Focused Exam_ COPD _ Subjective Data Collection

Subjective Data Collection: 32 of 32 (100.0%) Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Debrief Medication Selection Patient Teaching Prescription Writing Lab Pass Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. This study source was downloaded by from CourseH on :16:35 GMT -05:00 Reports purulent sputum production started two weeks ago Reports respiratory symptoms increased in the last four months Followed up on characteristics of respiratory distress Reports sputum is mostly clear with occasional yellow, gray, or dark color Reports wheezing Reports cough sounds like crackling Asked about aggravating factors Reports exertion worsens symptoms Reports coughing fits after smoking Asked about treatment and relieving factors of respiratory symptoms Reports trying to hold off on smoking cigarettes as long as possible Asked about severity of respiratory distress Reports breathing difficulty and associated discomfort is a 6/10 Asked about effects of health on social activity Reports low social activity - doesn't feel up to getting out and about Past Medical History Asked about existing health conditions Reports chronic bronchitis related to COPD Followed up on chronic bronchitis COPD diagnosis Reports diagnosed with "Class B" COPD Reports diagnosed after respiratory distress episode Asked about ER visits or hospitalizations Reports hospitalization after miscarriage at age 24 Reports most recent hospitalization was two years ago Reports most recent hospitalization was for respiratory distress episode Home Medications Asked about home medications Reports taking a long-acting beta-agonist (LABA) Followed up on LABA Reports the LABA is formoterol inhaler Reports formoterol dose of 12 micrograms This study source was downloaded by from CourseH on :16:35 GMT -05:00 Reports only using once every 12 hours, once in the morning and once at night Reports using LABA this morning Reports the LABA is not very effective Denies medication side effects Asked about supplements and vitamins Denies use of supplements or vitamins Asked about medication regimen adherence Denies missing doses Asked about spirometry Reports sporadic spirometry readings at home Reports most recent FEV1 reading was 1.37 L, 49% of her predicted FEV1 Asked about oxygen use Denies oxygen therapy due to cigarette smoking Asked about allergies Denies allergies Asked about vaccines Denies recent influenza vaccine Denies recent pneumococcal vaccines Social History Asked about living environment Reports she lives with her daughter Reports recently moving in with her daughter because of her declining health Reports stress from arguments with daughter over smoking Asked about substance use Reports cigarette smoking Denies drinking alcohol Denies using illegal substances Followed up on current cigarette smoking Reports three to five cigarettes a day for the past four months Reports stressful situations trigger her smoking Reports daughter convinced her to quit smoking because of declining health issues Reports husband's death of lung cancer makes her want to quit This study source was downloaded by from CourseH on :16:35 GMT -05:00 Followed up on history of cigarette smoking Reports started smoking at age 15 Reports quit smoking when her daughter was young but started smoking again in her 30s Reports 37 pack years according to an online calculator her daughter used Followed up on smoking cessation Reports trying to quit several times unsuccessfully with nicotine replacement therapy Reports having tried nicotine gum, lozenges, and patches Reports nicotine replacement therapy failed because she did not want to deal with the required compliance Reports her longest period without smoking was 10 years Asked about exercise Denies exercise due to fatigue, exhaustion, exacerbated symptoms upon exertion Asked about diet Reports eating mostly frozen meals when daughter is at work Reports her daughter cooks healthy meals for her Family Medical History Asked about relevant family history Reports father, smoker, died of a heart attack Reports mother died of smoking-related pneumonia Reports husband smoked and died of lung cancer Reports daughter is a "health nut" nonsmoker Review of Systems Asked about weight changes Reports weight gain of 30 pounds in the last two years Asked about review of systems for HEENT Reports vision is nearsighted Reports wearing glasses Asked about review of systems for integumentary Reports yellowing of skin, nails, and teeth Denies cyanosis This study source was downloaded by from CourseH on :16:35 GMT -05:00 Asked about review of systems for genitourinary Reports being postmenopausal Reports not sexually active Activities of Daily Living Asked about ADLs Reports difficulty moving around home Reports difficulty with activities like dressing or cooking due to exhaustio