Patient Interaction Report
Patient Interaction
A full medical history and examination was taken from this patient suffering from recurrent acute exacerbations of COPD and heart failure.
This 79 year old female has suffered with what she describes as a bad chest for over ten years frequently experiencing dyspnoea and chest infections. She recalls suffering many exacerbations and put this down to experiencing asthma attacks. The patient admitted she had smoked 10 cigarettes a day for 64 years- a 32 pack year history. She was experiencing recurrent exacerbations of shortness of breath, unable to walk without fatigue and sputum production.
My initial thoughts were that she did not seem to be able to breathe well at all. This was quite alarming to me however she told me that this was usual for her. I felt somewhat reassured but I noticed that it was difficult to make conversation with her properly because of the degree of dyspnoea. She was diagnosed with COPD in 2000 and put on …show more content…
Her tongue was slightly blue in colour signifying central cyanosis.
Her radial pulse was 84 beats a minute with a regular pulse. Respiratory rate was 15 breaths per minute.
On auscultation, she had normal heart sounds with no murmurs. There was an expiratory wheeze throughout both lungs. I could hear crepes bilaterally, more on the right than left- crackly on inspiration and wheezy on expiration, which could possibly suggest pulmonary oedema.
On palpation, percussion was more resonant on the left, as was vocal and tactile fremitus. There was also more chest expansion on the left than right.
She showed signs of peripheral oedema bilaterally at the ankles. This patient appears to suffer from right sided heart failure as there is peripheral oedema, although there were no signs of ascites or hepatomegaly. From her medical records, the first documented chest infection was when she was 70 years old- an acute respiratory infection, and such chest exacerbations have recurred ever
A full medical history and examination was taken from this patient suffering from recurrent acute exacerbations of COPD and heart failure.
This 79 year old female has suffered with what she describes as a bad chest for over ten years frequently experiencing dyspnoea and chest infections. She recalls suffering many exacerbations and put this down to experiencing asthma attacks. The patient admitted she had smoked 10 cigarettes a day for 64 years- a 32 pack year history. She was experiencing recurrent exacerbations of shortness of breath, unable to walk without fatigue and sputum production.
My initial thoughts were that she did not seem to be able to breathe well at all. This was quite alarming to me however she told me that this was usual for her. I felt somewhat reassured but I noticed that it was difficult to make conversation with her properly because of the degree of dyspnoea. She was diagnosed with COPD in 2000 and put on …show more content…
Her tongue was slightly blue in colour signifying central cyanosis.
Her radial pulse was 84 beats a minute with a regular pulse. Respiratory rate was 15 breaths per minute.
On auscultation, she had normal heart sounds with no murmurs. There was an expiratory wheeze throughout both lungs. I could hear crepes bilaterally, more on the right than left- crackly on inspiration and wheezy on expiration, which could possibly suggest pulmonary oedema.
On palpation, percussion was more resonant on the left, as was vocal and tactile fremitus. There was also more chest expansion on the left than right.
She showed signs of peripheral oedema bilaterally at the ankles. This patient appears to suffer from right sided heart failure as there is peripheral oedema, although there were no signs of ascites or hepatomegaly. From her medical records, the first documented chest infection was when she was 70 years old- an acute respiratory infection, and such chest exacerbations have recurred ever