Documenting a respiratory and sleep round
Ward notes through an exacerbation, discharge summaries, sleep study review letters and letters back to the referrer.
Day two of a COPD exacerbation
Day two, infective exacerbation of COPD. Less wheeze, still breathless walking to the bathroom.
Sats 90% on one litre, target 88 to 92. Resp rate 20. Scattered wheeze, no focal signs. Chest X-ray, no consolidation.
VBG pH 7.36, CO2 52.
Pred 50, day two of five. Doxycycline 100 daily, day two of five. Salbutamol through a spacer four-hourly, restart her tiotropium-olodaterol.
Inhaler technique with the nurse, update the action plan, pulmonary rehab referral. Home Friday if she's off oxygen.
Progress
Day 2, infective exacerbation of COPD. Less wheeze. Dyspnoeic on minimal exertion.
Examination
SpO2 90% on 1 L (target 88 to 92%). RR 20. Scattered wheeze, no focal signs.
Investigations
CXR: no consolidation. VBG pH 7.36, pCO2 52.
Medications
- Prednisolone 50 mg daily, day 2 of 5
- Doxycycline 100 mg daily, day 2 of 5
- Salbutamol via spacer 4-hourly
- Recommence tiotropium-olodaterol
Plan
- Inhaler technique review
- COPD action plan updated
- Pulmonary rehabilitation referral
- Discharge Friday if off oxygen
Ward, lung function and sleep
- Discharge summary
- The steroid and antibiotic end dates, the inhalers on discharge and the rehab referral.
- Sleep study review letter
- AHI, oxygen nadir and Epworth score, the CPAP decision and the driving advice given.
- Letter to the referrer
- For a lung function or ILD question: the findings, the impression and the plan.
