Focused Exam: COPD | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/7020232
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Your Results Lab Pass (/assignment_attempts/7020232/lab_pass.pdf)
Overview 1. Assessment 2. Recommendation and Monitoring
1. Assessm en t Model Note
Transcript
Ms. O'Connor presents to the clinic with worsening shortness of Debbie O’Connor is a 55-year-old White woman who has been
Subjective Data Collection
breath. She reports having an episode of bronchospasm three days previously diagnosed with Group B COPD, but whose symptoms
Objective Data Collection ago that caused a coughing fit. She has been a smoker since the age indicate she should be upgraded to Group C COPD. She is currently
of 15 and has had trouble breathing for years. She was hospitalized a smoker and smokes 3 - 5 cigarettes a day. She experienced a
Education & Empathy for COPD exacerbation 2 years ago. She states her symptoms have bronchospasm three days ago and has had increased fatigue and
progressed in the past 4 months and has been feeling more fatigued difficulty breathing since then. She has expressed a desire to quit
Documentation with worsening shortness of breath and productive cough. She smoking, which is vitally important in order to improve her condition.
describes her cough as wheezing and crackling which happens a few
Debrief times per hour and is worse after smoking.
Medication Selection
Patient Teaching
Prescription W riting
Comments
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1 of 1 6/3/20, 1:37 PM
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