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Findings
SpO2
only 93% on 24% supplemental oxygen
CXR
Equal lung fields: opacity in left lower lobe
Diaphrenic angles: costophrenic and cardiophrenic angles are unclear compared to right side
Subjective
HPC
PMHx
DHx
SHx
Smoking
Symptom based
Cough/sputum
SOB
Objective
Vital signs
Would be valuble to see if RR is high or low with supplemental oxygen
Auscultation
Fine inspiratory crackles as alvioli pop open with fluid contents
Bronchial breath sounds over lung fields (fluid transmits bronchial sounds to chest wall)
Cough assessment
Analyse effectiveness of cough
Sputum analysis/culture
colour
Infections content
ABG’s and hematology
WBC raise indicates infection
Is oxygen supplementation causing low RR, respiratory acidosis
Problem list
SOBAR
Hypoxemia
Reduced exercise tolerance/reduced self management
Increased sputum production/retention