ED Note

68-year-old male

Assessed in Majors Cubicle 4. Arrived via emergency ambulance.

Chief Complaint

Worsening shortness of breath and productive cough for 3 days.

History of Presenting Complaint

• Acute-on-chronic SOB, progressively worsening over 72 hours.
• Cough productive of green sputum.
• Associated wheeze and subjective fevers at home.
• No relief from increased use of salbutamol inhaler.
• Denies chest pain, haemoptysis, orthopnoea, or calf swelling.

Past Medical History

• COPD (GOLD stage III, 2 admissions in past year)
• Hypertension
• T2DM
• Appendicectomy (1985)

Medications

• salbutamol (Ventolin®) 100 mcg INH PRN
• tiotropium (Spiriva®) 18 mcg INH OD
• ramipril 5 mg PO OD
• metformin 500 mg PO BD

Allergies

• penicillin (maculopapular rash)

Social History

Ex-smoker (40 pack-year history, quit 2 years ago). Drinks 4 units of alcohol per week. Denies recreational drug use. Retired builder, lives with wife, independent with ADLs.

Family History

Father died of MI aged 72. Mother had T2DM.

Examination

A - Airway

Patent, speaking in short phrases.

B - Breathing

RR 26, SpO2 89 % on room air, improved to 91 % on 28 % Venturi mask. Increased work of breathing with accessory muscle use. Diffuse expiratory wheeze and coarse crackles at the right base.

C - Circulation

HR 108 bpm, regular. BP 138/84 mmHg. CRT < 2 s. HS I + II + 0, JVP not elevated.

D - Disability

GCS 15/15 (E4 V5 M6). PEARL 3 mm bilaterally. Grossly intact motor and sensory function. CBG 7.2 mmol/L.

E - Exposure

Temp 37.9. Abdomen soft, non-tender. Calves soft, non-tender, no peripheral oedema.

Investigations

Blood Results

WCC 14.2 x 10^9/L, Hb 145 g/L, Plt 280 x 10^9/L, CRP 85 mg/L, Na 137 mmol/L, K 4.3 mmol/L, Urea 6.8 mmol/L, Creat 92 µmol/L.

ECG

Sinus tachycardia, rate 106 bpm, no acute ischaemic changes.

VBG

pH 7.36, pCO2 6.4 kPa, HCO3 27 mmol/L, Base Excess +2.1, Lactate 1.4 mmol/L.

POCUS

B-lines noted at right lung base with small focal consolidation, no pleural effusion, normal LV contractility.

Impression

Infective exacerbation of COPD with right basal pneumonia.

Plan

1. Controlled oxygen therapy via 28 % Venturi to target SpO2 88–92 %.
2. Back-to-back nebulisers: salbutamol 5 mg NEB and ipratropium bromide 500 mcg NEB.
3. Stat dose prednisolone 40 mg PO.
4. Empirical antibiotics for penicillin-allergic CAP/IECOPD: doxycycline 200 mg PO stat.
5. Formal CXR requested.
6. Refer to Acute Medical Unit for admission and ongoing respiratory monitoring.

Discussion With Family

I discussed the patient's condition and management plan with his wife, Sarah, at the bedside with the patient's consent. We reviewed his diagnosis of an infective exacerbation of COPD complicated by pneumonia and the need for hospital admission. Given his severe underlying lung disease and previous admissions, we discussed ceilings of care and resuscitation status. Both the patient and his wife agreed that in the event of a cardiopulmonary arrest, he would not wish for CPR, and a DNACPR order was completed. He remains for full active medical management, including non-invasive ventilation if required, which they both understood and agreed with.

Dr James Vance, MBBS MRCGP, General Practitioner (ED Streaming)