Emergency Department Assessment Note

1. Chief Complaint: "Short of breath and coughing up green phlegm."

2. History of Presenting Complaint: 68-year-old male presents with a 3-day history of worsening dyspnoea and productive cough with purulent green sputum. Symptoms began following a mild viral URTI 5 days ago. Reports increased use of salbutamol inhaler (up to 10 puffs/day) with minimal relief. Reduced exercise tolerance, currently breathless walking from bed to bathroom.

3. Associated Symptoms: Subjective fevers, wheeze, mild pleuritic chest tightness on coughing. Denies haemoptysis or orthopnoea.

4. Past Medical History: Chronic Conditions: COPD (GOLD Stage 2), hypertension, T2DM. Previous Surgeries: Laparoscopic cholecystectomy (14/05/2016). Previous Episodes: Two infective exacerbations of COPD in the past 12 months managed in the community; no previous ITU admissions or NIV requirement.

5. Medication History: Current Medications:

• tiotropium (Spiriva®) 18 mcg INH OD
• salbutamol (Ventolin®) 100 mcg INH 2 puffs PRN
• amlodipine 5 mg PO OD
• metformin 500 mg PO BID Allergies: Penicillin (maculopapular rash).

6. Social History: Smoking: Ex-smoker, quit 3 years ago (40 pack-year history). Alcohol Use: 4 units/week. Drug Use: Denies illicit drug use. Living Situation: Lives with wife in a two-storey house; independent with all ADLs.

7. Review of Systems: General: Feverish, fatigued. No unintentional weight loss. Cardiovascular: No central crushing chest pain, palpitations, or ankle swelling. Respiratory: SOB, productive cough, wheeze. Gastrointestinal: Appetite reduced. No nausea, vomiting, or diarrhoea. Neurological: No headache, dizziness, or confusion. Musculoskeletal: Mild generalised myalgia. Skin: No rashes or lesions.

8. Examination Findings:

Vital Signs

Temperature: 37.8 °C Heart Rate: 104 bpm Respiratory Rate: 24 breaths/min Blood Pressure: 138/82 mmHg Oxygen Saturation: 91 % on room air (target 88-92 %) General Appearance: Alert, speaking in short sentences, mild accessory muscle use at rest. Head and Neck: JVP not elevated, trachea central, no cervical lymphadenopathy. Chest/Lungs: Diffusely polyphonic wheeze throughout both lung fields, coarse crepitations at the right base. Heart: HS I + II + 0, regular tachycardia. Abdomen: Soft, non-tender, no distension, normal bowel sounds. Extremities: Warm and well-perfused, no peripheral oedema, calves soft and non-tender, peripheral pulses intact. Neurological: GCS 15/15 (E4 V5 M6), no asterixis, gross motor and sensory exam normal.

9. Investigations: Laboratory Tests:

• FBC: WCC 14.2 x 10^9/L (Neutrophils 11.8 x 10^9/L), Hb 148 g/L, Plt 265 x 10^9/L
• U&E: Na 137 mmol/L, K 4.3 mmol/L, Urea 6.1 mmol/L, Creatinine 84 µmol/L
• CRP: 68 mg/L
• VBG: pH 7.38, pCO2 5.6 kPa, HCO3 26 mmol/L, Lactate 1.4 mmol/L Imaging Studies: CXR shows hyperinflated lung fields consistent with COPD and mild patchy consolidation in the right lower zone. No pneumothorax or pleural effusion. ECG Findings: Sinus tachycardia at 102 bpm, normal axis, no acute ischaemic changes.

10. Impression and Differential Diagnosis:

11. Infective exacerbation of COPD with mild right lower lobe community-acquired pneumonia (CURB-65 = 1).

12. Differential: Acute heart failure (unlikely given absence of oedema and clear CXR vasculature), pulmonary embolism (low clinical probability, clear history of infection).

13. Plan: Immediate Management:

• salbutamol 5 mg NEB STAT and ipratropium bromide (Atrovent®) 500 mcg NEB STAT
• prednisolone 30 mg PO STAT
• doxycycline 200 mg PO STAT
• paracetamol 1,000 mg PO STAT Further Investigations: Sputum MC&S sent. Repeat clinical review and SpO2 check 1 hour post-nebulisers (improved to RR 18 breaths/min, SpO2 92 % on room air, speaking in full sentences). Consultations: Discussed with community Respiratory Rapid Response Team; accepted for virtual ward support. Discharge Instructions: Discharged home with prednisolone 30 mg PO OD for 5 days and doxycycline 100 mg PO OD for a further 4 days. Advised to continue regular tiotropium and use salbutamol via spacer. Return to ED immediately if experiencing worsening breathlessness, confusion, drowsiness, or chest pain. Follow-Up: Community Respiratory Team to visit tomorrow (15/10/2023 at 10:00). GP review in 4 weeks for post-exacerbation check and repeat CXR in 6 weeks to ensure resolution of consolidation.