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History of Presenting Complaint

Mr Thomas is an independent, cognitively intact 69-year-old Indigenous man living with his wife in the Kalumburu community of WA. 

He presented to the community nurse with severe respiratory distress.  The RFDS were called to transport Mr Thomas to Perth for urgent assessment and treatment.  The transfer team noted Mr Thomas’ oxygen saturation of 91% and suspected right lower zone pneumonia.  He was given high flow oxygen, IV ceftriaxone and merepenum and stabilised. His wife accompanied him because of Mr Thomas’ unfamiliarity with urban Australia.

As well as an accurate history of the current presentation it is vital to collect information regarding previous cognitive status, previous functional status, medication use, co-morbid conditions, pain levels, alcohol and drug use and environmental factors in any person presenting with altered mental state.

A diagnosis of CHANGE in mental state can only be made with a good assessment of BASELINE function.