A 64-year-old white man had been familiar to the respiratory care consult team. He had a history of both chronic bronchitis and emphysema.

ADMITTING HISTORY

A 64-year-old white man had been familiar to the respiratory care consult team. He had a history of both chronic bronchitis and emphysema. Although he had not been hospitalized in more than 2 years, he received extensive care 4 years ago for a left lower lobe pneumonia that compromised his already severe chronic obstructive pulmonary disease (COPD). He was placed on the ventilator for 17 days. His medical record showed that hospital personnel experienced difficulty weaning him from the ventilator for both pathophysiologic and psychologic reasons. Despite this experience, he continued to smoke about 30 cigarettes a day, a habit he started when he joined the Navy at 19 years of age.

Since the episode 4 years ago, however, the patient’s medical history had been essentially unremarkable. As instructed, he scheduled twice-yearly appointments with his doctor. Most of the time, he demonstrated a productive cough and wheezing. The man generally took several medications, including daily dosages of antibiotics as needed for upper respiratory infections, a SABA with an anticholinergic PRN, a combination of LABA plus anticholinergic for maintenance, and an inhaled corticosteroid.

Three or four times a week, for about 30 minutes, the patient also performed a number of breathing exercises that members of the pulmonary rehabilitation team showed him.

He had worked as a custodial engineer for more than 30 years in the local public-school system. At the time of this admission, he was 7 months from his planned retirement. Even though he had suffered from chronic bronchitis and emphysema for many years, he had always been considered a reliable, hardworking employee by the school administration and his fellow workers. Although he often had gone to work feeling less than good, he always had been able to finish the day without major problems. He seldom complained about his health because he did not like to draw attention to himself.

Copyright © 2020 by Elsevier Inc. All rights reserved.

Copyright © 2020 by Elsevier Inc. All rights reserved.

2

About 4 days before the present admission, however, he started to find it difficult to endure an entire workday. He told his wife that he thought he was getting the flu, with symptoms of fatigue, chills, and a cough that was increasing in severity and becoming more productive. He nevertheless continued to go to work each day, and he made it to the end of the week. At home on Saturday, 2 hours before admission, he suddenly became very short of breath with minimal exertion. At one point, he was unable to climb the stairs to his bedroom without stopping several times to rest. Concerned, his wife helped him into the car and drove him to the hospital.

PHYSICAL EXAMINATION

The man was in obvious respiratory distress. He was sitting in a wheelchair, with his arms braced on the arms of the chair, using his accessory muscles of respiration. He was thin but well nourished. His skin appeared cyanotic, and his fingers were clubbed. He was demonstrating pursed-lip breathing, and his chest was barrel shaped. He demonstrated a frequent, strong cough productive of large amounts of thick yellow and green sputum. He stated that he had been coughing so much and so hard that his chest hurt around his left “collar bone.”

His vital signs were as follows: blood pressure 145/85, heart rate 94 bpm, respiratory rate 20/minute, and oral temperature 37.9(C (100.3(F). Palpation of the chest was unremarkable. Percussion revealed hyperresonant notes bilaterally. Auscultation revealed diminished breath sounds and course crackles throughout both lung fields. His heart sounds were diminished. Expiration took him three times as long as inspiration.

His last pulmonary function test (PFT), taken about 6 months ago at his last doctor’s appointment, showed a moderate-to-severe obstructive disorder. His chest x-ray in the emergency room revealed dark, translucent lung fields; depressed and flattened hemidiaphragms; and a long, narrow heart. A small (10%) lower anterior pneumothorax was noted between the second and third ribs on the right. His ABGs on room air were as follows: pH 7.53, PaCO2 48 mm Hg, HCO3- 38 mEq/L, and PaO2 57 mm Hg. His baseline ABGs at his last medical appointment were as follows: pH 7.42, PaCO2 69 mm Hg, HCO3- 41 mEq/L, and PaO2 74 mm Hg. At this time the physician ordered systemic corticosteroids, a SABA with an anticholinergic, an antibiotic, and a respiratory care consult.

Based on the above clinical data, how would you SOAP this patient? (SOAP 1)

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