COPD exacerbation with nebulizer

Clinical note

COPD exacerbation with nebulizer

CC: Shortness of breath x3 days, established patient.
HPI: 66 y/o with COPD on tiotropium, worsening dyspnea, increased sputum volume and purulence, using rescue albuterol 6x/day. No fever, no chest pain. 40 pack-year former smoker.
Exam: SpO2 91% RA, RR 22, diffuse expiratory wheeze, prolonged expiration. No accessory muscle use.
Treatment: Albuterol nebulizer treatment 2.5 mg given in clinic, post-treatment SpO2 94%, wheeze improved.
A/P: Acute exacerbation of her COPD. Prednisone 40 mg x5 days, doxycycline x5 days, continue tiotropium. Return precautions given, ER if worse.
MDM: moderate. E/M separately identifiable from the nebulizer treatment.