Physician's Assistant

Refined clerking Thu 12 June 2025 16:15

Last Modified: 298 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Shortness of breath and productive cough for 2 weeks

History of Presenting Complaint:
This 52-year-old gentleman presents with a 2-week history of progressive shortness of breath and productive cough of yellow-green sputum.

Patient reports feeling increasingly short of breath and has been struggling with activities of daily living. He has been managed in the community for chest infection for 2 weeks prior to admission with oxygen saturations of 76% on air. No reported fevers.

ED team attempted NIV but did not tolerate within seconds of starting.

Past Medical History:
• COPD (2021)
• Thoracic kyphosis (2021) 
• Depression
• Asthma (2004)
• Right leg ulcers - currently dressed, referred to vascular (DNA'd appointments twice)
• Previous IV drug user - history of heroin, crack cocaine and valium use with some suspicion of ongoing drug use in vascular referrals.

Drug History:
• Epimax cream topical PRN
• Paracetamol PRN
• Codeine 15mg PO PRN
• Ferrous gluconate 300mg PO OD
• Salbutamol inhaler PRN
• Trimbow inhaler

Allergy History:
• NKDA

Social History:
Lives with daughter who acts as primary carer. Requires assistance with activities of daily living. Current smoker - > 30 pack/year history. Denies alcohol consumption. Previous IV drug user with ongoing concerns about current drug use. Limited mobility and self-care capacity.

On Examination:
General Appearance: Unkempt. Tar stained fingers, smoke staining to nose.
Observations: HR 87, normal sinus rhythm
• Cardiovascular: Normal heart sounds, good peripheral pulses, bilateral pitting oedema to knees
• Respiratory: Significant kyphoscoliosis, wheeze bilaterally with decreased air entry on left, tight sounding wheeze on right, wheeze in lower zones
• Other: Dry mucous membranes, no peripheral oedema in upper limbs, warm peripherally, no rashes on legs

Investigations:
• Initial ABG: pH 7.266, pCO2 10.8, base excess -9.8
• ABG post 1x round of medical management: pH 7.304, pCO2 9.25, base excess -8
• Further ABG after 1 hour of resus: pH 7.28, pCO2 9.78, base excess -7.7
• ECG: Normal sinus rhythm, rate 87, no signs of ischaemia
• Chest X-ray: Reviewed (query previous chest surgery - patient denies)

Impression:
Type 2 respiratory failure secondary to multifactorial causes:
• Acute exacerbation of COPD with infective component
• Chest wall deformity (kyphoscoliosis) contributing to respiratory compromise
Possible ongoing substance use complicating management

Management Plan:
1. One hour of back-to-back nebulisation with optimal medical management
2. Repositioning to achieve maximal respiratory function given kyphoscoliosis
3. Target oxygen saturations 88-92% to facilitate CO2 elimination
4. If no improvement, retrial of NIV with mild opiate premedication
5. IV fluids and supportive care
6. VTE prophylaxis with LMWH
7. Nicotine replacement therapy as requested
8. Respiratory bed
9. Escalation plan: Not for CPR due to poor functional status. For ITU discussion and NIV. Patient has capacity and understands life-saving nature of interventions.
10. Stop co-amoxiclav and give doxycycline only as per guidelines
11. Steroids for 5 days - IV hydrocort currently given acute illness

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Refined clerking Thu 12 June 2025 16:15

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