Order Description
Write a brief summary of the patients current health problems, relevant history and specific early management provided to address the primary problem prior to arriving to your ward. this should be
sufficient to set the scene for the reader and should take up no more than 1 to 1.5 pages.
64yrs female presents with shortness of breath and worsening cough last 3/7.

Background
1) severe brittle COPD – 4 admissions this year, current smoker (not a candidate for home oxygen), speculated lung mass RLZ
2) Hypercholesterolaemia
3) Prev TIA
4) AF – not anti coagulated
5) Osteoporosis

Medications
Rosuvastation 20mg night, Metoprolol 12.5mg twice daily, Aspirin 100mg daily, Seretide 250/25 x2puffs twice daily, atrovent 500mcg x4 daily, temazepam 10mg night and paracetamol 1g 4 times/day as
required

Lives with husband, away a lot. current smoker, independent with activities daily living, mobiles independently.

3/7 worsening shortness of breath, left sided chest pain and more frequent cough
shortness of breath progressive and similar to other episodes of admission
left sided chest pain, sharp since 1500hrs today, worse on inspiration and coughing, worse on pushing
cough more frequent, usually productive but unable to produce sputum
no fevers/sweats/shakes
always feeling cold
mobilisies to the mailbox, usual daily activity
eating and drinking as normal

On examination
T 36.6, HR 87, RR 22, BP 96/64 (normal), oxygen sats 89% on 2ltrs/min
Speaking in short sentences
Decreased air entry bibasally, no creps, no wheeze

Investigations
WCC 14.5, CRP 98 – raised inflammatory markers
Chest X-ray clear – no consolidation
ECG -poor R weave profession, Q waves in III and aVF, flattened T waves in V6, I, aVL

Implication
non-infective exacerbation of COPD,
type 1 respiratory failure
Postural hypotension

Admitt under oncall physician
Steriods – Prednisone 50mg for 3 days
Oral antibiotics – doxycycline
Usual meds, DVT prophylaxis, s
Bronchodilators – salbutamol nebulisors
Slow IVFLuids – hypotension
Chest physio for sputum clearance