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    Health Assessment of Bronchial Asthma Patient

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    Shetal Sharma
    Pallab Das, a 62-year-old male, was admitted to the hospital suffering from fever, shortness of breath, and blue skin. He has a long history of respiratory issues such as coughing, wheezing, and breathing difficulties, exacerbated by his history of smoking for over 20 years and exposure to dust from his job as a bus driver. A physical examination revealed diminished breath sounds, rhonchi, wheezing, and crepitations in his lungs, consistent with his diagnosis of chronic bronchial asthma.

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    Health Assessment of Bronchial Asthma Patient

    Uploaded by

    Shetal Sharma
    219 views3 pages
    Pallab Das, a 62-year-old male, was admitted to the hospital suffering from fever, shortness of breath, and blue skin. He has a long history of respiratory issues such as coughing, wheezing, and breathing difficulties, exacerbated by his history of smoking for over 20 years and exposure to dust from his job as a bus driver. A physical examination revealed diminished breath sounds, rhonchi, wheezing, and crepitations in his lungs, consistent with his diagnosis of chronic bronchial asthma.

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    Pallab Das, a 62-year-old male, was admitted to the hospital suffering from fever, shortness of breath, and blue skin. He has a long history of respiratory issues such as coughing, wheezing, and breathing difficulties, exacerbated by his history of smoking for over 20 years and exposure to dust from his job as a bus driver. A physical examination revealed diminished breath sounds, rhonchi, wheezing, and crepitations in his lungs, consistent with his diagnosis of chronic bronchial asthma.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    219 views3 pages

    Health Assessment of Bronchial Asthma Patient

    Uploaded by

    Shetal Sharma
    Pallab Das, a 62-year-old male, was admitted to the hospital suffering from fever, shortness of breath, and blue skin. He has a long history of respiratory issues such as coughing, wheezing, and breathing difficulties, exacerbated by his history of smoking for over 20 years and exposure to dust from his job as a bus driver. A physical examination revealed diminished breath sounds, rhonchi, wheezing, and crepitations in his lungs, consistent with his diagnosis of chronic bronchial asthma.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    HEALTH ASSESSMENT OF A PATIENT SUFFERING FROM BRONCHIAL

    ASTHMA

    NAME: Pallab Das


    AGE: 62years SEX: Male RELIGION: Hindu
    MARITAL STATUS: Married
    BED NO: 22
    REG NO: PA34011
    WARD: Male Medicine Ward
    DATE OF ADMISSION: 12.1.2020
    UNDER DR: Unit III
    ADDRESS: Mahakalpally , Siliguri.

    CHIEF COMPLAIN DURING ADMISSION: fever, shortness of breath, blue skin. He


    was finding breathing difficulty during talking, walking and doing any work.

    PRESENT HISTORY OF ILLNESS: patient is having dyspnoea, fever, cough, chest


    pain,odema over feet, wheezing during expiration at night, finds problem while inspiring
    which gets better with inhaler since 3 months.

    PAST HISTORY OF ILLNESS:


    There is a history of repeated cough and cold recurrent rhinorrhea, during his childhood, he
    also had suffered from measles during his childhood. Whenever there is any stress and
    during winters he starts having respiratory distress and for this problem he was once
    admitted in the hospital when his wife died in 2012. He has been suffering from cough with
    expectoration since last two years, and is on duolin inhaler. He has no history of cardiac
    problem, gastro intestinal, neurological or musculoskeletal disorders till date. There is no
    history of surgeries done in the past.

    PERSONAL HISTORY:

    Education: he has completed primary education and left his schooling


    Occupation: he use to be a bus driver so used to get exposed to dust whole day.
    Support system: he has a son who looks after his family who is a teacher by professional.
    Any personal habits: patient used to smoke cigarettes 10/day approx for more than 20 years,
    he occasionally used to drink alcohol, once in a month or two.
    Housing:well ventilated pucca house, single room for each member.
    Exercise: he does pranayam in the morning since few months.
    Sleep pattern: he uses two big pillows while sleeping, wakes up suddenly in the night due to
    nightmares as stated by the patient and suffers from distress which calms down of its own
    sometimes and sometimes he uses puff.

    FAMILY HISTORY:
    They are 2 brothers and 4 sisters, he being the oldest of all, his maternal uncle use to have
    same kind of problem and died due to stroke as reported, rest no one is having similar
    respiratory problem. His father died in a road traffic accident, mother died due to old age.
    DIET HISTORY:
    Patient takes meal 3 times a day and is very fond of eating oily and spicy foods which he
    cannot digest now a days , the amount of meal has grossly decreased since two years, he is no
    allergies to food.

    DRUG HISTORY: patient is on duolin inhaler since 2 years

    BRIEF SOCIO ECONOMIC HISTORY:


     No of family members: they are six members in their family, patient,his son ,
    daughter-in-law, their 2 child and another unmarried son who earns a grocery
    shop.
     Health status of family members: his younger son has a seizure disorder as he
    reported, rest all well.
     Total family income: 25-30 thousand a month.
     Housing condition: they have their own pucca house, well ventilated with
    toilet facility as patient’s son said.
     Water supply: tube well.
     Type of toilet: sanitary.
     Cooking fuel- LPG

    PHYSICAL ASSESSMENT:

    Temperature-99.8 degree farenheit


    Pulse-100 b/min
    Repiratory rate-38b/min
    Blood pressure-110/90mmHg
    SPO2-92 % without oxygen and 100 with 5 l/min

    INSPECTION:

    Position- high fowler’s position, not able to lie straight or in semi fowler position.
    Oxygen inhalation-5 l/min
    Nasal flaring- not present
    Pursed lip breathing- not present
    Mouth breathing- present
    Hydration- well maintained. Tongue wet.
    Skin color- pale, tongue pale.
    Neck veins-not distended.
    Accessory muscles of respiration ie sternocleidomastoid and intercostal muscle are working.
    Upper respiratory tract is clear when seen orally, there is no odema or polyp.
    Shape of the chest-normal
    Respiratory pattern- expration time longer than inspiration,shallow breathing, abdominal
    movement, respiratory difficulty while talking.
    Clubbing –absent.
    Edema- absent.
    Peripheral cyanosis- absent
    Central cyanosis: absent

    PALPATION:

    Skin turgor- normal


    Apex beat- couldnot localize properly
    Trachea- midline
    Movement- both sides of the lungs are moving simultaneously and symmetrically
    Vocal/ tactile fremitus- symmetrically reduced all over the chest.

    PERCUSSION:

    Resonant all over the chest


    High pitched sound heard at 5th intercoastal space.

    AUSCULTATION:

    Breath sound diminished


    Rhonchi and Wheezing- present during expiration
    Prolong expiration
    Vocal resonance- diminished all over the chest
    Coarse crepitations at lung base.

    SUMMARY:

    Pallab Das has a history of chronic smoking and exposure to dust allergen for many years
    and after many years of the exposure to the different allergens he has developedbronchial
    asthma. His living style and food habit has grossly changed due to aging process as well as
    his general condition which has deteriorated over years, a positive attitude is that patient is
    very optimistic type, performs activity of daily living by his own to some extents and does
    respiratory exercises on his own will.

    CONCLUSION:

    Patient is on rest, medications and oxygen inhalation going on, feeding with semisolid diet
    and passing urine and stool normally. His general condition is not stable.

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