Download Chart number：2513536-2 Name：陳×× Gender：Male Age：65 y/o

Chief complaint： Dyspnea this afternoon
Present illness：
The 65 y/o M patient had COPD for 5 years. None of his family had this problem. He had smoked 2 ppd for 40
years and quitted smoking progressively for past 3 years and didn't smoke now. He attended the O. P. D. at MMH
and took medicines， including Theophylline、 Atrovent Inh、Ventolin、Prednisolone and Berotec Inh， regularly
for his COPD. He was admitted 92/1/10 for a previous episode of COPD and the symptoms of COPD were relieved
during hospitalization， and he discharged on 92/1/16. He had received influenza vaccine on 92/1/20. He became out
of breath following slight exertion， such as climbing a flight of stairs. He denied PND and orthopnea. He noted an 8
kg weight loss over the past one month and his appetite was poor at home. On 92/2/9， he had dyspnea suddenly at
the afternoon and was sent to the E.R. of MMH by his families. At E.R.， his vital signs were normal and
consciousness was clear. Blood gas(O2 nasal cannula ：4 l / min) showed pH was 7.312, pCO2 47.5, pO2 161.7,
HCO3 23.5, BE –3.1, and O2 sat was 98.9﹪.Hb/Ht were 15.6 / 47.8. Chest PA disclosed hyperinflation of bilateral
hemilungs、 flatting of both hemidiaphragms and lung marking were decreased. WBC was 14400 and empiric
antibiotics were given to him. After initial treatment， he was then admitted for further evaluation and treatment of
his COPD. The pt’s was a man of asthenic habitus who appeared chronically ill. He denied that he and his families
had URI symptoms， such as cough、 sore throat and sneezing…， these days. Intercostal spaces retracted on
inspiration and bulged on expiration. Breath sound was decreased、 percussion was tympanic、 wheezing and there
was no rales on bilateral lung field. There was no fever、 breathing laboringly through pursed lips、 JVE、
hepatojugular reflex and pitting edema. Heart sound was regular and there was no murmur.
Dr Buttrey’s rewrite:
Chief complaint： Dyspnea for several hours
Present illness：
A 65 y/o M patient had had COPD for 5 years. He had smoked 2 ppd for 40 years but quit gradually 3
years previously and was now no longer smoking. He was managed in the MMH OPD and regularly used
theophylline, Atrovent Inh, Ventolin, prednisolone, and Berotec Inh for his COPD. He was admitted
92/1/10-16 for exacerbation of COPD, and his symptoms were relieved during that hospitalization. He
received influenza vaccine on 92/1/20. He became out of breath following slight exertion, such as climbing
a flight of stairs, [when?]. He denied PND and orthopnea. He noted an 8 kg weight loss over the past one
month and his appetite was poor at home. On 92/2/9, he had sudden onset of dyspnea in the afternoon
and was sent to the MMH ER by his family. In the ER his vital signs were normal [Was the respiratory rate
really normal? That’s a VS.] and he was alert. On 4L/min nasal O2, his blood gases were 2 pH 7.312,
pCO2 47.5, pO2 161.7, HCO3 23.5, BE –3.1, and O2 sat 98.9%. Hb/Ht were 15.6/47.8. Chest PA disclosed
hyperinflation of the lungs bilaterally, flattening of both hemidiaphragms, and decreased lung markings.
WBC was 14400 and empiric antibiotics were started. None of his family had COPD, and he denied that
he or his family had recent URI symptoms, such as cough, sore throat and sneezing. The diagnosis in the
ER was exacerbation of COPD.
Missing information: Has he ever had PFTs? If so, when, and what did they show? How does he take his
medicine? What is his normal level of functioning? You mention the previous hospitalization—has he been
having increasing frequency of hospitalization and/or worsening of his symptoms? Does he normally have
wheezing with his SOB? Was there wheezing this time? What was he doing when the sudden SOB
occurred? How long between the onset of dyspnea and arrival in the ER? (That should be the duration
noted in the CC.) Any risk factors for pulmonary embolism? Any chest pain? Any history of fever? Was his
respiratory rate really normal in the ER?!
Don’t include PE findings in the PI except for important findings noted in the ER. What is written at the end
sounds like your PE on the ward. That should be saved for the PE, not recorded in the HPI.
Comments
Content:
This is generally a good history, including at least something about most of the points that should be covered in
someone with a chronic disease in whom an exacerbation is suspected. Those points are:
1. Enough information about the original diagnosis so that we’re sure we know what we’re dealing with.
[In this history, the items that most convince me that he has COPD are the smoking history, CXR, and mild
CO2 retention. The medications are obviously appropriate for such a diagnosis, but the fact that a person
has been given certain medications doesn’t, unfortunately, confirm the diagnosis. If a misdiagnosis has been
made, the patient may be receiving incorrect medications!]
2. A description of the baseline level of functioning, including whether the disease is generally stable or
has been getting worse (or better). [Knowing about the previous hospitalization is helpful here, but we
still don’t know how well he usually functions. The statement about SOB with slight exertion is very good,
but the timing hasn’t been clearly stated. Is this his usual condition or has it been this way only recently?]
3. Medications and how they are used. [The list here is excellent! But it’s also important to find out if he
takes them as directed. We should also assess the patient’s skill in using an inhaler. This information is
important because we have an excellent opportunity for any patient education that is necessary while the
patient is in the hospital.]
4. A description of the recent acute episode: onset, progression, severity, possible inciting factors,
associated symptoms, etc. [Again, this has been fairly well handled here, althoug a few other symptoms
such as fever should be inquired about. Remember that negative information is often as important as
positive data, as you demonstrated by noting the absence of URI symptoms in the patient or his family.]
5. Information, positive or negative, that would suggest or rule out other possible diagnoses. [In this case,
I think we need to have a high index of suspicion for other causes of acute SOB in an older patient. We must
force ourselves to think about them because the natural tendency is to focus on the COPD and assume that
is the sole problem. In fact, the sudden onset of the problem and his relatively good oxygenation make me
wonder if we’re dealing with something else. At the very least, I’d think about pulmonary embolism and
heart disease. One “red flag” in his history is the weight loss, which definitely requires further investigation.
Certainly some patients with COPD lose weight as a consequence of their disease, but we shouldn’t assume
that to be the case here. This is another reason it’s important to understand his symptoms in the month
before this acute episode. If his lung disease was relatively stable, I’d definitely look for a different cause of
the weight loss.]
One further comment on his ABGs. We must do our best to obtain room air gases before starting O 2. (I realize it’s
the ER residents who need to hear this!) Also, unless I have previous information on whether or not the patient
retains CO2, I would start with 2L or even 1L of nasal O 2. This man clearly doesn’t need 4L, although we usually
can’t predict a patient’s requirements before checking the gases. I hope that once these results were obtained,
someone turned down his nasal oxygen. One wonders, too, if he had a respiratory acidosis when he arrived or
whether we helped him to develop it by giving more O2 than he needed. It’s often important to explain to family
members why we need to draw the arterial blood before starting the oxygen and also to keep them from fiddling with
the O2 setting. If these things are a problem, it’s our job to give appropriate education, not just to give up!
English:
consciousness was clear: Although this is grammatically correct, we don’t say it. We use “The patient was alert.” In
the PE under General Appearance, I would simply write “Alert” followed by a further description, as appropriate. In
this case, that must include a comment on whether or not he appeared dyspneic.
bilateral hemilungs: We write “both lungs.” “Bilateral” is not used in English in this way to denote normal structures.
The adjective in this case is used to distinguish between different nouns. We don’t have any lungs other than the
bilateral ones! We don’t also have a set of quadrilateral or unilateral lungs. You can use “bilateral” to describe
abnormalities because the abnormality could be either bilateral or unilateral. (E.g., “There were bilateral infiltrates on
CXR.” It can also be used as an adverb modifying the verb that relates to a normal structure: “The lungs were clear
bilaterally.” Note, too, that there are 2 lungs, one on each side. There is no such thing as a hemilung.
After initial treatment， he was then admitted for further evaluation and treatment of his COPD.: Although this is a
common final sentence in the PI, it doesn’t tell us much. I’d rather just include the presumed admitting diagnosis
(which may or may not be correct). The only time I give further information is if the reason for admission is unclear.
That’s not the case here.