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COPD and Anti-asthmatics Concept Lab Case Study: Debbie O’Connor Assignment

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COPD and Anti-asthmatics Concept Lab Case Study: Debbie O’Connor Assignment-Shadow Health-Focused Exam: COPD and Anti-asthmatics Concept Lab Case Study: Debbie O’Connor/Assignment : Shadow Health-Focused Exam: COPD and Anti-asthmatics Concept Lab Case Study: Debbie O’Connor Patient: Debbie O�...

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  • May 19, 2021
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ProfMiaKennedy
Assignment 12.2: Shadow Health-Focused Exam: COPD and Anti-asthmatics Concept Lab

Case Study

Patient: Debbie O’Connor

DOB: 10/05/1964

Height: 5’5

Weight: 195lbs

Allergy: NKDA

Previous diagnosis: 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

, describes 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.

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