Health History Diagnosed with asthma as a child (age 7)

Ben was out for a jog, where approximately 20 minutes into the run he developed severe
shortness of breath and tightness in the chest. An ambulance was called and transported
him to hospital.
SOCIAL:
Ben, a university graduate, lives with parents and two younger siblings. He is a very fit,
young adult male who plays competition football.
PRESENTATION:
Patient Complaints: Severe dyspnoea
No Loss of consciousness
Meds Salbutamol inhaler
Health History Diagnosed with asthma as a child (age 7)
He has presented to hospital on two previous occasions for asthma related
symptoms. Following his last admission 2 years ago he had Pulmonary
Function Tests: FEV1/PEFR 80% of predicted, PEFR variability 30%
On Examination
A – Patient talking in single words, pursed lips
B – Spontaneous, resting RR 34, severe dyspnoea
Short shallow breathes, with use of accessory muscles
Tightness in chest
Dry cough
Peak expiratory flow rate ?140 ml
Auscultation – ?BS, with diffuse wheezes, auditory inspiratory and
expiratory wheeze
Percussion: hyperresonant
SpO2 93% on 4L O2
C – Resting PR128, BP 90/60, centrally warm and perfused
Elevated JVP +5 cm
D – GCS 15, PERL 3+,
E – Temp 36.7, no complaints of chest pain
2
F – RR 34, BP 90/60, resting PR128,
Patient catheterized urine output low
40mls/hour BSL 5.9
I – Pulmonary function tests – see above
ECG – Normal, no signs of ST elevation
Bloods – ABG: Ph7.35, PaCO2 45mmHg, PaO2 70mmHg, HCO3
24mmol, BE +4 Chest X-ray – Normal, hyper-inflated with flattening
of diaphragm
Bloods – NAD
Glossary of terms and abbreviations
NAD No abnormality detected
ABG Arterial Blood Gas
BP Blood pressure
ET End Tidal CO2 is the amount of CO2 in exhaled gas
GCS Glasgow comma scale
LOS Loss of consciousness
RR Respiratory rate
PERL Pupils equal and reacting to light
PMH Past or previous medical history
PR Pulse Rate
RR Respiratory Rate
SOB Short of breath
SpO2 Saturation of oxygen onto haemoglobin in arterial blood
# Fracture
(L) Left
(R) Right