REASON FOR VISIT:
1. Severe emphysema.
2. Cor pulmonale.
3. Polycythemia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who has very severe COPD. He was last seen by Dr. Doe last January. At that time, his FEV1 was 1.54 L or 41% of predicted. He also had erythrocytosis due to hypoxemia. It was recommended that he be placed on oxygen therapy, at least 16 hours a day. He was on a variety of inhalers as well. Over the last year and a half or so, he has been very confused over what he was supposed to do. He was on both Advair and Symbicort. He was on Spiriva at one point and thought it did very well for him, but this was taken off and he was placed on DuoNeb three times a day via nebulizer. He still is very dyspneic with exertion. He has chronic peripheral edema despite taking hydrochlorothiazide. He does have a chronic duskiness of his nail beds. He did quit smoking finally two years ago.
On questioning, he does snore. He does have excessive daytime sleepiness. He does not sleep in the same room as his wife, though he does recall being told that he has potential witnessed apneas. He weighs 254 pounds and the weight has been fairly stable. It was around 252 pounds a year and a half ago. He has not been explored for the possibility of sleep apnea. He had a chest x-ray last month that showed emphysema, but no infiltrates or any other abnormality. He was given a course of antibiotics at that time. He has not had any systemic corticosteroids. He has a history of some possible claudication, low back pain and hypertension though he is not on any medication other than hydrochlorothiazide, Symbicort, Advair and DuoNeb.
He has not had any problems with chest pain, no history of venous thromboembolism. He has not complained of any cough or sputum, though he is very dyspneic with exertion. No major wheezing. He has not had any overt infectious processes other than last month, when he had a little bit of increase in dyspnea and he was given some antibiotics. He has not lost or gained much weight though his appetite is good. He is not having problems with headaches or dizzy spells or palpitations though he does have a fine tremor, likely due to excessive beta-agonist usage.
He has oxygen at home including portable devices, though he has only been using it a couple of hours in the morning and a couple of hours in the evening. He does not sleep with it, does not walk around with it.
ALLERGIES: HE IS NOT ALLERGIC TO ANY MEDICATION.
PHYSICAL EXAMINATION: GENERAL: This is a pleasant male, alert and oriented. There is duskiness to his nail beds indicating cyanosis, a little duskiness to his lips as well. He is overweight at 254 pounds. He does have rounded facies. HEENT: The oropharynx is Mallampati class III. There is no nasal airflow obstruction. There is some injection of his sclerae, particularly on the right side, but no drainage. Conjunctiva is hyperemic. NECK: I did not detect any overt jugular venous pressure elevations, though the neck is fatty. There was general fattiness of the supraclavicular fossa, but no mass. LUNGS: Lung fields had good air entry. There appeared to be reduced inspiratory capacity, in part due to air trapping, in part due to his obesity. There is no wheezing or expiratory airflow obstruction though there was some mild prolongation with forced exhalation maneuver. CHEST: There is no chest wall tenderness. HEART: The heart rate was regular without ectopy. I do not detect any gallop or murmur; the sounds though were distant. ABDOMEN: The abdomen had tense truncal obesity. EXTREMITIES: The extremities had 2+ bilateral peripheral edema, some redness to the skin though no overt induration or any ulcerations. The edema did tend to go up to the upper tibial area.
LABORATORY DATA: The last hemoglobin from August was 17.6 g/dL. He states that about every two months, he does get phlebotomy. The leukocyte count was 5.8. His hemoglobin was as high as 19.6 in July and 20.2 in May.
Spirometry today discloses a very severe degree of airflow obstruction with the FEV1 at 1.05 L or 28% of predicted, which is reduced from January, when it was 1.54 L. The forced vital capacity is 2.82 L or 61% of predicted with an obstructive ratio of 37%. Diffusing capacity is 17.5 or 60% of predicted corrected for hemoglobin of 18.2 g/dL and carboxyhemoglobin of 1.9%.
The arterial blood gas on room air discloses a PO2 of 46.1, PCO2 of 66.7, and pH of 7.36.
The home O2 evaluation disclosed correction of the oxygen saturation to 92% with 2 L. On exertion, it took 5 L to maintain even at 89% on a continuous system. The heart rate at baseline was 84 beats per minute, did not appreciably rise. He did walk 120 feet in 38 seconds on 2 L, though on 5 L he walked a distance of 400 feet in 2-1/2 minutes.
IMPRESSION:
1. Very severe chronic obstructive pulmonary disease/emphysema.
2. Polycythemia due to chronic hypoxemia.
3. Signs and symptoms that require exploration of obstructive sleep apnea.
4. Obesity.
5. Cor pulmonale.
6. Peripheral edema due to cor pulmonale and hypoxemia and obesity.
TREATMENT: I changed his diuretic from hydrochlorothiazide to furosemide 20 mg a day. I have also explained to him the medications and the goals of therapy. He will take Spiriva 18 mcg a day, Symbicort 160/4.5 two inhalations twice a day and albuterol on an as-needed basis. Discontinuing Advair and DuoNeb. I explained that he needs oxygen therapy 24 hours a day for mortality benefit, symptomatic benefit and the correction of polycythemia. It is hoped that oxygen therapy over the next several months will negate the need for phlebotomy. He does get hemoglobin checked at his local institution every two months, and if it is over 18, phlebotomy is usually done. He is not having symptoms of hyperviscosity. I would recommend 2 L of oxygen at rest, 5 L continuous with exertion, and I empirically chose 3 L nocturnally. I am not planning on doing a nocturnal oxygen saturation study, as I believe he probably has some obstructive sleep apnea. Therefore, a polysomnogram is ordered to evaluate for apneas as well as any alveolar hypoventilation. It is possible that he might need bilevel positive pressure ventilation. The nocturnal oxygen can then be fine tuned based on this. He also gives a history of significant periodic leg movements and kicking around in his bed. This also would be evaluated at the sleep lab. Often this corrects with the use of CPAP therapy, though a dopamine agonist might be necessary as well. He will return to the pulmonary clinic in three months or sooner if the need arises. He is up-to-date on his pneumococcal vaccine, and he will get his flu vaccine when available.
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