1. HOPC Woke up at night with SOB not relieved by puffer 1 week history of non purulent cough No infective features RESP Hx: Cough – 1 wk Phlegm – white Heamoptsysis – Nil Wheeze – Nil Dyspnoea + orthopnoea + paroxysmal nocturnal dyspnoea – Yes. Cannot exercise much Hoarse voice – Nil Chest Pain – Nil Sinusitis – Nil Fever – Nil Weight loss – Nil Patient X – 65 year old male, retired, brought by ambulance on the 12 th of April 2010.

2. PMHx Emphysema for past 12 yrs – suffers from SOB regularly (no home O2 therapy, no pred) HT Depression Pre hosp meds: Salbutamol, dex & atras. Allergic to flagyl Social Hx Lives with wife 50 Pack years smoker – started at 11 and quit last December Nil alcohol or recreational drugs Family Hx Father died from brain tumor Brother died from lung cancer (but never smoked)

3. Examination findings (patient file) Amb report (12 th ) O/E: nil pyrexia, HR 82, BP 150/88, O2 sat 96% (10 L O2 therapy), RR 26 GCS 15, Temp 35. No pain. Ex: Increased resp effort, use of Acc muscles. Skin is warm and patient appears pink in colour. Trachea central, mild midzone wheeze, HS normal, JVP normal but easily seen, nil ankle oedema. Hosp Ex (12 th ) BP 96/71, HR 88, O2 sat 87%, afebrile, decreased airway entry, nil wheeze, HS normal. 8.00 Am 13 th : O/E: HR 55, RR18, O2 sat 90% RA, BP ? No pain. A/E decreased, & equal, barrel chest. Slight bilateral crackles. Tremor

4. DDx Asthma Pulmonary oedema Upper resp tract obstruction PE Anaphylaxis Exac of COPD

5. Ix PEF – if not too ill. Arterial blood gases CXR FBC, U&E, CRP ECG Blood cultures (if pyrexial) Sputum culture

6. Plan (12 th ) Admit to resp Medication: seretide (inhaler), escitalopram (antidepressant – SSRI), irbesartan (HT), olenzepine (anti-psychotic), prednisolone. DVT prophylaxis Keep O2 sat > 88% Ix CXR – large right sided bullae Other Ix required. Bullae - areas of destroyed lung tissue that create large dilated air sacs.

7. Figure 6: Chest x-ray showing a giant bulla occupying more than two thirds of the right hemithorax and compressing the underlying lung upward and towards the mediastinum.

8. Emphysema – Barrel chest, pursed lip breathing (pink puffer in COPD), use of accessory muscles; Palpation - reduced expansion, hyper-inflated chest and decreased vocal fremitus; Percussion - resonant percussion note with decreased liver dullness; Auscultation - decreased vocal resonance, decreased breath sounds with early inspiratory crackles & prolonged expiration