Respiratory Ward Round Note

Specialty: Respiratory Physician Respiratory Ward Round Note Date: 1 November 2024 Current Status and Overnight Events: Patient remained stable overnight with no acute desaturation events. Oxygen requirements are stable at 2L via nasal cannula to maintain SpO2 >92%. The patient reports feeling slightly less breathless today and appears to be making gradual improvement in overall clinical trajectory. Active Problems: 1. Community-Acquired Pneumonia (CAP) Status: Responding well to antibiotics. Afebrile for 24 hours. Cough productive of less purulent sputum. Lung sounds improving with decreased crackles in the right lower lobe. Plan: Continue IV Ceftriaxone 1g OD and Oral Azithromycin 500mg OD. Monitor inflammatory markers. Consider step-down to oral antibiotics if continued clinical improvement and normalising inflammatory markers. 2. Chronic Obstructive Pulmonary Disease (COPD) exacerbation Status: Symptoms of breathlessness improving. No increase in sputum volume or purulence. Peak expiratory flow rate (PEFR) stable at 250 L/min. Plan: Continue regular Salbutamol and Ipratropium bromide nebulisers QDS. Review inhaled corticosteroid (ICS)/long-acting beta-agonist (LABA) therapy. Encourage ambulation and chest physiotherapy. NIV settings: Not applicable. 3. Type 2 Diabetes Mellitus Status: Blood glucose levels well-controlled on current insulin regimen. HbA1c 7.1% on last check. Plan: Continue current insulin regimen. Monitor BGL pre-meals and at bedtime. Dietician review for nutritional optimisation. Past Medical History: 1. Community-Acquired Pneumonia (previous admission 6 months ago) 2. Chronic Obstructive Pulmonary Disease (diagnosed 5 years ago) 3. Type 2 Diabetes Mellitus (diagnosed 10 years ago) 4. Hypertension 5. Hyperlipidaemia Escalation Status: Ceiling of care: Full active medical treatment. DNACPR status: Not for Resuscitation (NFR) discussed and documented. ICU suitability: Not suitable for ICU due to significant co-morbidities and advanced age, patient and family wishes respected. General escalation plan: Ward-based care with senior review for any deterioration. History of Present Illness: Patient is a 78-year-old male who presented to A&E five days ago with a 3-day history of increasing shortness of breath, productive cough with yellow sputum, and fever. Symptoms began insidiously, progressing to significant dyspnoea at rest. Associated symptoms included generalised malaise and reduced appetite. No haemoptysis or chest pain reported. Patient has a known history of COPD. Review of Systems: Respiratory: Persistent productive cough, improving shortness of breath, no pleuritic chest pain. Cardiovascular: No palpitations, no peripheral oedema. Gastrointestinal: Reduced appetite, no nausea, vomiting, or diarrhoea. Genitourinary: No dysuria or frequency. Musculoskeletal: Generalised weakness. Neurological: No headache, dizziness, or focal neurological deficits. Medications: Ceftriaxone 1g IV daily Azithromycin 500mg oral daily Salbutamol nebuliser 5mg QDS Ipratropium bromide nebuliser 500mcg QDS Insulin Glargine 16 units nocte Metformin 500mg BD Ramipril 5mg OD Atorvastatin 20mg OD VTE Prophylaxis: Enoxaparin 40mg subcutaneous daily. Allergies: Penicillin - Rash Social History: Patient is a retired factory worker with a 50-pack-year smoking history, quit 10 years ago. Lives with his wife in a two-story house. No significant occupational exposures. Limited social support network apart from wife and occasional visits from daughter. Observations: NEWS: 3 RR: 18 breaths/min SpO2: 94% on 2L nasal cannula HR: 82 bpm BP: 130/75 mmHg Temp: 36.8°C Physical Examination: General appearance: Elderly male, appears comfortable at rest, no obvious distress. Mild tachypnoea. Pulmonary examination: Inspection: Symmetrical chest expansion, no accessory muscle use. Palpation: Normal tactile fremitus. Percussion: Resonant throughout, no dullness. Auscultation: Decreased breath sounds bilaterally with scattered fine crackles at both lung bases, more prominent on the right. No wheeze. Cardiovascular examination: Normal S1/S2, no murmurs. Peripheral pulses palpable and symmetrical. No peripheral oedema. Jugular venous pressure not elevated. NIV Settings and Weaning Plan: Not applicable. Diagnostic Studies: Bloods: Full Blood Count (1 November 2024): WBC 9.2 x 10^9/L (down from 14.5), Neutrophils 7.0 x 10^9/L. Hb 12.5 g/dL. Platelets 250 x 10^9/L. C-Reactive Protein (1 November 2024): 35 mg/L (down from 180 mg/L). Urea & Electrolytes (1 November 2024): Na 138 mmol/L, K 4.1 mmol/L, Creatinine 85 umol/L. ABG: Not applicable. Imaging: Chest X-ray (30 October 2024): Right lower lobe consolidation consistent with pneumonia. No pleural effusion. Cardiomegaly. Other: ECG (30 October 2024): Sinus rhythm, no acute ischaemic changes. MDT Input: Physiotherapy: Patient tolerating chest physiotherapy well, engaging in mobilisations. Plan for continued daily sessions with focus on airway clearance and graded exercise. Nursing concerns: Patient requires assistance with personal care. Good oral intake. Reports mild discomfort with cough. Social Work: Discussed discharge planning with patient and wife. Identified potential need for care package at home. Referral initiated. Clinical Impression: Primary diagnosis of Community-Acquired Pneumonia (CAP) is responding well to broad-spectrum antibiotics, evidenced by improving clinical observations and inflammatory markers. Exacerbation of COPD has also settled. No other new acute respiratory pathology identified. Differential diagnosis of viral pneumonia considered on admission but less likely given response to antibiotics. Discussion with Patient on Ward Round: Patient was informed of improving pneumonia and settling COPD exacerbation. Explained that antibiotics would be reviewed for conversion to oral therapy soon. Patient expressed relief and understanding of the plan. Asked about discharge date; advised that it would be dependent on continued improvement and social support arrangements. Patient agreed to continued physiotherapy and social work involvement. Plan: 1. Continue IV Ceftriaxone 1g OD. 2. Continue Oral Azithromycin 500mg OD. 3. Daily review of inflammatory markers (CRP, WBC). 4. If CRP <50mg/L and afebrile for 48 hours, switch IV Ceftriaxone to oral Amoxicillin 500mg TDS. 5. Continue current bronchodilator therapy. 6. Physiotherapy review daily. 7. Dietician review for nutritional assessment. 8. Monitor blood glucose levels closely. Discharge Planning: Estimated discharge timeframe: Within 3-5 days, once stable on oral antibiotics and care package arranged. Barriers: Requirement for home care package, current mild residual weakness. Required support: Referral to community occupational therapy for home assessment, provision of a 4-times-daily care package, patient education on medication management and self-management of COPD. Follow-Up Plan: 1. Follow-up Chest X-ray in 6-8 weeks as outpatient. 2. GP review in 1 week post-discharge. 3. Respiratory outpatient clinic appointment in 3 months for COPD review. Jobs: 1. Chase social work for care package update. 2. Arrange repeat CRP and FBC for tomorrow morning. 3. Consult dietician for patient review. 4. Book follow-up CXR and Respiratory clinic appointment.