Author: William Tansey, Sachin Sekhsaria, Harjinder Chaggar / Editor: Stephen Sheridan / Codes: / Published: 27/02/2026
This independent, previously active tourist arrived from India four weeks ago. He is an ex-smoker (40 pack-year history, quit 5 years ago) with no known drug allergies. His past medical history includes well-controlled hypertension, gallstones, hypercholesterolaemia, and type 2 diabetes.
He reports a 5-day history of fever and lethargy, progressive shortness of breath, and an intermittent non-productive cough. In the last 48 hours, he developed a vesicular rash, and today he became confused and difficult to rouse.
Vital signs: Temperature 38.2 C, SpO 89% on 15 L/min O via non-rebreather mask, BP 124/73 mmHg.
Arterial blood gas: pH 7.339, pO 7.37 kPa, pCO 4.29 kPa, Na 127 mmol/L, lactate 3.3 mmol/L, HCO 18.2 mmol/L, base excess 8.5.
Examination:
- CVS: Normal heart sounds, no murmurs.
- Respiratory: Bilateral transmitted crackles, sparse expiratory wheeze.
- Abdomen: Soft, non-tender, no organomegaly.
- Neurology: No lateralising signs, no features of encephalitis/encephalopathy.
Bloods, cultures, and a portable chest X-ray are requested.
Initial management (following on-call microbiology advice):
- High-flow Oxygen
- IV Co-amoxiclav
- Oral Aciclovir
- Arterial monitoring: Arterial line facilitates serial ABGs and can accommodate later invasive cardiac output monitoring.
- CPAP planned once a side room is available, with step-up care to HDU.
