General follow-up

Subjective

• Worsening SOB and productive cough x 5 days.
• Increased yellow sputum, wheezing, mild fatigue.
• Unable to walk > 1 block or complete light housework without resting.
• Denies fever, chills, chest pain, hemoptysis, or lower extremity edema.
• Slightly decreased due to coughing spells.
• Lives with wife; grandson visited 1 week ago with URI symptoms.
• prednisone 40 mg PO QD x 5 days, doxycycline 100 mg PO BID x 5 days.
• CXR, CBC, BMP, viral respiratory panel.
• Pulmonology.
• He is advised of most recent labs done on 12/03/2025 showing WBC 8.2, Hb 14.1, Cr 0.9, eosinophils 350 cells/mcL.
• Advised to start prednisone 40 mg PO QD and doxycycline 100 mg PO BID, see Pulmonology
• Advised labs CBC, BMP, viral respiratory panel
• RTC 1 week

Past Medical History

• COPD (GOLD stage 2), HTN, hyperlipidemia.
• Former smoker (40 pack-years, quit 2019).
• Adherent to daily maintenance inhaler; using rescue inhaler 4-5x/day recently.
• Penicillin (rash).
• Denies recent travel.

Social History

• Retired machinist; enjoys woodworking (currently paused due to dust/SOB).
• Denies alcohol use; sleeps 6 hrs/night, recently propped on 2 pillows.

Objective

• Vitals: BP 136/82 mmHg, HR 92 bpm, RR 22/min, SpO2 91 % on RA, Temp 37.1 °C.
• Lung exam: Diffuse expiratory wheezes bilaterally, prolonged expiratory phase, no focal crackles.
• Cardiac exam: RRR, normal S1/S2, no murmurs, rubs, or gallops.
• Abdominal exam: Soft, non-tender, non-distended, normoactive bowel sounds.

Assessment

• Acute exacerbation of COPD, likely triggered by viral URI.

Plan

• Order stat CXR (PA and lateral), CBC, BMP, and SARS-CoV-2/Flu/RSV PCR.
• Start prednisone 40 mg PO QD x 5 days and doxycycline 100 mg PO BID x 5 days; continue tiotropium (Spiriva®) 18 mcg INH QD; salbutamol (albuterol, ProAir®) 90 mcg/actuation INH 2 puffs q4h PRN SOB.
• Reviewed proper spacer technique for salbutamol MDI; patient demonstrated correct usage in clinic.
• RTC in 1 week for clinical re-evaluation, or sooner if no improvement in 48-72 hrs; f/u with Pulmonology in 4 weeks.
• Proceed to ED immediately for severe dyspnea at rest, SpO2 < 88 %, chest pain, confusion, or high fever.
• Reinforced strict adherence to daily tiotropium maintenance therapy and completing full 5-day steroid/antibiotic course.
• Administered annual influenza vaccine today; advised RSV and pneumococcal conjugate vaccination at next routine visit once acute illness resolves.
• Routine lipid panel review and woodworking dust mask counseling deferred to next wellness visit.