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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