PEC - Admission

Reason for Presentation

• Acute shortness of breath and productive cough.

History of Presenting Illness

• 68yo male
• Accompanied by wife, Margaret.
• Onset of worsening dyspnoea 3 days ago, acute deterioration at 06:00 today.
• Increasing wheeze and cough productive of purulent green sputum.
• Subjective fevers, chills, and mild pleuritic right-sided chest pain.
• Grandchildren visited last week with viral URTI symptoms.
• Known severe COPD on home oxygen (1 L/min nocturnal).
• Seen by GP 2 days ago; commenced on oral amoxicillin 500 mg PO TID with no improvement.
• Denies orthopnoea, PND, haemoptysis, or calf swelling.

Management En Route With QAS

• Nebulised salbutamol 5 mg and ipratropium bromide 500 mcg administered; titrated O2 via nasal prongs at 2 L/min.
• Mild improvement in work of breathing; SpO2 improved from 84 % on room air to 90 %.

Past Medical History

• COPD - Dr A. Patel
• Hypertension - Dr S. Gomez
• T2DM - Dr S. Gomez
• Laparoscopic cholecystectomy (2015)
• Mild anxiety

Medications

• Tiotropium (Spiriva®) 18 mcg INH daily
• Fluticasone furoate/vilanterol (Breo Ellipta®) 100/25 mcg INH daily
• Salbutamol (Ventolin®) 100 mcg INH PRN
• Perindopril 5 mg PO daily
• Metformin 1,000 mg PO BID

Allergies

• Penicillin (rash) - noted tolerant to amoxicillin recently, however avoid beta-lactams if severe.

Social History

• Lives at home with wife in a single-storey house; independent with ADLs, uses a 4-wheeled walker for long distances.

Drug, Tobacco, Alcohol History

• Social drinker, 2 standard drinks per week.
• Ex-smoker, ceased 5 years ago (45 pack-year history).
• Denies illicit drug use.

Family History

• Father died of AMI at 72; mother had T2DM.

Immunisation History

• Up to date with annual influenza and COVID-19 boosters; Pneumovax received 3 years ago.

Examination

Vitals

• 78 kg
• 8.4 mmol/L
• 0.2 mmol/L
• 38.2 °C
• 145/85 mmHg
• 108 beats/minute
• 91 % on 2 L/min NP

General: Alert, oriented, speaking in short sentences, moderate respiratory distress, using accessory muscles.

CVS: Tachycardic, dual heart sounds, nil murmurs, JVP not elevated, nil peripheral oedema.

Resp: Tachypnoeic (RR 26), diffuse expiratory wheeze throughout, coarse crepitations at right lung base, decreased air entry bilaterally.

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

Neuro: GCS 15, PEARL 3 mm, moving all four limbs equally.

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

Investigations

Bloods

Bloods: - sent to Sullivan Nicolaides Pathology

• WCC 15.8 x 10^9/L, Neutrophils 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 74 mL/min, Lactate 1.8 mmol/L. VBG: pH 7.33, pCO2 54 mmHg, HCO3 28 mmol/L.

Microbiology

Microbiology: - sent to Sullivan Nicolaides Pathology

• Sputum MCS and respiratory viral PCR pending; Blood cultures x 2 sets pending.

Radiology

• CXR: Hyperinflated lung fields consistent with COPD, new patchy consolidation in the right lower zone.

ECG and Cardiac Monitoring

• Sinus tachycardia at 108 bpm, nil acute ischaemic changes.

Point-of-care COVID-19 and Influenza A/B RAT negative.

Assessment

• Acute infective exacerbation of COPD secondary to right lower lobe community-acquired pneumonia.
• Mild compensated type 2 respiratory failure.

Management in Emergency

• Hydrocortisone 100 mg IV stat, doxycycline 200 mg PO stat, ceftriaxone 1 g IV stat, paracetamol 1,000 mg PO stat, back-to-back nebulised salbutamol 5 mg and ipratropium 500 mcg.
• Work of breathing settled, RR decreased to 20, SpO2 stable at 91 % on 2 L/min O2, repeat VBG pH 7.36, pCO2 50 mmHg.

Plan

• Admit under Respiratory Team, Dr A. Patel - notified and accepted for admission - thanks
• Discussed via telephone at 11:15.
• Dr Patel will review the patient on the afternoon ward round at 14:00.
• Physiotherapy for chest clearance - notified and agrees to consult - thanks
• Diabetic diet as tolerated.
• Oral fluids encouraged; 0.9 % sodium chloride at 60 mL/hr IV if oral intake poor.
• Ceftriaxone 1 g IV daily, doxycycline 100 mg PO BID, prednisolone 40 mg PO daily for 5 days, salbutamol 5 mg NEB QID + PRN, enoxaparin 40 mg SC daily.
• Q4H vitals, continuous pulse oximetry, aim SpO2 88–92 %, repeat VBG if increasing drowsiness or respiratory distress.
• Transfer to Respiratory Ward (Ward 4B), telemetry bed not required.