SOAP Note: Acute Exacerbation of COPD in a Primary Care Encounter

Chief complaint: "My breathing has been worse for three days." A 67-year-old female with a 40-pack-year smoking history and established chronic obstructive pulmonary disease (COPD) reports increasing dyspnea, an increase in sputum volume, and a change in sputum color from clear to yellow-green over three days. She denies fever, chest pain, and hemoptysis. She has been using her albuterol inhaler every two hours with only brief relief and is adherent to her maintenance tiotropium.

Vitals: T 37.4 °C, HR 98, RR 24, BP 138/84, SpO₂ 88% on room air. General: alert, using accessory muscles, speaking in short phrases. Respiratory: prolonged expiratory phase, diffuse expiratory wheezes, and diminished breath sounds at the bases bilaterally. Cardiac: tachycardic, regular rhythm, no murmurs. No peripheral edema.

The presentation meets all three Anthonisen criteria — worsening dyspnea, increased sputum volume, and increased sputum purulence — which together support a moderate-to-severe exacerbation likely to benefit from antibiotics (GOLD, 2023). The differential includes community-acquired pneumonia, heart failure, and pulmonary embolism; the absence of fever, focal consolidation, and edema makes an infective COPD exacerbation the most probable diagnosis pending a chest radiograph.

• Titrate supplemental oxygen to a target SpO₂ of 88–92% to avoid suppressing hypoxic respiratory drive.
• Administer short-acting bronchodilators via nebulizer: albuterol with ipratropium.
• Begin a short course of oral prednisone (40 mg daily for 5 days) per GOLD guidance.
• Start empiric antibiotics given purulent sputum and all three Anthonisen criteria.
• Obtain chest radiograph and reinforce smoking-cessation counseling and inhaler technique before discharge.