Transcription - 20250612T 16-49.mp3

So next patient is mark yeo yeo 95 207 5 it's a 52 year old gentleman presenting shortness of breath and productive cough investigations blood gases reveal initial ph 7.266 with p c o 2 10.8 and base excess 9.8 arterial blood gas ph 7.304 with p c o 2 9.25 and base excess 8 arterial blood gas after small amount of medical management ph 7.28 p c o 2 9.78 with basics of 7.7 alright so I'm mark lassie 1 of the medical registrars nice to meet you mark I'm sorry to see you in hospital I hear you've been struggling with your breathing for a few weeks is that right yeah and tell me about that I'm slightly out of the hospital feeling short of breath yeah for 2 weeks now yeah have you had a cough yeah what are you bringing up yellow greeny grotty stuff yeah yeah how many times a day are you bringing it up they're not doing it now they're have work okay who lives with you at home my daughter your daughter and does she look after you or do you look after her she looks after you and what kind of help do you need at home okay that's fine do you you smoke cigarettes how many a day do you smoke yeah and how long have you done that for were you alive yeah yeah is it more than 20 a day no you sure no okay when's the last time you had a wash just when it's dry not sure when's the last time you got out of the house don't know okay do you drink alcohol no no not at all but oh yeah would you like a nicotine patch while you're in hospital yeah then an inhaler maybe yeah okay we'll get that sorted do you get cravings for cigarettes thing in the morning yeah I do yeah yeah okay that's fine yeah I'll just have a look at you if that's okay got good regular pulses peripherally you feel warm you've not got any peripheral edema which is good do you ever get chest pain or chest tightness yeah how often do you get chest pain I've got you've copd I know that you've actually got pitting edema to the knees bilaterally okay I'll put this into your heart heart sounds are normal there's wheeze and decreased temperature on the left very tight sounding wheeze on the right a wheeze in the lower entry can I see your tongue quite dry isn't it yeah you had any fevers lately no no fevers it's awful no rashes on your legs touch your tongue quickly is it sore too no it's fine alright we will give you some more misting masks for an hour hour so we give you an hour of back to back nebulization and see if we can control this nasty buildup of carbon dioxide in your blood if that's the case then great if not then we'll have to try putting you back onto that misting that strong mask that blows air at you again right but we can give you a bit of medicine to try and help with that is that alright yeah fine do you see the respiratory team no no oh yeah yeah I do yeah some okay yeah I do know okay fine I'll have a look at the letters then and I think it's always important to discuss with people about resuscitation when they come into hospital about what you'd want if you were to deteriorate if you're your breathing were to become so bad that you need to go to intensive care would you want that yeah oh that's fine well if you didn't do that you'd probably die yeah I have to speak to the intensive care team I'll see what they think about taking you to intensive care it'd be very challenging to manage because of your kyphosis in your spine I mean it'd be very difficult to get their tubes in the right places but I'll have a chat with them and see what they think right I think if you were to deteriorate over the course of days and weeks to the? Where your heart were to stop I don't think that jumping up and down your chest would make any meaningful difference is that alright yeah don't think you should have cpr but we'd have to refer you to itu and do niv great I don't know yet we refer you to itu if we need to we'll give you that noninvasive ventilation the strong mask if we need to I won't jump up and down in your chest if you if you were to deteriorate further alright okay I'll get all of these things sorted for you we'll carry on giving you some intravenous fluids we'll tinker with your oxygen saturations to get them in the right range so that you blow off your carbon dioxide from the 88 to 92 we'll get a tracing of your heart which I'll have a look at I'll have a look at your chest x-ray you had some surgery on your chest is that right that's what did you have any surgery to your chest no haven't I'll I'll have another look at the x-ray alright well let's give it an hour of this listing of these listing masks and then we'll talk again okay yeah okay talk to you then so on examination significant gyphoscoliosis compression multifactorial type 2 respiratory failure secondary to chest wall deformity and exacerbation of copd infective plan 1 hour of back to back nebulization with optimal medical management repositioning to achieve maximal respiratory function number 3 if no improvement retrial of niv with mild opiate alongside in the investigations ecg normal sinus rhythm rate 87 no signs of ischemia vt prophylaxis with lame molecular weight heparin and the last thing is tep form not for cpr but for it and an iv so past medical history depression copd 2021 thoracic kyphosis 2021 asthma 02/2004 previous iv drug user some suspicion about ongoing drug use previous use of heroin crack and valium no known drug allergies right leg ulcers currently dressed referred to vascular but did not attend twice current medications effimax cream paracetamol is required codeine 15 mg is required ferrous gluconate 300 mg once a day salbutamol inhaler trimbo inhaler information from the ed team being managed in the community for a chest infection for 2 weeks productive cough tight chested no known fevers saturation is in the community 76% on air plan bile of niv patient did not tolerate within seconds of starting noninvasive ventilation pulled mask off understands that this is a life saving intervention that has capacity to refuse I'd like to medicate emergency the disabled car park which is car park s I'd like to medicate emergency to the disabled car let's see when you make them

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

Summary

Investigations

Plans