COPD Debbie O’Connor shadow health Subjective Data

Patient Interview Guide: Respiratory Patient

Chief Complaint

Finding: Established chief complaint and reason for admittance (Found)

Pro Tip: A patient’s chief complaint highlights their presenting concerns. Asking about it allows them to voice their symptoms.

Example Question: When did your symptoms start?

History of Present Illness

Finding: Asked about additional symptoms (Found)

Pro Tip: Asking about the duration of current health issues helps gather details about their present illness.

Example Question: Do you feel fatigued?

Onset and Duration of Symptoms

Finding: Reports most severe fatigue and difficulty breathing began three days ago (Available)

Pro Tip: Asking about the duration of current health issues helps gather details about their present illness.

Example Question: When did your fatigue begin?

Finding: Reports purulent sputum production started two weeks ago (Found)

Pro Tip: Asking about the duration of current health issues helps gather details about their present illness.

Example Question: When did your productive cough begin?

Finding: Reports respiratory symptoms increased in the last four months (Available)

Pro Tip: Asking about the duration of current health issues helps gather details about their present illness.

Example Question: How long have you had your symptoms?

Characteristics of Respiratory Distress

Finding: Reports sputum is mostly clear with occasional yellow, gray, or dark color (Found)

Pro Tip: Asking about the characteristics of their sputum helps understand their condition.

Example Question: What does your sputum look like?

Finding: Reports wheezing (Available)

Pro Tip: Asking about the characteristics of their respiratory distress helps understand their condition.

Example Question: Are you wheezing?

Finding: Reports cough sounds like crackling (Available)

Pro Tip: Asking about the characteristics of their cough helps understand their condition.

Example Question: What does your cough sound like?

Aggravating Factors

Finding: Reports exertion worsens symptoms (Available)

Pro Tip: Asking about factors worsening their symptoms helps understand their condition.

Example Question: Does exertion make your symptoms worse?

Finding: Reports coughing fits after smoking (Found)

Pro Tip: Asking about factors worsening their symptoms helps understand their condition.

Example Question: When do you have coughing fits?

Treatment and Relieving Factors

Finding: Reports trying to hold off on smoking cigarettes as long as possible (Found)

Pro Tip: Asking about treatment attempts helps understand their condition.

Example Question: How long do you wait between cigarettes?

Finding: Reports breathing difficulty and associated discomfort is a 6/10 (Found)

Pro Tip: Asking about the severity of their symptoms helps understand their condition.

Example Question: Can you rate your symptoms on a scale of 1 to 10?

Effects on Social Activity

Finding: Reports low social activity – doesn’t feel up to getting out and about (Found)

Pro Tip: Asking about the impact on their life helps understand the severity.

Example Question: How do your symptoms prevent you from social activities?

COPD Debbie O’Connor shadow health Subjective Data

Patient History

Chronic Bronchitis and COPD

Diagnosed with chronic bronchitis related to COPD (Class B) following a respiratory distress episode.

Uses a formoterol inhaler (LABA) twice daily (morning and night) for COPD, but reports it’s not very effective.

FEV1 reading (spirometry test) is 1.37 L, which is 49% of predicted lung function.

Denies using oxygen therapy due to cigarette smoking.

Medications

Formoterol inhaler (LABA) – twice daily

Smoking History

Started smoking at age 15.

Quit smoking when her daughter was young but restarted in her 30s.

Currently smokes 3-5 cigarettes daily for the past four months.

Has a 37 pack-year history of smoking.

Tried quitting smoking several times using nicotine replacement therapy (gum, lozenges, patches) but failed due to a lack of adherence.

Longest quit period was 10 years.

Daughter is supportive of her quitting smoking.

Social History

Lives with her daughter due to declining health.

Reports stress from arguments with her daughter over smoking.

Denies alcohol or illegal drug use.

Daughter cooks healthy meals for her, but when she’s not home, the patient eats mostly frozen meals.

Denies exercising due to fatigue, exhaustion, and worsening respiratory symptoms with exertion.

Family History

Father: Smoked and died of a heart attack.

Mother: Died of smoking-related pneumonia.

Husband: Smoked and died of lung cancer.

Daughter: Non-smoker and health conscious.

Review of Systems

Weight: Gained 30 pounds in the last two years.

Eyes: Nearsighted and wears glasses.

Skin: Yellowing of skin, nails, and teeth (jaundice). Denies bluish discoloration (cyanosis).

Genitourinary: Postmenopausal and not sexually active.

Activities of Daily Living (ADLs): Difficulty moving around the house and performing tasks like dressing and cooking due to exhaustion.

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