Case Study- Sputum Retention PDF

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Summary

CPP notes 2019-2020...

Description

34 year old female PC

Consultant referral to Outpatients for Physiotherapy intervention for management of Bronchiectasis

HPC

Diagnosed with Bronchiectasis five years ago after admission with chest exacerbation. Has had a productive cough for many years. Since diagnosis managed self at home and normally productive of ½ cup sputum per day. Patient not adhering to current physiotherapy regime as it does not fit in with routine. Starting to get increase in numbers of exacerbations and impacting on daily function as not able to do as much without being SOB. All managed at home but 3 in last six months. Patient seems knowledgeable on condition. Patient concerned re coughing due to leaking of small amounts of urine

PMH

Pneumonia as a child complicated with empyema

SH

Lives with Husband and 2 young children aged 5 and 3 Has dog Full time employed as Teacher Active life style Gym 3 time per week until last six months . Less due to increasing SOB Never smoked

DH

Nil at moment Has emergency antibiotics at home in case of signs of infection

Objecvtive: Resp

SV room air, RR- 12, Resp Pattern- normal,

Ausc

Breath sounds throughout Reduced A/E right mid zone Crackles right base

ABGs

Not indicated

Exp

Decreased right midzone

Palpation

No Palp crepes at tidal volume breathing

CXR /CT

CT report shows Bronchiectatic changes right mid and lower zone

CVS

Temp 37.0

Renal

Nil of note

HR 98 SATS 99%

BP 125/80

MSK

Nil of note

Micro

Staphlococcus aureus in sputum sample 6/12 ago

Hands

Clubbed

Position

Sitting in chair

Observe

Looks Well Sounds like trying to suppress cough...