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Assignment 12.2: Shadow Health-Focused Exam: COPD and Anti-asthmatics Concept Lab;D. OConnor

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Assignment 12.2: Shadow Health-Focused Exam: COPD and Anti-asthmatics Concept Lab;D. OConnor Case Study Patient: Debbie O’Connor DOB: 10/05/1964 Height: 5’5 Weight: 195lbs Allergy: NKDA Previous d... iagnosis: COPD Group B – chronic bronchitis Current diagnosis: COPD Class C – chronic bronchitis Scenario: Ms. O’Connor is a 55-year old Caucasian female who has come to the doctor’s office reporting worsening of COPD symptoms and a recent, frightening episode of bronchospasm. She is a long-term smoker (37 years) and would like assistance with smoking cessation. Home medications: Formoterol inhaler 12mcg single-use q12 hours Vitals: Temp 37C (Temporal), Blood pressure 129/79 (Automatic), Heart rate 90 (NSR), O2 sat 92% (room air), Respiratory rate 26. Assessment: Ms. O’Connor is in today stating she feels her lungs “are falling apart” due to worsening shortness of breath. She reports that three days ago she had an episode of bronchospasm causing a coughing fit that made her apprehensive about her pulmonary health. She has been a smoker since the age of 15 and has had trouble breathing for years being hospitalized for a COPD exacerbation two years ago. She complains of feeling very uncomfortable with breathing difficulty being a 6 out of 10. Patient states symptoms have progressed in the recent 4 months as she has been getting more fatigued with worsening shortness of breath on minimal exertion, and a productive cough expectorating phlegm. She This study resource was shared via CourseHscribes the cough as a wheezing, crackling sound which happens a few times an hour throughout the day with worsening frequency after she smokes a cigarette. She reports feeling anxious about her health and when symptoms arise although she denies having an anxiety disorder. The patient describes the sputum as mostly clear with episodes of yellow, gray and dark-colored expectoration. She denies seeing any blood but does describe it as the texture being thick starting two weeks ago. Ms. O’Connor reports constant wheezing and a strong desire to stop smoking to reduce her breathing symptoms. She reports multiple attempts at quitting smoking with the longest being 10 years when she had her daughter. She has tried using gum, patches and lozenges being unsuccessful at most attempts due to lack of required compliance. Reports symptoms have made her less social with no desire to go out even affecting her activities of daily living. Denies oxygen use out of fear of igniting a fire. Lives with her daughter who is a nonsmoker and is supportive of her mother's decision to stop smoking. Ms. O’Connor states her daughter cooks most of her meals however when she is not around, the alternative is frozen meals. She reports a 30lb weight gain over the last couple of months. She uses Formoterol inhaler twice a day and denies the use of any other medications including vitamins. Denies alcohol and drug use. Denies having a fever, having contracted influenza recently. She admits to not having the flu shot in some time and was educated on the importance of being diligent about having the shot yearly as recommended by the CDC. Ms. O'Connor uses an incentive spirometer at home achieving an FEV1 reading of 1.37L, which she states is approximately 49% of her goal therapy. She reports no exercise due to symptoms. Reports no major eyesight issues other than nearsightedness, no surgeries, one miscarriage at a young age. Reports yellow discoloration of the skin around the mouth, teeth, nails, and fingers. Denies any cyanosis. She is postmenopausal, not sexually active. [Show More]

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