COPD Cascade

• 79 year old male

• Neurologically intact

• 3L O2 nasal at baseline 

• In hospital Day 12

• PMHx: OSA/OHS (on CPAP), CAD, Afib (on Pradaxa), sick sinus syndrome s/p PPM, hypothyroidism, GERD, MDD, COPD, BPH, chronic anemia (IDA), thrombocytopenia

• Presentation: Left shoulder pain radiating to arm, DOE

• Admitted for: Acute hypoxic respiratory failure

• Key findings: Right exudative pleural effusion, MRSA lower respiratory culture positive 

• Chest tube: In place pleural fluid pending

Active Problems

1. Acute Hypoxic Respiratory Failure

• Still requiring NC (not used at baseline)

• On vancomycin (MRSA susceptible)

• No fever, no worsening leukocytosis → reassuring response

• Good UOP with IV Lasix 60 yesterday

• Plan:

  • Wean daytime O2 as tolerated

  • Continue Duonebs

  • Continue vancomycin

  • Ambulatory sats before discharge

  • Pulmonology following

2. Exudative Right Pleural Effusion

• Thoracentesis: 20cc removed, negative culture

• CT chest: stable moderate effusion

• CXR: increased effusion

• Thoracentesis + chest tube: 800cc serosanguinous, exudative fluid

• Chest tube removed due to pain

• somnolence, diffuse wheezing

• Plan: Continue management as above

3. Small Right Basilar Pneumothorax (stable)

• Post-procedure, stable

• Plan: monitor, thoracic imaging if worsening

4. HFpEF (EF 63%)

• TTE: trivial pericardial effusion

• Plan:

  • Continue furosemide 80mg daily + 80mg MWF

  • Additional IV Lasix 60mg today

  • Strict I&O

5. COPD

• Home: Symbicort

• Inpatient: switched to Duonebs q6h per pulm

6. Dysphagia / Choking Risk

• SLP: dental soft, thin liquids, upright position

• Patient elected regular diet after risk discussion

• Plan: Continue upright intake precautions

7. Fungal Rash (Groin)

• Plan: Clotrimazole cream BID

Stable Chronic Conditions

• OSA: nightly CPAP

• Afib: continue Pradaxa (held for procedure)

• Anxiety / Insomnia: sertraline 200mg daily, clonazepam 0.5mg BID, trazodone 100mg QHS, melatonin 3mg QHS

• GERD: pantoprazole

• Hypothyroidism: levothyroxine 125 mcg daily

• BPH: tamsulosin 0.8mg nightly

• Chronic normocytic anemia (IDA): Hgb 9.5, no overt bleeding, declined EGD/colonoscopy → CTM

• Chronic thrombocytopenia: no prior workup → outpatient follow-up

Other Orders/Status

• Diet: Regular, replete K if <4

• Prophylaxis: Pradaxa

• Code status: Full Code