Clinical Cases in Paramedicine. Группа авторов
She says hello as you introduce yourself to her.
Patient assessment triangle
General appearance
Alert. Speaking in short sentences. She looks panicked.
Circulation to the skin
Flushed cheeks.
Work of breathing
Breathing appears rapid and shallow. An audible wheeze is noted.
SYSTEMATIC APPROACH
Danger
None at this time.
Response
Alert on the AVPU scale.
Airway
Clear.
Breathing
RR: 28. Regular and shallow. No accessory muscle use. Expiratory wheeze on auscultation.
Circulation
HR: 100. Regular and strong. Capillary refill time <2 seconds. Flushed cheeks and peripherally warm.
Disability
Moving all four limbs.
Pupils equal and reactive to light (PEARL).
Exposure
Bystanders have left. Next of kin are now on scene.
Temperature: warm summer evening – approx. 20 °C.
Vital signs
RR: 28 bpm
HR: 100 bpm
BP: 125/74 mmHg
SpO2: 93%
Blood glucose: 5.2 mmol/L
Temperature: 36.9 °C
PEF: 300 L/min
GCS: 15/15
4 Lead ECG: sinus tachycardia
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
Aside from auscultation, which you have already done, what examination techniques should you incorporate into this patient assessment? Inspection – observe the chest for an abnormalities such as wounds, scars, bruising, asymmetry and recession.Palpation – feel for any asymmetry, vocal fremitus and tenderness.Percussion – hyper‐ or hypo‐resonance.
What adventitious (added) sounds might indicate asthma and why? Expiratory wheeze. This sound is made when air has a restricted path through the bronchi, due to inflammation and muscle spasm in the airways.
What medicine (pharmacology) is likely to relieve the patient’s symptoms and why? Nebulised salbutamol – it is a Beta2, adrenergic agonist that relaxes smooth muscle in the bronchi.
Case Progression
You treat the patient with 5 mg of nebulised salbutamol and 6 L of oxygen. The nebuliser finishes and you remove the mask.
Patient assessment triangle
General appearance
The patient is now speaking in full sentences.
Circulation to the skin
Flushed.
Work of breathing
Normal effort of breathing.
SYSTEMATIC APPROACH
Danger
None at this time.
Response
Alert.
Airway
Clear.
Breathing
RR:16. Regular. Normal depth. No accessory muscle use. No wheeze or adventitious sounds.
Circulation
HR: 105. Regular and strong. Capillary refill time <2 seconds. Flushed cheeks and peripherally warm.
Disability
No change.
Exposure
No change.
Vital signs
RR: 16 bpm
HR: 105 bpm
BP: 128/78 mmHg
SpO2: 97%
Blood glucose: not repeated
Temperature: not repeated
PEF: 380 L/min
GCS: 15/15
4 lead ECG: sinus tachycardia
1 What kinds of questions would you ask this patient specifically related to asthma as part of the history‐taking process? See Table 1.1.
Table 1.1 History‐taking questions
| Asthma history Does this feel like your normal asthma? Is this the worst it’s ever been? What time did this episode start today? Do you take your asthma medication regularly? What were you doing when it started today? What usually triggers your symptoms? When was the last time your visited your GP and/or went to hospital with these symptoms? Have you ever been intubated or been in ICU with these symptoms? Medication history What asthma medications do you take? How frequently do you have to take your medication? Do you usually have to take your inhaler while exercising? When was the last time you had a medication review with your GP? Have you had any recent changes in medication? Do you take any other medications? Have you had any coaching on the best way to take your inhaler? F/SH (family and social history) Does anyone else in your family experience asthma? Do you smoke? If so, how frequently? Do you drink or take any drugs recreationally? Who do you live with? What do you do for work? Do you exercise regularly? Are you under any particular stress at the moment? Past medical history (PMH) Do you have any other medical problems? Do you have any allergies? Have you had a cough or cold recently? |
1 The patient is 160 cm tall, what should her predicted peak expiratory flow reading (PEFR) be? Her first reading