Focused Exam: COPD Results | Turned In
Advanced Pharmacology - Summer 2019, NURS 5304
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Subjective Data Collection: 32 of 32 (100.0%)
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Chief Complaint
Indicates an item that you found.
Indicates an item that is available to be found.
Patient Data
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A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.
Established chief complaint and reason for admittance
Reports a bronchospasm three days ago Reports increased difficulty breathing Reports desire for smoking cessation aids
History of Present Illness
Asked about additional symptoms Reports fatigue and weakness
Reports purulent sputum Reports cough
Reports feeling anxious about symptoms and worsening health issues
Asked about onset and duration of Reports most severe fatigue and difficulty
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
This study source was downloaded by 100000815110306 from CourseHero.com on 07-30-2021 06:27:28 GMT -05:00 Reports formoterol dose of 12 micrograms
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
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" non- smoker
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
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