independent prior to his admission here
and he needed more time with physical therapy to get better. SOB better with nebs, no CP, no fever. BP
106/60, HR 84, RR 20, O2 96 with 2L, T 98. Labored breathing. Cardio: RRR. Lungs decreased breath
sounds, wheezing improved. 07/11/20XX @ 1110. Patient still wants a ―couple more days‖ in the hospital.
Explained that everything we are doing here can be done at the extended care facility.
Plan: We will postpone discharge and discuss the case with the home health nurse who will visit the
patient. COPD exacerbation - continue O2, albuterol and Atrovent nebulizers, Solu-Medrol, Rocephin, and
Zithromax; continue PT. Ativan prn for anxiety. Ambien prn for insomnia. Plan for transfer tomorrow.
07/12/20XX @ 0800. No fevers/chills, no cough, no CP, SOB stable. 98/58, 88,18, 94% with 2L, T: 98.
Cardio: RRR. Lungs: decreased breath sounds. WBC down to 10.8. Pt walked down hall with PT assistance.
Plan for transfer today.
Discharge Summary
PRINCIPAL DIAGNOSIS: End-stage chronic obstructive pulmonary disease with hypercapnic respiratory
failure requiring bi-level positive airway pressure.
SECONDARY DIAGNOSES:
1-Recent Ativan withdrawal
2-Anxiety
3- History of longstanding tobacco use
4- Borderline elevation in troponin, currently improved
5- Moderate pulmonary hypertension on echocardiogram
6- Cachexia
7-No intubation, allow natural death status
PROCEDURES: Initial blood work which included a white blood cell count of 15.5 on admit, currently 10.8
on discharge. Chest X-ray did not show any acute infiltrates or disease, just underlying chronic obstructive
pulmonary disease. Initial arterial blood gas showed a hydrogen ion concentration of 7.24 with a partial
pressure of carbon dioxide of 73, bicarbonate of 30.2. Follow-up blood gas after being on bi-level positive
airway pressure for a period of time showed a hydrogen ion concentration of 7.35, partial pressure of
carbon dioxide of 59, partial pressure of oxygen of 91, bicarbonate of 31.7. Troponin peak was 0.043 on
admit with subsequent decline. B-type natriuretic peptide maximum was 125 and was last 29. Urinalysis did
show trace protein, some red blood cells, although there was a traumatic Foley insertion and some white
blood cells. A urine culture, however, was without growth.
The patient was admitted to intensive care unit with frequent albuterol and Atrovent nebulizers, bi-level
positive airway pressure, intravenous Soul-Medrol. Was started on Rocephin and Zithromax. Received
Ativan for anxiety as well as some morphine as well as physical therapy. The patient’s respiratory status has
somewhat stabilized. He is very end-stage unfortunately. We did have some discussion of going home
with hospice versus extended care facility and unfortunately, I do not think he is a candidate to go home
on hospice at this time as there are no options for 24-hour care there. We will plan to discharge to go to
an extended-care facility for ongoing care mainly directed at comfort care. In discussion with the patient,
he does not wish to have heroic measure. Does not want to be intubated. He remains a no intubation,
allow natural death status at this time. He will be discharged in stable but terminal condition to go to the
extended-care facility for comfort directed care.
DISCHARGE MEDICATIONS: He will go on Omnicef 300 mg twice a day for the next 4 days; prednisone
taper, 40 mg for 3 days, 30 for 3 days, 20 for 3 days, 10 for 3, and then continue with 5 mg daily tablet for
re-evaluation with his primary care doctor for ongoing use. He will go on Xopenex nebulizers every 4
hours and every 2 hours as needed, lactobacillus over the counter 3 times a day while on the antibiotic,
Ativan 1 mg every 6 hours as needed for anxiety, Remeron 15 mg daily, Roxanol 20 mg/cc give 0.5 to 1 cc
every hour as needed of air hunger, Ambien 5 mg at bedtime as needed for sleep, Spiriva 1 puff daily,
Pepcid 20 mg daily, Colace 100 mg twice a day.
DISCHARGE INSTRUCTIONS: Recommend avoiding excessive oxygen use as it may suppress hypoxic
respiratory drive. He should call or return to emergency room for temperature over 101, worsening
shortness of breath, chest pain, progressive leg swelling, or other problems. He can have a regular diet.
My Courses
Tammie Thomas Global Menu
Review Test Submission: Chapter 10 Review
Review Test Submission: Chapter 10 Review
User
Course 2021 Certified Documentation Expert Inpatient (CDEI ) - #AAPC
Test Chapter 10 Review
Started 1/6/22 10:57 AM
Submitted 1/6/22 11:48 AM
Status Completed
Attempt Score 94.66666 out of 100 points
Time Elapsed 50 minutes out of 2 hours
Results Displayed Submitted Answers, Correct Answers, Feedback
Question 1 5 out of 5 points
Case 7:
History and Physical Examination
Albert Smith
DOB: 4/15/19XX
Admit Date: 07/04/20XX
CHIEF COMPLAINT: Progressive shortness of breath over the 1 week prior to admission in this patient with
known longstanding underlying COPD.
This patient was seen and examined in the emergency room. History was mainly obtained from the patient
himself and there is a friend at the bedside as well who helps, and the history is a little bit limited as he is
on BiPAP, so it is difficult to understand him through the mask.
HISTORY OF PRESENT ILLNESS: This patient is a 74-year-old male patient with known COPD with a
baseline FEV1 of 0.9 which was done in 20XX and on chronic oxygen who presents complaining of
progressive shortness of breath over the last week. On presentation to the ER, he was noted to be in
severe distress, tripoding, using all accessory muscles. He, however, did improve after being placed on
BiPAP with 2 continuous nebulized albuterol treatments. He is now able to talk in short sentences without
significant dyspnea. He remains on the BiPAP, however. He notes he does use his oxygen continuously at
2-4 L/minute. Sounds like he was overusing Ativan for anxiety and was going through prescriptions
quickly. He follows with Dr. Jones. He did not renew the last prescription since he felt he was overusing it
and he felt increased anxiety and difficulty sleeping. Felt like he had some withdrawal symptoms, became
progressively short of breath. Over the last couple of days, he has coughed up a few hard rubbery things
from the back of his throat but otherwise had no significant cough. He denies any pleuritic chest pain or
hemoptysis. He has no history of DVT or pulmonary embolism. He has had no fever or chills. No recent
sick contacts. No recent travel. No swelling of his legs recently.
ALLERGIES: He has no known drug allergies.
PRIMARY DOCTOR: Dr. Jones.
PAST MEDICAL HISTORY: Significant for longstanding tobacco use in the past. He also has history of
,Review Test Submission: Chapter 10 Review – 2021 ...
severe COPD. On his last FEV1, he had severe diffusion changes and FEV1 of 0.9. He required up to 6
L/minute with ambulation to maintain saturations around 87%. He did see Dr. Thompson a few times in
the past, his last was in 20XX. He has been maintained using oxygen regularly and has not gone back.
HOME MEDICATIONS: Ativan which he was overusing and was stopped about a week ago. He was placed
on citalopram 20 mg daily for anxiety symptoms; albuterol 2 puffs, he says he had been using it twice a
day but up to 4 times a day more recently; Spiriva 1 inhalation daily; and oxygen 4 L/minute. Denies other
over-the-counter herbal medicines.
SOCIAL HISTORIES: He lives alone. He has lived locally for a long time. He has a brother in another state,
but no other local family. He is a retired business owner. He has had a couple of businesses in the past. He
does have a home nurse visiting twice a week. He did smoke on and off since age 13. He quit about 15
years ago.
FAMILY HISTORY: Significant for father who died of COPD at around age 100. His mother died at age 78
of unknown causes. Brother lives in another state, he is older. He denies other medical problems. No
family history of cancer, DVT, or pulmonary embolism.
REVIEW OF SYSTEMS: Constitutional: Denies unexplained fevers or sweats. His baseline ambulation, he has
about 60 feet at its best, had been down to about 30 feet over the last week or so. HEENT: Denies sore
throat, sinus pressure, postnasal drip. Respiratory: Again, please refer to the HPI. Cardiovascular: Denies
any chest pain with exertion, palpitations, heart racing, or syncope. GI: Denies any change in bowel
movements, GERD, or constipation. GU: Denies any dysuria, hematuria. Neurologic: He denies any
recurrent headaches, stroke, or seizure symptoms.
PHYSICAL EXAMINATION: Vital Signs: 02 92% on 4L; resp rate 20; blood pressure 127/76; pulse initially
122, since come down. Is saturating well. He is afebrile in the ER. General: This time, he is able to converse
with short sentences due to the BiPAP. He has mild accessory use. He has severe cachexia, has particularly
supraclavicular cachexia. Chest: No obvious axillary lymphadenopathy. Lung fields reveal diffusely
decreased breath sounds with very little air movement throughout, so I think this is his baseline, some
wheezing noted bilaterally. Cardiovascular: He is mildly tachycardic. He has a regular rate and rhythm.
Distant heart sounds. Abdomen: Soft, non-tender without guarding or rebound. GU: There are normal
femoral pulses without bruits. No inguinal lymphadenopathy. Extremities: No obvious peripheral edema.
Skin: No obvious findings.
PAST SURGICAL HISTORY: A prior appendectomy in the past and he had a skin graft to his left lower
extremity that he cannot remember the cause of.
LABORATORY EXAMINATION: Initial troponin of 0.043. BUN and creatinine are 16 and 1.0 respectively.
Sodium 137, potassium 4.3. His initial pH on the ABG was 7.24, CO2 of 73, bicarb of 30. White count of
15.5 with 83 segs, 11 lymphs, 6 monos. Hemoglobin 14.5, platelet count of 306. BNP of 59. Chest X-ray
does not show any acute infiltrates. EKG: Normal sinus rhythm. No ST/T changes.
Chest X-ray did not show any acute infiltrates or disease, just underlying chronic obstructive pulmonary
disease. Initial arterial blood gas showed a hydrogen ion concentration of 7.24 with a partial pressure of
carbon dioxide of 73, bicarbonate of 30.2. Urinalysis shows trace protein, some red blood cells, although
there was a traumatic Foley insertion and some white blood cells. Urine culture is pending.
IMPRESSION:
1- Chronic obstructive pulmonary disease exacerbation and acute respiratory failure in this patient with
severe underlying chronic obstructive pulmonary disease, markedly reduced FEV1. Again, the patient has
improved with BiPAP and continuous nebulizer treatments in the ER. We will admit to the intensive care
unit on albuterol and Atrovent nebs. We will use Solu-Medrol 60 mg q. 8 h. Start Rocephin and Zithromax,
he has received doses in the ER. Cachexic. We will continue to follow clinically. I did discuss the patient’s
code status. He does not wish to be intubated even if it means he does not leave the hospital, he is aware
of this and is competent to make his own wishes. A do not intubate order was written. In addition, we will
check a 2D Doppler to evaluate his right-sided heart pressures and check Doppler ultrasound of the
bilateral lower extremities.
2- Recent withdrawal from Ativan. We will give Ativan as needed here. Continue to monitor clinically for
further withdrawal symptoms.
3- History of longstanding tobacco use, quit. Continue to follow.
4- Borderline elevation of detectable troponin. We will check a repeat EKG and repeat troponin levels in the
morning as well. Again, continue to monitor in ICU.
Progress Notes
,Review Test Submission: Chapter 10 Review – 2021 ...
07/05/20XX @ 0400. Patient with chronic obstructive pulmonary disease exacerbation with acute
respiratory failure. Patient tolerating BiPAP overnight for 20 minutes at a time. SOB better with nebs, no
CP, no fever. Labored breathing, accessory muscle use noted. Cardio: RRR. Lungs: diffusely decreased
breath sounds with very little air movement throughout, wheezing bilaterally. BP 116/68, HR 84, RR 22, O2
94 with 4L, T 98.0
Follow-up blood gas after being on bi-level positive airway pressure for a period of time showed a
hydrogen ion concentration of 7.35, partial pressure of carbon dioxide of 59, partial pressure of oxygen of
91, bicarbonate of 31.7.
EKG: Normal sinus rhythm. No ST/T changes. Repeat troponin wnl. Bilat LE doppler negative for clots.
Echocardiogram:
1- Severely technically limited study
2- Grossly normal left ventricular size and function
3- Small hemodynamically insignificant pericardial effusion
4-Right ventricular enlargement with preserved function
5- Pulmonary hypertension
6-Right atrial enlargement
Plan: COPD exacerbation and acute respiratory failure - continue Solu-Medrol 60 mg q. 8 h., Rocephin
and Zithromax, albuterol and Atrovent nebs prn. Try to wean off BiPAP.
07/06/20XX @ 1230. Patient off BiPAP for respiratory distress. Only minimal SOB, which improves with
nebs, no CP, no fever. Somewhat labored breathing with accessory muscle use noted. Cardio: RRR. Lungs:
wheezing, diffusely decreased breath sounds with very little air movement throughout. Patient reports he
is feeling anxious and complains of poor sleep.
BP 108/66, HR 89, RR 20, O2 93 with 4L, T 98.1
Plan: COPD exacerbation - continue O2, albuterol and Atrovent nebulizers, Solu-Medrol 60 mg q. 8 h.,
Rocephin and Zithromax; Ativan prn for anxiety. Ambien prn for insomnia.
07/07/20XX. Mainly nodding yes or shaking head no in response to questions. Denies pain. Likes Ambien,
reports improved sleep. Does feel like Roxanol helps. Mouth feeling dry. No pain. Breathing feels better.
no CP, no fever. Cardio: RRR. Lungs: decreased breath sounds throughout, wheezing improved. Abdomen
soft and + bowel sounds. Cachectic.
BP 104/62, HR 85, RR 24, O2 94 with 4L, T 98
Plan: COPD exacerbation - continue O2, albuterol and Atrovent nebulizers prn. Solu-Medrol 60 mg q. 8 h.,
Rocephin and Zithromax; Ativan prn for anxiety. Ambien prn for insomnia. Roxanol prn for pain/air
hunger.
07/08/20XX @ 1120: Breathing feels better, able to verbalize this today. Negative CP, some wheezing, no
belly pain. Lying supine, access muscle use noted, tachypnea. Lungs: decreased breath sounds with some
wheezing. End-stage COPD admitted with exacerbation overall doing much better on 2L O2. Urine culture
shows no growth to date.
BP 98/59, HR 89, RR 22, O2 93 with 2L
Plan: COPD exacerbation - continue albuterol and Atrovent nebulizers as needed, Solu-Medrol, Rocephin,
and Zithromax; Ativan prn for anxiety. Ambien prn for insomnia. Roxanol prn for pain/air hunger. PT to
assess.
07/09/20XX @ 1030. Chart reviewed, patient seen by PT. Feeling better, eating more. Up to chair today,
wants to try walking this afternoon. Afebrile. Pursed lip breathing, access muscle use noted. Card: RRR,
distant. Lungs: decreased breath sounds with some wheezing. Abdomen non-tender. Significant CO2
retention.
BP 102/61, HR 81, RR 20, O2 94 with 2L
Plan: COPD exacerbation - continue O2, nebs, Solu-Medrol, Rocephin, and Zithromax; PT to work with
patient on mobility issues. Ativan prn for anxiety. Ambien prn for insomnia. Roxanol prn for pain/air
hunger.
07/10/20XX @ 0740. Patient remained stable/comfortable, no new problems. No edema. Up to chair
today but refused to work with PT any further. Afebrile. Card: RRR, distant. Lungs: decreased breath
sounds. Abdomen non-tender. Cachectic.
BP 100/60, HR 85, RR 20, O2 95 with 2L
, Review Test Submission: Chapter 10 Review – 2021 ...
Plan: COPD exacerbation - continue nebs, Solu-Medrol, Rocephin, and Zithromax; continue PT. Ativan prn
for anxiety. Ambien prn for insomnia. Plans for transfer later today.
07/11/20XX @ 0800. The patient’s friends and the patient himself were refusing to be discharged to
extended care facility yesterday. They were stating that he was independent prior to his admission here
and he needed more time with physical therapy to get better. SOB better with nebs, no CP, no fever. BP
106/60, HR 84, RR 20, O2 96 with 2L, T 98. Labored breathing. Cardio: RRR. Lungs decreased breath
sounds, wheezing improved. 07/11/20XX @ 1110. Patient still wants a ―couple more days‖ in the hospital.
Explained that everything we are doing here can be done at the extended care facility.
Plan: We will postpone discharge and discuss the case with the home health nurse who will visit the
patient. COPD exacerbation - continue O2, albuterol and Atrovent nebulizers, Solu-Medrol, Rocephin, and
Zithromax; continue PT. Ativan prn for anxiety. Ambien prn for insomnia. Plan for transfer tomorrow.
07/12/20XX @ 0800. No fevers/chills, no cough, no CP, SOB stable. 98/58, 88,18, 94% with 2L, T: 98.
Cardio: RRR. Lungs: decreased breath sounds. WBC down to 10.8. Pt walked down hall with PT assistance.
Plan for transfer today.
Discharge Summary
PRINCIPAL DIAGNOSIS: End-stage chronic obstructive pulmonary disease with hypercapnic respiratory
failure requiring bi-level positive airway pressure.
SECONDARY DIAGNOSES:
1-Recent Ativan withdrawal
2-Anxiety
3- History of longstanding tobacco use
4- Borderline elevation in troponin, currently improved
5- Moderate pulmonary hypertension on echocardiogram
6- Cachexia
7-No intubation, allow natural death status
PROCEDURES: Initial blood work which included a white blood cell count of 15.5 on admit, currently 10.8
on discharge. Chest X-ray did not show any acute infiltrates or disease, just underlying chronic obstructive
pulmonary disease. Initial arterial blood gas showed a hydrogen ion concentration of 7.24 with a partial
pressure of carbon dioxide of 73, bicarbonate of 30.2. Follow-up blood gas after being on bi-level positive
airway pressure for a period of time showed a hydrogen ion concentration of 7.35, partial pressure of
carbon dioxide of 59, partial pressure of oxygen of 91, bicarbonate of 31.7. Troponin peak was 0.043 on
admit with subsequent decline. B-type natriuretic peptide maximum was 125 and was last 29. Urinalysis did
show trace protein, some red blood cells, although there was a traumatic Foley insertion and some white
blood cells. A urine culture, however, was without growth.
The patient was admitted to intensive care unit with frequent albuterol and Atrovent nebulizers, bi-level
positive airway pressure, intravenous Soul-Medrol. Was started on Rocephin and Zithromax. Received
Ativan for anxiety as well as some morphine as well as physical therapy. The patient’s respiratory status has
somewhat stabilized. He is very end-stage unfortunately. We did have some discussion of going home
with hospice versus extended care facility and unfortunately, I do not think he is a candidate to go home
on hospice at this time as there are no options for 24-hour care there. We will plan to discharge to go to
an extended-care facility for ongoing care mainly directed at comfort care. In discussion with the patient,
he does not wish to have heroic measure. Does not want to be intubated. He remains a no intubation,
allow natural death status at this time. He will be discharged in stable but terminal condition to go to the
extended-care facility for comfort directed care.
DISCHARGE MEDICATIONS: He will go on Omnicef 300 mg twice a day for the next 4 days; prednisone
taper, 40 mg for 3 days, 30 for 3 days, 20 for 3 days, 10 for 3, and then continue with 5 mg daily tablet for
re-evaluation with his primary care doctor for ongoing use. He will go on Xopenex nebulizers every 4
hours and every 2 hours as needed, lactobacillus over the counter 3 times a day while on the antibiotic,
Ativan 1 mg every 6 hours as needed for anxiety, Remeron 15 mg daily, Roxanol 20 mg/cc give 0.5 to 1 cc
every hour as needed of air hunger, Ambien 5 mg at bedtime as needed for sleep, Spiriva 1 puff daily,
Pepcid 20 mg daily, Colace 100 mg twice a day.
DISCHARGE INSTRUCTIONS: Recommend avoiding excessive oxygen use as it may suppress hypoxic
respiratory drive. He should call or return to emergency room for temperature over 101, worsening
shortness of breath, chest pain, progressive leg swelling, or other problems. He can have a regular diet.
