Discovery Call

Clinician Specialty: Healthcare Assistant Previous Admissions & Self-Management: Patient's last hospital admission was approximately three months ago for a severe asthma exacerbation. The onset was sudden, following a viral infection. Triggers that led to admission included a worsening cough, increased wheezing, and significant shortness of breath, which developed rapidly over 24 hours. Patient attempted to contact their GP but was advised to call 111, who then recommended emergency services. Patient assesses that they generally manage their asthma well day-to-day with regular medication, but struggles during periods of illness or high stress. Patient is aware of warning signs for their condition, including increased cough, wheezing, and breathlessness, and knows to use their reliever inhaler. Patient perceives their prescribed preventer and reliever inhalers as highly effective when used correctly. Recent medication review by the GP occurred two months prior to this admission, with no changes made. Last specialist (respiratory consultant) appointment was on 1 November 2023. Patient would like additional help with stress management techniques to prevent asthma flare-ups and further education on identifying early signs of infection. Medical History & Records Review: Patient confirmed documented conditions of asthma and mild eczema. No additional conditions are currently being treated. Medications & Allergies: Known allergies include penicillin (rash) and house dust mites (rhinitis). No food or other substance allergies. Patient reports good adherence to prescribed medications, using their preventer inhaler twice daily and reliever as needed. No recent changes to medications reported. Patient occasionally purchases over-the-counter antihistamines for seasonal allergies. Inhaler Review: Patient is using a Fostair Nexthaler (preventer) and Ventolin Evohaler (reliever). Patient demonstrated good understanding of correct inhaler technique for both devices. COPD Exacerbations: Not applicable, patient has asthma, not COPD. Lifestyle & Vaccinations: Height (m): 1.65 Weight (kg): 78 BMI: 28.7 Weight management signposted: Yes, patient was signposted to local weight management services. Smoking status: Never smoked. Cessation advice given: Not applicable. Cessation referral: Not applicable. Stop smoking service signposted: Not applicable. Alcohol units per week: Approximately 6 units per week. Patient advised about alcohol: Yes, advised on recommended weekly limits. Substance misuse / illicit drug use: Denies any substance misuse or illicit drug use. Physical activity level: Engages in moderate intensity exercise (brisk walking) 3 times a week for 30 minutes. Physical activity signposted: Yes, patient was signposted to local walking groups and online resources for physical activity. Last influenza vaccination: 1 November 2023 Last pneumococcal vaccination: 1 November 2022 Last COVID-19 vaccination: 1 November 2023 (booster dose) Shingles vaccination: Not yet indicated based on age. RSV vaccination: Not yet indicated. Immunisation status REQUIRED: Up-to-date with routine vaccinations, including flu and pneumonia. COVID booster received. Immunisation advice given: Advised on upcoming seasonal flu vaccination and future COVID boosters. NHS Health Check indicated: Yes, recommended due to age and BMI. COPD Warning Signs Education: Not applicable, patient has asthma, not COPD. Heart Failure Warning Signs Education: Not applicable, no history of heart failure. Patient Care Plan Summary: This discovery call focused on reviewing your asthma management and overall health. We discussed your last hospital admission for an asthma flare-up and noted good understanding of your condition's warning signs. You manage your asthma well day-to-day with your Fostair and Ventolin inhalers. We explored your lifestyle, including your excellent vaccination status, and provided information on healthy eating and increasing physical activity. You expressed interest in learning stress management techniques and understanding early infection signs. Primary Health Goals: * Improve stress management to reduce asthma triggers. * Increase understanding of early infection warning signs relevant to asthma. * Engage with recommended weight management resources. * Attend NHS Health Check.