Pulmonary Hospital Consult

Pulmonologist Subjective: - Reason for Visit: Evaluation of new onset dyspnoea and persistent cough in a 68-year-old male recently admitted for community-acquired pneumonia. - History of Presenting Illness: Mr. John Doe, a 68-year-old male, was admitted five days ago with community-acquired pneumonia, presenting with fever, productive cough, and shortness of breath. He completed a 5-day course of azithromycin and ceftriaxone. While fever and cough have improved, he reports new onset dyspnoea, particularly on exertion, which was not present at admission. He denies chest pain, palpitations, or orthopnoea. He reports occasional clear sputum production. Oxygen saturation on room air has been fluctuating between 90-92% over the last 24 hours, requiring 2L nasal cannula to maintain sats >94%. - Past Medical History: - Hypertension - Type 2 Diabetes Mellitus - Hyperlipidaemia - Former smoker (quit 10 years ago) - Current Medications: - Oxygen 2L nasal cannula (as needed to maintain sats >94%) - IV Ceftriaxone 1g daily (completed course) - Azithromycin 500mg daily (completed course) - DVT prophylaxis: Enoxaparin 40mg SC daily - Furosemide 20mg IV daily - Home Meds : - Lisinopril 10mg daily - Metformin 500mg twice daily - Atorvastatin 20mg daily - Allergies: Penicillin (hives) - Social History: Lives with wife. Retired factory worker. Former smoker (20 pack-years, quit 10 years ago). Occasional social alcohol use (1-2 drinks per week). Denies illicit drug use. No known occupational exposures to asbestos or silica. - Family History: Father died of myocardial infarction at 72. Mother has Type 2 Diabetes and hypertension. No family history of pulmonary fibrosis or severe asthma. Review of Systems: - Constitutional symptoms: Denies fever, chills, night sweats, or significant weight loss. Reports mild fatigue. - Eyes: Denies blurred vision, diplopia, or eye pain. - Ears, Nose, Mouth, Throat: Denies sore throat, rhinorrhoea, or epistaxis. - Cardiovascular: Denies chest pain, palpitations, or oedema. - Respiratory: Reports new onset dyspnoea on exertion, persistent mild cough with clear sputum. Denies haemoptysis, wheezing, or orthopnoea. - Gastrointestinal: Denies nausea, vomiting, diarrhoea, constipation, or abdominal pain. Good appetite. - Genitourinary: Denies dysuria, frequency, urgency, or haematuria. - Musculoskeletal: Denies joint pain, swelling, or muscle weakness. - Integumentary (Skin): Denies rashes, lesions, or itching. Skin is warm and dry with good turgor. - Neurological: Denies headache, dizziness, syncope, numbness, or tingling. - Psychiatric: Denies anxiety, depression, or sleep disturbance. - Endocrine: Reports stable blood sugars at home. No new heat/cold intolerance. - Hematologic/Lymphatic: Denies easy bruising, bleeding, or lymphadenopathy. - Allergic/Immunologic: No new allergic reactions. No history of immunodeficiency. Objective: Examination: - General: Appears comfortable at rest, mild distress with exertion. - Vitals: T 37.0°C, HR 88 bpm, BP 130/80 mmHg, RR 20 bpm, SpO2 92% on room air, 96% on 2L nasal cannula. - Respiratory: Lungs clear to auscultation bilaterally with good air entry. No wheezes, crackles, or rhonchi. No accessory muscle use at rest. No clubbing or cyanosis. - Cardiovascular: S1/S2 normal, regular rhythm, no murmurs, rubs, or gallops. No peripheral oedema. - Abdominal: Soft, non-tender, non-distended, normoactive bowel sounds. - Extremities: No clubbing, cyanosis, or oedema. Investigations: - Chest X-ray (30 October 2024): Resolving right lower lobe infiltrate. No new infiltrates or effusions. Cardiac silhouette normal. - CT Chest (1 November 2024): Bilateral ground-glass opacities, predominantly in the lower lobes, with some interlobular septal thickening, suggestive of organising pneumonia or diffuse alveolar damage. No definite pulmonary embolism. Small bilateral pleural effusions. - CBC (1 November 2024): WBC 8.2 x 10^9/L, Hb 13.5 g/dL, Plt 250 x 10^9/L. - CRP (1 November 2024): 45 mg/L (down from 120 mg/L on admission). - BNP (1 November 2024): 150 pg/mL (normal). - Echocardiogram (29 October 2024): Ejection fraction 55%, mild diastolic dysfunction. Impression & Plan: Interstitial lung changes post-community acquired pneumonia, likely organising pneumonia. 1. Post-Pneumonia Dyspnoea and Hypoxia - Likely organising pneumonia, possible acute interstitial pneumonia or drug-induced lung injury. - Differential diagnosis for Issue 1: Exacerbation of undiagnosed interstitial lung disease, chronic obstructive pulmonary disease, heart failure exacerbation, pulmonary embolism, drug-induced lung injury. - Investigations planned for Issue 1: Further evaluation for aetiology of ILD. Consider bronchoalveolar lavage (BAL) and transbronchial biopsy if ground-glass opacities persist or worsen. Pulmonary function tests (PFTs) once stable for baseline. - Treatment planned for Issue 1: Optimise oxygen support to maintain SpO2 >94%. Consider a short course of high-dose corticosteroids (e.g., Prednisolone 0.5-1 mg/kg/day) if no contraindications and if clinical picture supports organising pneumonia. Close monitoring for clinical response. - Relevant referrals for Issue 1: Referral to outpatient pulmonary clinic for follow-up and PFTs. 2. Persistent Cough - Likely post-infectious or related to interstitial changes. - Treatment planned for Issue 2: Symptomatic management with cough suppressants as needed. Continue to monitor for sputum production and character. Plan discussed with patient and his wife.