DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with a history of restrictive lung disease and a recent productive cough. She recently finished a dose of methylprednisolone. She presents today short of breath. Initial pulse ox was 69% on room air. She decompensated rapidly and additional review of systems was obtained from her husband.
He states she has been short of breath, worsening over the past few weeks. She has been seen on an outpatient basis by Dr. John Doe, her pulmonologist. She was recently on an antibiotic course of azithromycin as well as an additional antibiotic, that he cannot remember the name of, as an outpatient. He states she did improve some, but over last few days, she has been much worse.
This morning, he noticed that she has been having a lot of shortness of breath and had been falling asleep very easily, and he decided to bring her into the hospital.
REVIEW OF SYSTEMS: A complete review of systems was obtained, negative unless otherwise specified above.
PAST MEDICAL HISTORY:
1. Restrictive lung disease.
2. Scoliosis.
3. Pneumonia.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Negative for tobacco. Negative for alcohol. She does not live alone. She occasionally needs help with activities of daily living and her husband assists her, but not normally.
PHYSICAL EXAMINATION:
VITAL SIGNS: On initial evaluation, GCS was 14. The patient’s pulse ox was 69% on room air. She was immediately placed on a non-rebreather and then bagged and intubated. Temperature afebrile. Respiratory rate on initial evaluation about 36.2, pulse about 14, and blood pressure 178/80.
GENERAL APPEARANCE: The patient is a well-developed female, using accessory respiratory muscles, with significant shortness of breath and distress.
PSYCH: She is unable to complete full sentences.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular motions are grossly intact. Dry mucous membranes.
SKIN: Pale, diaphoretic, cyanotic.
NECK: Supple. Positive accessory respiratory muscle use.
HEART: Regular S1, S2. Positive tachycardia.
LUNGS: Diffusely wheezy and rhonchorous throughout all lung fields moving minimal air.
ABDOMEN: No rebound, guarding, rigidity. Difficult to assess secondary to patient’s intubation and sedation status, but no areas of ecchymosis or distention. Positive bowel sounds.
EXTREMITIES: Cool, cyanotic, diaphoretic, 1+ pulses upper and lower extremities.
DIAGNOSTIC AND LABORATORY STUDIES: BMP reveals a chloride of 88, CO2 greater than 44, glucose 178, otherwise within normal limits. Blood cultures x2 pending. ABG reveals a pH of 7.36, within normal limits. PCO2 of 283.6, PO2 of 54, HCO3 of 46.2. Base excess of 17.4. CK-MB 1.9. Troponin less than 0.015. WBC elevated at 12.2, hemoglobin 11.4, hematocrit 40.5, and platelet count 244. Lactic acid 1.4. An EKG shows a sinus rhythm at a rate of 72 beats per minute with peaked T-waves. A repeat EKG done approximately 30 minutes later showed less peaked T-waves. A chest x-ray showed scoliosis with interstitial infiltrates as well as an infiltrate in the right upper lobe. The ET tube was in place about 3 cm to 4 cm above the carina, and the OG tube was in place below the diaphragm. The BNP was only 338. GFR greater than 60.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. She was immediately placed on a non-rebreather on initial evaluation, and then, as she rapidly declined, she was bagged with adequate ventilation. Her O2 saturation was brought to 99-100% while being bagged. The patient was intubated using rapid sequence intubation. Etomidate 30 mg IVP and succinylcholine 100 mg IVP were administered.
A MAC 4 was utilized with a size 8 ET tube. Vocal cords were visualized. The tube was placed through the vocal cords. Bilateral breath sounds were auscultated. There was inadequate CO2 change in color as well as inadequate CO2 waveform. The patient was placed on a vent AC FiO2 100%, rate of 12, PEEP of 5, tidal volume 500. The patient subsequently required a decrease in tidal volume and increase in respiratory rate to 18, as her CO2 was significantly elevated, and she was having an increase in airway pressures; therefore, the tidal volume was decreased.
The EKGs were obtained showing peak T-waves, and as the T-waves were peaked, a repeat EKG was completed. Aerosolized, DuoNeb treatments were given through the ET tube by Respiratory who managed her care throughout the ED course. The patient was placed on Levaquin 750 mg IVPB for this right upper lobe pneumonia. CT of the head revealed no acute intracranial abnormality, possible sphenoid sinusitis. CT of the chest was pending.
The patient was given Solu-Medrol 125 mg IVP for the COPD exacerbation. The ICU was consulted and agreeable to see the patient and admit the patient to the medical ICU for respiratory failure and pneumonia under the service of Dr. Jane Doe. The patient did tolerate all procedures well, as well as the labs, without any complications. She did require sedation with propofol after being intubated as she was having some coughing and gagging with the tube. The patient’s care was discussed with her husband, and he was agreeable to her plan of care and agreeable to her being admitted to the ICU.
FINAL DIAGNOSES:
1. Acute respiratory failure secondary to chronic obstructive pulmonary disease/restrictive lung disease exacerbation.
2. Pneumonia, likely community acquired.
PLAN: To admit the patient to the medical ICU under the care of Dr. Jane Doe for further treatment.
CONDITION ON ADMISSION: Stable.
