Focused Exam: COPD Debbie O’Connor shadow health transcript sample
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Total Time:125 min
 | Hello Debbie O’Connor, My name is Danielle Scott. I will be your provider today. | Greet 03/30/20 3:44 PM CDT |
 | Hello. | |
| Can you verify your Name and birthday? | Question 03/30/20 3:44 PM CDT |
| I was born on October 5 . . . [Ms. O’Connor reports the correct birth year.] | |
| What brings you in today? | Question 03/30/20 3:44 PM CDT |
| I’m having so much trouble just trying to breathe. And I’ve had these terrible coughing fits. A few days ago, a bronchospasm. My health is going downhill fast . . . I know it has to do with my smoking habit. It’s so hard to kick. I was hoping I could get something to help me. | |
| I’m sorry to hear that you are experiencing anxiety over your current health conditions. Not being able to breathe is a scary condition. With the right therapy, and if you quit smoking, you’ll begin to feel better. | Empathize 03/30/20 3:47 PM CDT |
| That’s very kind. | |
| Are you experiencing any other symptoms? | Question 03/30/20 3:48 PM CDT |
| I feel exhausted. I’m just so weak now, that even walking up the stairs feels exhausting. I had this awful coughing fit three days ago. But I’ve had trouble breathing for several months now. I’ve also been coughing up some nasty phlegm. | |
| When did you start coughing up the phlegm | Question 03/30/20 3:50 PM CDT |
| I cough up sputum all the time. It’s been like this for a couple of weeks. It’s this dark gray — or sometimes yellow color. | |
| Any aggravating factors? | Question 03/30/20 3:51 PM CDT |
| Honestly, smoking makes my breathing worse. I have these terrible coughing fits afterwards. Kind of a no-brainer, but I can’t help myself. I can’t handle the withdrawal, so I just try to hold out between cigarettes as long as I can. | |
| Is there anything that relieves the symptoms? | Question 03/30/20 3:52 PM CDT |
| Nothing seems to make my symptoms feel better — not even my inhaler. I know for sure that smoking makes it worse. I try to hold off as long as I can between cigs. But still . . . I think if I quit I’d feel better. | |
| How bad is you breathing? (Clarified to How severe are your breathing problems?.) | Question 03/30/20 3:52 PM CDT |
| Breathing is so hard, all the time. I guess I’d put it at a 6 out of 10. (Clarified to how severe my breathing problems are.) | |
| How does your health affect your social life? | Question 03/30/20 3:53 PM CDT |
| My breathing problems sure aren’t helping my social life any. I was never exactly a social butterfly, but now I’m not up to going out. Even normal things–shopping, picking up my meds. | |
| Do you have any other existing health conditions? | Question 03/30/20 3:54 PM CDT |
| I’ve only got Group B COPD. The chronic bronchitis kind. [AUDIO COMING SOON] | |
| Any recent hospitalizations? | Question 03/30/20 3:55 PM CDT |
| I haven’t been to the hospital in about two years. I had a bad breathing episode and they said I had COPD. | |
| What medications are you currently taking? | Question 03/30/20 3:57 PM CDT |
| I have an inhaler that I use for my COPD — a formoterol inhaler. | |
| How often you do you use your inhaler? | Question 03/30/20 3:58 PM CDT |
| I use it twice a day, morning and night. Every 12 hours. | |
| Whats the dosage of the inhaler? | Question 03/30/20 3:58 PM CDT |
| I take 12 micrograms of formoterol. | |
| Do you take any supplements or vitamins? | Question 03/30/20 3:59 PM CDT |
| I don’t take any vitamins or supplements or any of that stuff. | |
| Are you complaint with your medicine? (No matching questions found.) | Question 03/30/20 3:59 PM CDT |
| Do you miss doses of medications? (Clarified to Do you miss doses of your medication?.) | Question 03/30/20 4:00 PM CDT |
| No, I never miss doses. I use my inhaler once in the morning and once at night. I find that easy enough to remember. (Clarified to if I miss doses of my medication.) | |
| Do you use a spirometer? | Question 03/30/20 4:00 PM CDT |
| I have a spirometer, yes. Only use it sometimes. Got an FEV1 reading of 1.37 L the other day. That’s 49%. | |
| Do you have any allergies? | Question 03/30/20 4:01 PM CDT |
| I don’t have any allergies, never had an allergic reaction . . . nothing like that. | |
| Do you use home oxygen? | Question 03/30/20 4:01 PM CDT |
| I don’t use oxygen . . . it could probably help me. But I’d blow myself up, smoking near it. | |
| Oxygen therapy could help alleviate some of your symptoms of breathlessness and fatigue. Unfortunately, you cannot use oxygen therapy if you smoke. It’s too dangerous. Once you quit smoking, you can seek this treatment. | Educate 03/30/20 4:04 PM CDT |
| You certainly know your stuff. | |
| Have you had any vaccines? | Question 03/30/20 4:05 PM CDT |
| I’ve had vaccines before, but . . . it’s been a long time. | |
| At your age, and with your health conditions, it’s vital that you get an annual flu shot, and that you receive a pneumococcal vaccine every ten years. These two infections could have terrible effects on your health because your respiratory system is already compromised. | Educate 03/30/20 4:08 PM CDT |
| That’s good to know. | |
| Do you live at home alone? | Question 03/30/20 4:11 PM CDT |
| I live with my daughter, Ava. I moved in when my health started getting worse. She takes care of me. | |
| do you drink alcohol? | Question 03/30/20 4:11 PM CDT |
| I don’t touch the stuff. My daddy was a drinker, and I saw what it did to him. | |
| Any substance abuse? | Question 03/30/20 4:12 PM CDT |
| No, that never appealed to me. | |
| how long have you been a smoker | Question 03/30/20 4:12 PM CDT |
| I started smoking when I was 15. I’ve smoked for a long time. Had a little success quitting. I stopped for ten years when my daughter was born. But, I picked up the habit again. I’ve tried quitting since my husband died, but . . . it’s hard. | |
| I’m sorry that you lost your husband. That sounds like it must have been very difficult for you. | Empathize 03/30/20 4:15 PM CDT |
| Thanks. | |
| how many cigarettes do you smoke per day | Question 03/30/20 4:15 PM CDT |
| Typically I smoke between three and five cigarettes a day. It’s been that way for the last four months. Ever since I relapsed. Smoking makes my breathing worse, so . . . I try to hold off as long as I can between cigarettes. | |
| It’s vital that you quit smoking as soon as possible in order to get some relief from you COPD symptoms. Smoking is putting your life in danger and making your symptoms worse. I can point you towards community or national smoking cessation programs that can help support you while you are quiting | Educate 03/30/20 4:20 PM CDT |
| I’ll be sure to keep that in mind. | |
| Do you exercise? | Question 03/30/20 4:20 PM CDT |
| I can’t exercise. I can’t even move around the house without feeling fatigued and out of breath. Exerting myself in any way makes me feel worse. | |
| Tell me about your diet? | Question 03/30/20 4:21 PM CDT |
| Well, I’m too weak to cook. I eat microwavable meals if I’m alone. Pasta, pizza, rice, all that. My daughter cooks nice food . . . quinoa, salads, salmon. | |
| When you COPD symptoms have been alleviated it is important that you try to eat well and get some light exercise. Not exercising can exacerbate your symptoms, and some exercise will help you breathe easier and build lung capacity | Educate 03/30/20 4:23 PM CDT |
| Oh! That makes sense. | |
| Any family history of illness? | Question 03/30/20 4:24 PM CDT |
| My parents died from smoking their whole lives. It was a different time . . . my father had a heart attack at 42. My mother edged him out, but she eventually got pneumonia. | |
| Changes in your weight? (Clarified to Has your weight changed recently?.) | Question 03/30/20 4:24 PM CDT |
| I’ve gained 30 pounds these past two years. (Clarified to if I have had weight changes recently.) | |
| Do you have any problems with your vision | Question 03/30/20 4:26 PM CDT |
| I’m nearsighted, but my glasses work fine. | |
| have you noticed any shin issues (No matching questions found.) | Question 03/30/20 4:26 PM CDT |
| Any skin changes? | Question 03/30/20 4:27 PM CDT |
| Skin’s been turning yellow around my mouth and fingers. From cigarettes, I’m sure. At least I haven’t turned blue. | |
| Any issues with your menses (No matching questions found.) | Question 03/30/20 4:28 PM CDT |
| WHen was you last period | Question 03/30/20 4:28 PM CDT |
| I haven’t had a period since I went through menopause. | |
| Do you work? | Question 03/30/20 4:28 PM CDT |
| I’m retired. Used to be an office manager. | |
| Hello, I have written some prescriptions | Question 03/30/20 5:02 PM CDT |
| Sure thing, honey. | |
| For the tiotropium inhaler, take missed dose as soon as possible. | Question 03/30/20 5:03 PM CDT |
| Ok. I understand. | |
| use the rescue inhaler for acute symptoms | Question 03/30/20 5:03 PM CDT |
| I’ll be sure to do just that. | |
| do not swallow the capsules, they should be inhaled with the inhaler | Question 03/30/20 5:04 PM CDT |
| I understand. | |
| Inhale the capsule twice to get the full dose | Question 03/30/20 5:04 PM CDT |
| Alright. | |
| stop the medication and contact the doctor if you experience bronchospasm immediately after a treatment | Question 03/30/20 5:06 PM CDT |
| Isn’t this inhaler supposed to keep that from happening? | |
| yes, youre right. thats why it is important to contact us | Question 03/30/20 5:06 PM CDT |
| Alright. I think I understand. | |
| common side effects will be dry mouth | Question 03/30/20 5:07 PM CDT |
| Alright. | |
| keep the capsules inside the packaging | Question 03/30/20 5:07 PM CDT |
| Understood. | |
| be sure to use the medication as recommended | Question 03/30/20 5:08 PM CDT |
| Okay. | |
| prep the inhaler before use | Question 03/30/20 5:08 PM CDT |
| I’ll be sure to keep that in mind. | |
| seek help if you can not control your breathing | Question 03/30/20 5:09 PM CDT |
| I sure hope that doesn’t happen. | |
| you might feel nervous | Question 03/30/20 5:09 PM CDT |
| Thank you for letting me know. I’ll keep an eye out for that. | |
| for the varenicline take missed dose as soon as possible | Question 03/30/20 5:10 PM CDT |
| I’ll be sure to do just that. | |
| begin smoking cessation counseling immediately | Question 03/30/20 5:11 PM CDT |
| I won’t stop trying to quit, no matter what. I have to make it happen this time. | |
| it will cause dry mouth | Question 03/30/20 5:11 PM CDT |
| I can try to deal with that if it happens. | |
| stop medication if you experience an allergic reaction | Question 03/30/20 5:12 PM CDT |
| I’ll keep an eye out for those side effects. | |
| contact provider if you have thoughts of hurting yourself or depression | Question 03/30/20 5:13 PM CDT |
| That’s awful scary. Are you sure I should be taking this medicine? | |
| Its rare, we just want to be safe | Question 03/30/20 5:13 PM CDT |
| Alright. As long as you think it will work. | |
| anything else? | Question 03/30/20 5:13 PM CDT |
| Ok. See you later. |
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