Profile

ADMISSION REASON

Profile

75M from home alone on L2HCP

Supportive son

Independent with pADLs, independent mobility on short distance, scooter for long distance

Ex-smoker with 75 pack years, quit 6 years ago

PC

Dyspnoea

HPC

10 day history of progressive dyspnoea and productive cough with mucky sputum (colour blind so unable to see exact colour) with profound lethargy - previously independent short distance, now unable to mobilise off the bed. He denied subjective fevers.

Initially brought by his son - patient was attending OPD CT chest scan at Bensons with his son, son noticed he was very dyspnoeic and unable to mobilise off bed, brought into LMH ED.

OPD CT was requested by his GP. He attended his GP 4/52 ago with similar compliant for 1/52 prior seeing GP (dyspnoea/productive cough) but was not as severe as current episode. He was reviewed but reportedly was not given any treatment (abx/steroid), advised to monitor and to do OPD CT chest. He's not had a PCR at the time.

He commenced on prophylactic dose of 50mg doxycycline as part of his winter COPD plan as per Dr Kruavit. He's never required a hospital admission prior. His COPD was previously well managed with GP/specialist OPD care.

He's on home oxygen. 2L at rest and up to 4L on exertion, noticed he was requiring up to 5L in the last 10 days even on minimal exertion (e.g. going to the toilet).

He does not think he had haemoptysis. He sees colour red as brown (as tested). He denied seeing any similar colour in his sputum.

He's x2 covid vaccinated. Not up to date with flu vaccination this year (and last year).

Currently he feels much improved than on initial visit to ED.

PMH

# COPD

- Known privately to Dr Anuk Kruavit at Elizabeth Specialist Suites

- Home O2 via CDMU home oxygen team at LMH

- 2L at rest and up to 4L on exertion

# Chronic back pain

# Colour blind

Med

Doxycycline 50mg OD

Trimbow 2 puffs BD

Theophyline 200mg OD

Esomeprazole 20mg OD

O/E

2L NP 95%, RR 24, HR 118, afebrile, BP 105/56

Dry mucus membrane, CRT < 3 sec, JVPNE, dry legs no pedal oedema, reduced skin turgor

Reduced AE in the R up to mid zone

Heart sounds duo, no murmurs

Abdo SNT

Investigations

CRP 395, WCC 16.92, Neut 14.8

Hb 139, LDH 352

Cr 58, eGFR >90

VBG

pH 7.44, pCO2 56, Bicarb 40

ECG - ST

Rapid negative

CT CAP - Severe emphysema with overlying consolidations, suggestive of infection

Imp

Infective exacerbation of COPD due to CAP

Sinus tachycardia in setting of hypovolaemia and CAP

Plan

Case discussed with Dr Crowhurst including CT scan

- AMU admission given patient not requiring additional support such as NIV and patient at his baseline oxygen requirement

- Suggest aim sats 88-92%

- Ceftriaxone/azithromycin

- Repeat CT chest 6/52 after DC with CDMU follow up

Discussed with AMU team - agreed with admission

Admit under AMU

7 steps - discussed, not for CPR/ETT, consideration of ICU for reversible causes

Clexane 40mg VTEP

Short-term mod in place

Ceftriaxone/azithromycin

37.5mg prednisolone OD further 4/7 then consider +/- taper

Septic screening - chase BC/full resp swab

Sputum MCS please

Encourage PO intake and IVT tonight

Consider mucolytics if increasing secretions noted

Monitor inflammatory markers

CASE 1

MER

reason for MER: tachypneoic RR40, desaturating 89% on 4L

attendees: gayle (reg), Te (RMO), Catlin (Intern), ward nurses

75M COPD on home oxygen 2L rest, 4L exertion

currently admitted under medics for IECOPD d/t severe CAP - neg CTPA

not improving w/ IV ceft + azit (has already had ceft) --> stepped up to IV Tazocin early this afternoon + reg puffers

met called earlier in the day for tachycardia and increased wob --> given IVT bolus, paracetamol, IV mg, slow IVT

7-step: not for CPR/ETT, for consideration of ICU for NIV/vasopressors

A - patent own

B - increased wob ++, accessory muscle use tripoding, unable to speak full sentences, unable to take puffers put on nebs RR 42, 89% on 4L, chest nil wheeze or crackles poor air entry

C - warm peripheries, BP 136/76, HR 133

Strong radial pulse

D - GCS 15, alert, oriented

E - Afebrile 36.3

Progress

Tazocin AM dose given

salbutamol + ipratropium nebs

IV hydrocort 100mg IV

portable CXR and ECG - unable to tolerate

arterial gas on 6L: pH 7.42, pO2 54, pCO2 42, bicarb 27.8, Hb 134, Na 140, K 4.2, glu 5, lac 1.3

Impression:

# IECOPD with evolving pnuemoniad/w ICU who will kindly come to review for consideration of hi-flo

reviewed by ICU reg with thanks, for escalation to ICU for NIV

Introduction

The information provided in this case study uses pseudonyms. Mr Sheppard a Seventy-six-year-old male presented to Alexander McEwin Regional hospital intensive care department. The patient was referred to hospital by his regular general practitioner after experiencing symptoms of increased dyspnea and tachypnoea for five days. Relevant past medical history for the patient includes chronic obstructive pulmonary disease (COPD)and emphysema. The primary survey approach used for assessment is airway, breathing circulation, disability and exposure (ABCDE). Mr Sheppard was maintaining own airway. Patients was tachypneic with respiratory rate of 38 and oxygen saturation level being 88% on 4litres oxygen. Patient had increased work of breathing and is unable to speak in full sentences and unable to use inhaler. On chest auscultation there is no bilateral wheeze, but poor air entry was noted. Pt is tripoding and there is definite use of accessory muscles. Circulation indicated warm peripheries with capillary return time of 3 seconds. Blood pressure was 140/7mmHg with mean arterial pressure (MAP) of 101 unsupported. On palpation patient had a strong radial pulse with heart rate of 130 beats per minute. 12 lead Electrocardiogram was done indicated sinus rhythm with enlarged right atrium. Heart auscultated indicated heart sounds no mummer. No signs of bleeding or hemorrhaging observed. Urine output noted to be 300 mls over past 6 hours. Mr Sheppard is alert and orientated to time, place, and person. Glasco comma scale of 15 and pupils both equal and reactive to light size 3+with equal power to all limbs note. Blood glucose level was 6.5mmol/l. Quick head to toe examination done while patient was lying in bed indicated no wounds, oedema or pressure injures. The skin was dry and intact, color was natural. The Tympanic temperature was 36.3o c. Therefore, this assignment will discuss the relevant pathophysiology, diagnostics, nursing and medical interventions to develop effective nursing care plans as well as discuss the ethical and legal consideration.

Presentation and pathophysiology

Pathophysiology