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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