Jane is a 50-year-old woman who was feeling feverish with a cough and generally unwell for 2 weeks. She is a smoker, reporting she smokes approximately one pack per day and has done so for the past 28 years. She states she normally has an intermittent cough, sometimes productive of clear sputum. She saw her general practitioner (GP) as she stated she felt much worse and was feeling quite breathless. Her cough had become productive of a green-coloured sputum. The GP found that Jane was lethargic but oriented, and auscultated coarse crackles in the right lower lobe (RLL) of her lung. She was coughing up green sputum and her doctor took a specimen for culturing. Her vital signs were: • BP – 134/86 mmHg • PR – 102 beats/minute • RR – 26 breaths/minute • T – 38.9°C • SpO2 – 92% with no supplemental oxygen The GP gave Jane a prescription for oral antibiotics. He sent Jane for a chest X-ray as he is suspecting bacterial pneumonia. Jane has a past history of COPD, hypertension, hypercholesterolaemia, and obesity. Her current medications are: Atorvastatin PO Atenolol PO Spiriva inhaler Salbutamol inhaler as required SOCIAL: Mrs Peterson lives with her husband and works part time as a cashier at the local RSL club. She has a good social network of friends centring around her involvement in the club. She has two adult children who live interstate. Investigations by GP The results of Jane’s further investigations confirm the presence of RLL pneumonia. The chest X-ray shows extensive infiltration of the infection throughout the RLL. When Jane presents back to the GP, she is noticeably more lethargic and feverish and she states her cough has been getting much worse over the past 3 days and she is not sleeping well. Her current vital signs are: • BP – 141/82 mmHg • PR – 106 beats/minute • RR – 30 breaths/minute, with very shallow breaths • T – 39.2°C • SpO2 – 90% with no supplemental oxygen The GP arranges for Jane to be admitted to hospital as her condition is deteriorating. Presentation to the Emergency department: 1. Increasing SOB with Flu- like symptoms (2/52) 2 . Current smoker +++ 3. COPD 4. Hypertension 5. Hypercholesterolaemia 6. Obesity Patient Complaints: Severe shortness of breath (SOB) with a productive cough and lethargy PMH : COPD, Hypertension, hypercholesterolaemia, obesity Meds: Atorvastatin PO, Atenolol PO, Spiriva inhaler, Salbutamol inhaler as required Antibiotics (2/52) (Taken over the last 2weeks) O/E A – Patient talking in half sentences B – RR Tachypnoea 30, Dyspnoeic, SOB Short shallow breaths, use of accessory muscles when breathing Productive cough with yellow/green sputum ↓AE bases with bibasal creps/crackles, no wheezes Percussion: Dull over bases SpO2 92% on 2L O2 Spirometry consistent with emphysema FEV1 = 1.02 = 59% FVC = 1.49 = 71% C – HR 104 regular, BP 145/80, warm, patient dry despite ↑JVP due to pulmonary hypertension, ECHO Normal LVF, no valvular disease, enlarged RA D – alert, GCS 15, PERL 3+ Abdomen soft, non-tender, no organomegaly detected, Calves soft E – Temp 39.0 F – RR 30, BP 140/80, PR 104, GCS 15, Diaphoretic G- BGL 4.1mmols/L I – Chest X-ray – AP erect. There are areas of congestion in the bases. There is patchy consolidation at the right lung base with loss of costal-phrenic angle on (R) side.   Questions: 1. A diagnosis of RLL pneumonia is likely to cause which of the following complications? a. Decreased respiratory rate b. Decreased tidal volume c. Increased blood pressure d. Increased expiration time 2. Which of the following is most likely to be related to the patient’s shallow, rapid breathing? a. Increased accessory muscle use b. Decreased ventilation c. Coarse crackles d. All of the above 3. The measurement taken with a pulse oximeter gives which of the following readings?