Dispatch
Medic 4 was dispatched to the above-listed address for difficulty breathing.
Chief Complaint
Pt is a 74 YOF with a chief complaint of shortness of breath. Pt was located sitting on the side of the bed at a residence. Pt was alert upon arrival.
History
History was obtained from Pt. Pt has a history of COPD and hypertension. Pt denies recent surgery or other pertinent history. It was reported that the shortness of breath built through the afternoon. Pt denies chest pain and a fever.
Allergies: no known drug allergies. Medications: as listed. Last oral intake was lunch.
Events leading up: Family found Pt leaning forward and using accessory muscles.
Onset was gradual. It is provoked by exertion. Quality is shortness of breath. Radiation: does not radiate. Severity 6/10. Time worse than at onset.
Assessment
Airway is intact. No airway compromise noted. Respirations are initially 28. Respirations are regular, labored, and shallow. Initial BP was 148/86. Pt's initial pulse is 112. The pulse is strong and regular. The Pt's skin is pale, warm, and dry. Pt appeared emergent. ER evaluation is indicated for difficulty breathing.
Physical Exam
Head: atraumatic and unremarkable. Pt is AOx4.
Neck: no JVD.
Chest: Pt reports shortness of breath and denies chest pain. Lung sounds reveal wheezes on the left and on the right. No paradoxical movement noted.
Abdomen: soft and nontender. Extremities: no edema. Pt is negative for DCAP-BTLS.
Diagnostic Tests
SPO2 88% on room air. Blood glucose 142 mg/dL. ETCO2 48 mmHg. 12-lead ECG shows sinus tachycardia with no ST elevation.
Primary Impression
COPD exacerbation.
Medications and Procedures
Oxygen was applied at 6 LPM by nasal cannula. SpO2 improved to 94%.
A duo-nebulizer was given by nebulizer. Work of breathing improved. No adverse reaction.
Transport
Pt was transported emergent to Kettering Medical Center. Pt remained improved during transport. A report was called in prior to arrival. Pt was released to the RN staff in room 12 in a stable condition.