Case 2

You are nearing the end of your late shift when an F2 doctor asks if he can discuss a 20-year-old asthmatic patient with you. His friend called an ambulance because he had become more breathless as the day went on. The patient reported that his salbutamol inhaler had run out a week ago and his steroid inhaler 3 months ago. He has moved region, is currently of no fixed abode and is not yet registered with a GP.

The patient’s observations on arrival were as follows:

• Pulse 104
• BP 120/80 mm Hg
• Respiratory rate (RR) 22 per minute
• Temp. 36.8 °C
• Oxygen saturation of 94% on room air

He was able to complete sentences in a single attempt and his measured PEFR was 270L/min. His best ever PEFR was 500L/min. but it has not been measured recently.

The F2 has followed the departmental asthma proforma and given the patient two 5 mg salbutamol nebulisers and prednisolone 40 mg. It is now 2 hours after his arrival and his observations are stable:

• Pulse 90 reg.
• RR 18
• Oxygen saturations 97% on air
• PEFR is 380 (76%) of his best

His inhaler been checked and found to be satisfactory. The F2 doctor would like to discharge him with a new salbutamol and beclometasone inhaler and suggest that he register with a GP in the morning for follow up in 2 days time.

Categorise the severity of this asthma exacerbation using the information above:

Although you know that this F2 doctor is extremely competent you have some concerns about the potential discharge of this patient late at night, particularly since he is of no fixed abode and has no GP.

What other factors would you wish to ascertain from the patients past medical history that may indicate that discharge could be associated with an increased risk of relapse?

The patient does not have a history of severe asthma and is not keen to stay. His best PEFR, however, has not been measured since he was 16 years old.

Explain why this information may influence management?

Although you have concerns about his social circumstances and follow up he declines your offer of admission for overnight observation. He says he will call his parents who can collect him (they live an hour away), take him home and then he will see his family GP for follow up. This seems a reasonable plan but you then find additional information in his pre-hospital paperwork that makes you strongly recommend admission. What new information could you have found that influenced your decision to admit him?

The patient agrees to stay and you refer the patient to the medical registrar, who is incredulous that a patient with life-threatening asthma has not had arterial blood gas sampling performed. She suggests that you 'take bloods', request a chest radiograph and, if his arterial blood gases are OK, she will accept him on the acute medical unit.

Which one of these investigations is least appropriate at this time?