Initial Impression/Empiric management: SOB likely COPD exacebation

Diagnostically:

CBC: non-remarkable

BMP: non-remarkable

Lactate mildly elevated, repeat ordered, likely type II hypoperfusion from resp distress and not c/w sepsis.

Troponin negative

VBG w/ acute on chronic hypercarbia.

Therapeutically: duonebs, continuous albuterol, steroids, magnesium,

Considered azithro v levoquin and _

BIPAP

ED Course/Reevaluation: On re-eval, resp status improved. Off BIPAP given pt refuses. Repeat VBG shows CO2 82. Pt placed back on BIPAP.

Assessment/MDM/Plan:

Presentation is most consistent with COPD exacerbation, severe.

DDx – Considered the following diagnoses though based upon evaluation, pt does not meet reasonable level of consistency with characteristic findings/likelihood for further pursuit at this time (risks/outweigh benefits of non-indicated testing). Shared decision making with with pt attempted to the extent possible.

Not c/w PNA given afebrile, no opacity in CXR.

Not c/w ACS given EKG w/o electrocardiographic evience of ischemia, troponin negative, no chest pain consistent with ACS.

Not c/w CHF given no pulm edema by exam nor CXR, euvolemic on exam, no new LE edema.

Counseling: Patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with proposed plan. All questions and concerns answered and addressed.

Supervision: Discussed and obtained approval/confirmation of evaluation (history/exam/diagnostics) and plan (assessment/interventions/disposition) with ED attending physician