Clinical note · #9
Office & outpatient
Provider: Dr. Last Name, First Name, MD
Date: 10/26/2023
Patient Information
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Name: Robert Adams
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Date of Birth: 02/09/1958
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Sex: Male
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Medical Record Number: 654321987
Chief Complaint
Mr. Adams presents with a history of COPD and has been seen following his recent hospitalization for a COPD exacerbation. He reports comfort today, using oxygen at 2L via nasal cannula with the head of the bed elevated. His appetite and energy levels are satisfactory, and he has no new complaints. He has not had any prior outpatient visits with a pulmonologist.
Medical History:
Mr. Adams has a known diagnosis of COPD and a history of frequent hospitalizations for COPD exacerbations. He is currently managed on the following medications:
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Duoneb 2.5 mg albuterol sulfate and 0.5 mg ipratropium bromide via nebulizer, four times a day (QID).
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Proventil HFA 90 mcg albuterol sulfate, two puffs every four hours as needed (PRN).
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Symbicort 160 mcg budesonide and 4.5 mcg formoterol fumarate dihydrate, two puffs twice a day (BID).
He recently completed a course of prednisone post-hospitalization.
Objective Findings:
Upon examination:
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Mr. Adams appears comfortable, sitting up in bed.
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Head, eyes, ears, nose, and throat (HEENT) examination shows no abnormalities, and he is at his baseline.
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Lung examination reveals decreased breath sounds throughout with good expansion. His breathing does not appear labored.
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The patient is currently on 2L of oxygen via nasal cannula continuously, and his pulse oximetry today was 96%.
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Cardiac examination reveals a regular rate and rhythm.
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Abdomen is soft and non-tender.
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Skin color is within normal limits, and it is warm and dry.
Assessment and Plan
1. COPD Exacerbation:
- Mr. Adams has a history of frequent COPD exacerbations, warranting a pulmonary consultation for further evaluation and management.
2. Medication Management:
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Continue current medication regimen:
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Duoneb 2.5 mg albuterol sulfate and 0.5 mg ipratropium bromide via nebulizer, QID.
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Proventil HFA 90 mcg albuterol sulfate, two puffs every four hours PRN.
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Symbicort 160 mcg budesonide and 4.5 mcg formoterol fumarate dihydrate, two puffs BID.
3. Oxygen Therapy:
- Continue oxygen therapy at 2L via nasal cannula continuously.
4. Follow-up:
- Monitor Mr. Adams closely for any changes or worsening of symptoms.
5. Pulmonary Consult:
- Schedule a pulmonary consult to further evaluate and manage Mr. Adams' COPD and discuss potential interventions to prevent future exacerbations.
Signed by the provider · 10/26/2023