A 70 year old female patient
Chief complaint: A 70 year old female patient [Kim] is admitted with a history of chronic, productive cough, breathlessness, and generalised malaise over the past year. Over the last two months she has noticed trouble with sleeping at night due to coughing and is generally feeling increasing tiredness. She is having difficulty with activities of daily living (ADL) due to weakness, exhaustion and breathlessness. For the past 24 hours he has also been suffering from chest tightness; however the patient denies any pain.
Personal history: The patient is a retired teacher. She has been fairly healthy for most of her working life. She exercises occasionally and has gained weight over the past 20 years however over the last 6 months has lost weight. She has been widowed for the last five years. She has two adult children, only one who lives in the same city. Kim smoked one packet per day of cigarettes since her early 20’s and describes herself as being ‘prone to chest infections’ including wheeze and chest tightness for the past number of years. She has the occasional drink.
Family history: Father died from complications related to ischaemic heart disease at 58. Her mother suffered a stroke at age 67 and lived in high care for her remaining 4 years.
Past medical/ surgical history: She has been admitted to hospital for treatment of lower respiratory tract infection (LRTI) twice in the last year. The patient has recently commenced on a low dose thiazide diuretic for hypertension. The patient denies any other history of cardiovascular disease, diabetes or hypercholesterolaemia.
Vital Signs:
• Respiratory rate 28 breaths per minute
• Sp02 90% on 3L via nasal prongs
• Heart rate is 90 beats per minute
• Blood pressure is 150/ 83 mm Hg
• Temperature is 37.9°C
Systems review
Neurological: GCS is 14/15 with pupils equal and reactive to light (PEARL).
Respiratory Inspection: The patient is sitting forward, using accessory muscles; she has a moist cough and is coughing regularly. The patient appears to be in respiratory distress. There are no abnormal thoracic landmarks or scars. You note an abnormal breathing pattern of tachypnoea and moist cough.
Palpation: Chest expansion is symmetrical and there is no tracheal deviation. There is limited mobility of the diaphragm and diminished vocal fremitus. There is no tenderness, lumps or lesions on the thorax.
Percussion: Dull sounds can be heard over lower lung fields.
Auscultation: There is air entry into all lung fields, however diminished in the lower bases. Bronchovesicular breath sounds can be heard with an I:E (Inspiratory/expiratory) ratio of 1:2. Coarse crackles can be auscultated on inspiration and a wheeze is present on expiration.
Cardiovascular Inspection: The patient is centrally pink; however peripheral cyanosis is present without clubbing.
Palpation: Peripheral pulses are palpable at +1. Calves are soft and non-tender. Jugular venous pressure (JVP) is less than 4cm.
Auscultation: Heart sounds of S1 & S2 are heard. There is no murmur.
An ECG confirmed sinus tachycardia and a portable chest radiograph showed shading in lower Left lung fields, with evidence of pneumonia. An arterial blood gas shows a pH 7.30, Pa02 68 mm Hg, PCO2 58 mm Hg, HCO3 27 mEq/L, and Lactate 2.1 mm Hg. Spirometry results include FEV1/FVC (ratio of forced expiratory volume in 1 second over forced vital capacity) of 62%.