67 y/o male ref by GP with dyspnoea at rest for 10 days a/w cough productive of green

sputum & wheeze on background pulmonary fibrosis. Previous admission 28th June for
same. Seen by MSHOOC.
Past Med:
Rheumatoid Arthritis
Pulmonary Fibrosis x 2 years
Meds
Arava 10mg OD
Prednisolone 5mg OD
Pantoprazole 40mg OD
Combivent Nebs
NKDA
Social: Retired farmer, lives with wife. Son nearby.
Non Smoker & 6 units 3-4 times/weeks
O/E: Alert, upright, 2L O2 via NP, orientated
Vitals:

RR 32
SpO2 94% on RA -> 96% on 2L
BP ~90/60
HR 65-117 irregularly irregular
Temp 38oC

CVS: HS 1 + 2 + 0, No murmurs
Rhythm: Irregularly irregular
JVP not raised
No peripheral oedema
Resp: Scattered creps bibasally R>L
Abdomen: SNT, BS+
CNS: Grossly Intact
Dry Mucous membranes
Plan:
Admit
Kardex
CXR

Bloods & Blood C+S

Sputum C+S
IV Taz
IV HC
Hold prednisolone
Combivent switched to Atrovent Nebs
Prophylactic LMWH
IVF: 1L over 4 hours then 8 hourly
Commenced bisoprolol 2.5mg OD

Bloods:
WCC: 15
Neut 13.26
Hb 12.5
PLT 613
CRP 131
Trop T 18.15
ESR 84

Na 134
K 4.3
Ur 3.9
Creat 71

CXR: Diffuse basal predominant lung opacification consistent with pulmonary fibrosis.
Impression of increased opacification in bases compared to previous.
Working Dx:
LRTI on b/g Pulmonary Fibrosis
New Onset A Fib
Management Day 2
ECG: Fast A Fib rate 132
Bloods improved
o WCC 8.7
o Neut 7.46
o Hb 12.1
o PLT 590
Trop T 10.48 <- 18.15

Na 141
K 4.8
Ur 3.6
Creat 64
CRP 105
BNP 3961

Management Day 3
IV steroids changed to PO prednisolone 30mg OD
ECG showing A Fib, still tachy -> Bisoprolol increased to 5mg
o CHADSVASC 1 no AC
Sputum from previous admission showed Serratia Marcescens
o Resistant to Ampicillin, Amoxicillin, Co-amoxiclav, Ceftriaxone, Tazocin
o Intermediate Ciprofloxacin
o Sensitive to Meropenem

Current sputum in progress

Taz stopped, started on Levofloxacin 500mg BD PO
Arava held on admission ?reason. Restarted.
Echo Requested last done in 2012
TFTs

Management Day 4
Echo
Mildly decreased LV function. EF 40-45%. Ventricular wall thickness
moderate increased. LA severely dilated.
RA mildly dilated. Mild aortic sclerosis. Moderate MR. Mild TR. Trace PR.
Estimated right ventricular systolic pressure moderately elevated at
48.4mmHg.

Started on Furosemide 40mg and Ramipril 1.25mg

?For AC

Management Day 5 (Friday 22/8/14)

Echo showing HF = CHADSVASC now 2
Started on Dabigatran 150mg BD
On 2L O2 consistently wean + ABG

ABG: Type 1 Respiratory Failure

o pH
7.5
o pO2
9.11
o pCO2
4.99
o HCO3
29.8

2L O2 restarted
TFTs Normal
Blood cultures Negative
Sputum culture reported
o Haemophilus Influenzae
o Intermediate: Erythromycin
o Sensitive: Ampicillin/Amoxicillin, Co-amoxiclav, Tetracycline, TriSulfamethoxazole
o Dr Haq discussed with micro and Levofloxacin continued.

Management Day 6
S/B MROC
Fast A Fib with episodes of Bradycardia
Asymptomatic

Telemetry required to investigate ?Tachy-Brady syndrome

T/F to Cardiology in Limerick