Physician's Assistant

Patient Details

Referral (15 weeks ago 17:35)

Referral Mon 22 December 2025 17:35

Last Modified: 15 weeks ago

MRN:

Content:

Investigations:
• Arterial blood gases: Chronic type 2 respiratory failure, CO2 retainer
• Echocardiogram 16/12: Impaired RV systolic function, right heart strain
• ECG: Cor pulmonale
• CT chest: Bullous emphysema, severe
• New pancreatic cystic mass identified
• Iron studies: Iron deficiency anaemia
• Lung function tests: Pending TOSCA CO2 levels overnight

Dear Colleague,

Thank you for referring this 71-year-old lady with severe COPD and alpha-1 antitrypsin deficiency who was admitted on 12/12 with flu-like symptoms and bilateral leg swelling. She has been managed by the respiratory team for cor pulmonale secondary to her severe COPD.

She has developed iron deficiency anaemia which has been managed with iron infusion. The fluid overload has now resolved. Unfortunately, her blood gases indicate end-stage COPD with poor prognostic indicators, with the respiratory team suggesting a prognosis potentially as short as 3 months.

Currently, she can speak in full sentences at rest but becomes breathless on walking around. She can manage on the flat but experiences breathlessness on stairs, which was her baseline at home. Her exercise tolerance is limited to 100-200 metres with a zimmer frame due to shortness of breath on exertion.

Socially, she lives at home with her sister who assists with cooking and cleaning. She mobilises independently and maintains her personal care. She is an ex-smoker, having quit over 10 years ago, and does not consume alcohol. She is keen to return home.

During admission, when mobilised to the bathroom, she became fatigued with oxygen saturations dropping to 70% with no improvement after 1 minute. Given her CO2 retention, there is a risk of over-oxygenation.

Impression:
• End-stage COPD with cor pulmonale
• Alpha-1 antitrypsin deficiency
• Chronic type 2 respiratory failure with CO2 retention
• Iron deficiency anaemia (treated)
• Pancreatic cystic mass (incidental finding)

Suggest:
1. Home oxygen assessment and provision
2. Consider NIV assessment given CO2 retention
3. TOSCA overnight CO2 monitoring as planned
4. Palliative care referral for end-stage COPD management
5. Follow-up regarding pancreatic cystic mass
6. Discharge planning with community respiratory support

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Refined clinic supervision (15 weeks ago 17:45)

Refined clinic supervision Mon 22 December 2025 17:45

Last Modified: 15 weeks ago

MRN:

Content:

Judith Edwards, 71, 501352.
Inpatient review
Main issue was respiratory deterioration secondary to severe COPD with cor pulmonale and fluid overload.

This 71-year-old lady was admitted on 12th December with flu-like symptoms and bilateral leg swelling. She is being managed by the respiratory team for cor pulmonale secondary to severe COPD and alpha-1 antitrypsin deficiency. Iron deficiency anaemia has been identified and managed with iron infusion. She presented with fluid overload which has now resolved. Blood gases indicate end-stage COPD with poor prognosticators, with the respiratory team suggesting a prognosis as low as 3 months. ABGs demonstrate chronic type 2 respiratory failure with CO2 retention. Echocardiogram on 16/12 shows right heart strain and impaired RV systolic function. CT thorax demonstrates bullous emphysema which is severe, with incidental finding of new pancreatic cystic mass. Currently speaking in full sentences at rest but becomes breathless on walking around. Can manage on the flat but breathless on stairs, which was her baseline at home. Lives at home with sister who assists with cooking and cleaning. Ex-smoker who quit over 10 years ago. Exercise tolerance 100-200 metres with walking frame due to shortness of breath. On mobilising to bathroom, oxygen saturations dropped to 70% with fatigue and no improvement after 1 minute. Given CO2 retention, there is risk of over-oxygenation. Lung function studies and overnight TOSCA monitoring arranged.

Plan was to arrange home oxygen assessment, lung function studies with overnight TOSCA CO2 monitoring, and continue respiratory team management.

Point to discuss in supervision: Incidental pancreatic cystic mass requires gastroenterology input for further assessment.

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Clinic letter (104 days ago 09:10)

Clinic letter Tue 23 December 2025 09:10

Last Modified: 104 days ago

MRN:

Content:

Diagnosis:
Cor pulmonale secondary to severe COPD and alpha-1 antitrypsin deficiency

Other Medical Diagnoses
• Iron deficiency anaemia
• Fluid overload (resolved)
• Chronic type 2 respiratory failure
• Right heart strain
• Bullous emphysema
• Pancreatic cystic mass (incidental finding)

Medications:
[Not specified in transcription]

Investigations:
• Arterial blood gases: Chronic type 2 respiratory failure, CO2 retainer
• Echocardiogram 16th December: Impaired RV systolic function, right heart strain
• ECG: Right heart strain pattern
• CT TAP: Bullous emphysema, severe. Incidental pancreatic cystic mass noted
• Lung function tests: Pending TOSCA results
• Oxygen saturations: 70% post mobilisation, no improvement after 1 minute

Plan:
1. Arrange home oxygen therapy assessment
2. Await TOSCA lung function results from respiratory team
3. Consider home NIV assessment given CO2 retention risk
4. Monitor overnight CO2 levels
5. Discharge planning for home with sister's support
6. Follow-up pancreatic cystic mass findings
7. Palliative care discussion given poor prognosis (estimated 3 months)

Dear Doctor,

Re: Judith Edwards, DOB: [Unknown], MRN: 501352

I am writing regarding Mrs Edwards, a 71-year-old lady who was admitted on 12th December 2024 with flu-like symptoms and bilateral leg swelling. She has been managed by the respiratory team for cor pulmonale secondary to severe COPD and alpha-1 antitrypsin deficiency. Overloaded and offloaded during admission.

During her admission, iron deficiency anaemia was identified and managed with iron infusion. However, her arterial blood gases demonstrate chronic type 2 respiratory failure with CO2 retention, which the respiratory team consider poor prognosticators indicating end-stage COPD with an estimated prognosis of 3 months to 1 year based upon ABGs and CT.

Echocardiogram on 16th December showed impaired RV systolic function with right heart strain, consistent with cor pulmonale. CT TAP revealed severe bullous emphysema and incidentally identified a pancreatic cystic mass requiring follow-up.

Functionally, Mrs Edwards can speak in full sentences at rest but becomes breathless on minimal exertion. Prior to admission exercise tolerance was limited to 100-200 metres on the flat due to shortness of breath. Following mobilisation to the bathroom as an inpatient, her oxygen saturations dropped to 70% with no improvement after one minute.

She lives at home with her sister who provides support with cooking, cleaning, and shopping. Mrs Edwards remains independent with personal care and mobilisation with a frame.

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