MR X

• Mr X - 78 year old male with emphysema

  
• Mr X - 78 year old male with emphysema

  • social history
  • ETOH = alcohol
  • drug history
  • Ventolin = increase air flow
  • prn = as required/when needed
  • Becotide = steroids
  • bd = twice a day
  • family history

  
• Symptoms:

  • chest tightness - wheeze sounds
  • shortness of breath
  • breathlessness
  • cough with phlegm (sputum) - if its wet/dry, what colour it is - if there's blood (haemoptysis)
  • pain
• Database questions:

  • HPC detail - GP involvement, number of admissions in the last year
  • social history - level of mobility, ability to perform daily activities, support at home, stairs
  • social history - how often, how much, when did he start, has he ever tried to stop
  • drug history - allergies, inhalers detail
• Observation of patient during subjective assessment:

  • colour
  • conscious level
  • distress
  • fatigue
  • breathing pattern
  • nutritional status
  • external apparatus
  • signs of increased work of breath