ED Admission

Reason for Presentation

• Acute SOB and productive cough

History of Presenting Illness

• 68yo Male
• Wife, Margaret, present at bedside
• Onset 3 days ago, acute deterioration at 06:00 today
• Worsening dyspnoea at rest, wheeze, and cough productive of purulent green sputum
• Subjective fevers, rigors, and mild R-sided pleuritic chest pain
• Grandchildren visited 5 days ago with viral URTI symptoms
• Baseline exercise tolerance 200 m on flat ground; no home O2
• Reviewed by GP Dr PATEL on 12/05/2025; commenced on oral amoxicillin with nil improvement

Review of Systems

• Nil orthopnoea, PND, or ankle swelling. Normal bowel and bladder habit.

Management En Route With QAS

• Salbutamol 5 mg NEB, ipratropium 500 mcg NEB, and O2 via Hudson mask at 6 L/min

• Mild improvement in work of breathing; SpO2 improved from 84 % on RA to 91 %

Past Medical History

• COPD (GOLD Stage II)
• HTN
• T2DM
• Appendicectomy (1985)
• Mild anxiety
• Respiratory physician Dr THOMPSON (private)

Medications

• Tiotropium (Spiriva®) 18 mcg INH daily
• Salbutamol (Ventolin®) 100 mcg INH PRN
• Perindopril (Coversyl®) 5 mg PO daily
• Metformin (Diabex®) 1,000 mg PO BD

Allergies

• Penicillin (generalised maculopapular rash)

Social History

• Lives at home with wife in a single-storey house. Independent with ADLs, nil formal services.

Drug, Tobacco, Alcohol History

• 2 standard drinks per week
• Ex-smoker, ceased 5 years ago (40 pack-year history)
• Nil recreational drug use

Family History

• Father died of AMI aged 72; mother had T2DM

Immunisation History

• COVID-19 (4 doses), annual influenza vaccine current, Pneumovax received 2022

Examination

Vitals

• 78 kg
• 9.2 mmol/L
• 0.2 mmol/L
• 38.2 °C
• 145/85 mmHg
• 108 beats/minute
• 90 % on 2 L/min NP

General: Alert, oriented, speaking in short phrases, moderate tachypnoea with accessory muscle use.

CVS: Tachycardic, dual heart sounds, nil murmurs, JVP not elevated, CRT < 2 sec, nil peripheral oedema.

Resp: Diffuse expiratory wheeze bilaterally, coarse crackles at RLL base, decreased air entry R base.

Abdo: Soft, non-tender, non-distended, bowel sounds present.

Neuro: GCS 15, PEARL 3 mm, moving all 4 limbs equally, nil focal deficit.

MSK: Normal gait prior to illness, calves soft and non-tender.

Investigations

Bloods

• WCC 15.8 x 10^9/L, Neut 13.2 x 10^9/L, Hb 142 g/L, Plt 280 x 10^9/L, CRP 115 mg/L, Na 136 mmol/L, K 4.1 mmol/L, Cr 88 umol/L, eGFR 76 mL/min/1.73m2, Lactate 1.8 mmol/L

Microbiology

• Respiratory viral PCR swab and sputum MCS pending; blood cultures x 2 sent

Radiology

• CXR: RLL consolidation consistent with pneumonia, background hyperinflation, nil pneumothorax or large effusion.

ECG: Sinus tachycardia 106 bpm, normal axis, nil acute ischaemic changes.

VBG: pH 7.36, pCO2 48 mmHg, HCO3 26 mmol/L.

Assessment

• Infective exacerbation of COPD secondary to RLL community-acquired pneumonia
• Mild hyperglycaemia

Management in Emergency

• Salbutamol 5 mg NEB stat, hydrocortisone 100 mg IV stat, doxycycline 200 mg PO stat, ceftriaxone 1 g IV stat, paracetamol 1,000 mg PO stat, controlled O2 therapy via NP titrated to 88-92 %

• HR decreased to 94 beats/minute, work of breathing improved, speaking in full sentences, SpO2 stable at 91 % on 2 L/min NP

Plan

• Admit under General Medicine team (Dr WILLIAMS)

  • Discussed via phone with Med Reg Dr CHEN at 14:15
  • Med Reg to review in ED within 2 hours

• Respiratory outreach CNC review requested for inpatient COPD action plan

• Diabetic diet

• Normal saline 1,000 mL IV over 12 hours, encourage oral fluids

• Charted regular prednisolone 40 mg PO daily for 5 days, doxycycline 100 mg PO daily, ceftriaxone 1 g IV daily, salbutamol 5 mg NEB Q4H PRN, and regular home medications

• Inpatient physiotherapy referral for chest physio and mobility assessment

• Q4H vitals, continuous pulse oximetry, target SpO2 88-92 %, BGL QID

• Transfer to Medical Ward bed when available