Summary of the patients current health problems
Write a brief summary of the patients current health problems, relevant history and specific early management provided to address the primary problem prior to arriving to your ward. this should be sufficient to set the scene for the reader and should take up no more than 1 to 1.5 pages. the paper should focus upon detailed explanation of the underlying pathophysiology related to the presenting problems.
Should include an introduction that describes how the case is to be presented and organised and a conclusion that draws the key themes together. Use a minimum of 10 scholarly references to support your discussion themes ensuring that you correctly reference you work. Must clearly demonstrate the related pathophysiology in the body of your paper.
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64yrs female presents with shortness of breath and worsening cough last 3/7.
Background
1) severe brittle COPD – 4 admissions this year, current smoker (not a candidate for home oxygen), speculated lung mass RLZ
2) Hypercholesterolaemia
3) Prev TIA
4) AF – not anti coagulated
5) Osteoporosis
Medications
Rosuvastation 20mg night, Metoprolol 12.5mg twice daily, Aspirin 100mg daily, Seretide 250/25 x2puffs twice daily, atrovent 500mcg x4 daily, temazepam 10mg night and paracetamol 1g 4 times/day as required
Lives with husband, away a lot. current smoker, independent with activities daily living, mobiles independently.
3/7 worsening shortness of breath, left sided chest pain and more frequent cough
shortness of breath progressive and similar to other episodes of admission
left sided chest pain, sharp since 1500hrs today, worse on inspiration and coughing, worse on pushing
cough more frequent, usually productive but unable to produce sputum
no fevers/sweats/shakes
always feeling cold
mobilisies to the mailbox, usual daily activity
eating and drinking as normal
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