Outline Of A Written Assessment Task

D.Z.is a 65-year-old man admitted to medical ward with an exacerbation of chronic obstructive pulmonary disease (COPD; emphysema). Past medical history (PMH) indicates hypertension (HTN), well managed with enalapril (Vasotec) past six years, diagnosis (Dx) of pneumonia yearly for the past three years. D.Z. appears cachectic with difficulty breathing at rest. Patient reports productive cough with thick yellow-green sputum. He seems anxious and irritable during subjective data collection. He states, he has been a 2-pack-a-day smoker for 38 years. He complains of (c/o) insomnia and

02 Assessment task – Communication and professional relationships with children, young people and adults. Explain why effective communication is important in developing positive relationship In order to contribute to positive relationships, effective communication is vital. By communicating effectively, we are encouraging a good relationship, be it with children, young people or adults. This means we are more likely to talk about things that need to be discussed.

According to the provider, the claimant's cough has been improved. His review of systems was positive for fatigue, malaise, sleep difficulty, shortness of breath, wheezes, and a cough. His blood pressure was 115/71 mmHg and his BMI was 30.35 kg/m2. The physical examination revealed wheezes. Clonazepam was prescribed for agitation. Atorvastatin, Nystatin, Citalopram, and a probiotic were prescribed. Continued use of Aspirin and a regular inhaler were suggested. Further, a follow-up visit with Endocrinology, Cardiology, and Pulmonology. As it relates to a spot in his lung, a repeat CT scan was recommended. The bronchial washes were negative for

History of Present Illness: Ms. Manock is a very pleasant 60-year-old woman with a history of severe COPD. She was previously seen by Elvira Aguila, MD. Her last office visit was in February 2015. Since that time, she states that over the last few weeks, she feels her dyspnea has worsened which is a result of increased humidity, which is normal for her. She has had a stable cough over the last six months, which is intermittently productive of sputum. She is using her supplemental oxygen at 2 L/minute with exertion and with sleep. She also notes postnasal drip, which is related to seasonal allergies.

History of Present Illness: Mr. Magnuson is a very pleasant 77-year-old gentleman who was previously seen in this office by Elvira Aguila, MD for COPD and hypoxic respiratory failure. He is here today for routine followed up. He was last evaluated in January 2015. Since that time, he states that his dyspnea is worse. He feels that it is related to the weather. He does state that he works around the house, although he does have significant functional limitations because of shortness of breath. His wife also confirms that he is able to do less and less. He has a stable, minimal cough. He is using 4L of oxygen at night as well as, as needed throughout the day. He continues to smoke three to four cigarettes on

These four conditions can cause the patients plateau pressure to be high. After checking for bronchospasm, retained secretions, Mucous plug, and a ET tube tip occlusion if nothing was found at This point I would call x ray to get a chest x ray to check for these four conditions. After getting the x rays back we would talk to the doctor and come up with a new plan for this specific patient according to our newest findings. However, in the mean time I think that the patient would benefit from a decrease in their tidal volume and their respiratory

Chronic obstructive pulmonary disease (COPD) affects an estimated 24 million individuals in the United States, where half of these people do not even know they have it (COPD Foundation 2014). COPD governs a deluge of ailments including: emphysema, refractory asthma, some forms of bronchiectasis, and the very prevalent chronic bronchitis. Chronic Bronchitis is a long-term pulmonary disease where there is a problem in the airway of the lungs, making it very difficult to breath, especially when one is trying to exhale air out of the airways. It is clinically defined as cough production of sputum occurring on most days in three consecutive months over two consecutive years (Chaudhry

Respiratory: Patient denies having history of lung diseases such as asthma, emphysema, bronchitis, pneumonia, or tuberculosis. She also denies having chest pain with breathing, wheezing or noise breathing, shortness of breath, hemoptysis, sputum, toxin or pollution exposure. Patient states that she had common cold with some productive cough for about a week last month. Also, patient states that occasionally she experiences shortness of breath when she runs for more than 40 minutes. Patient states that her last chest x-ray was 1 years ago, and the results were negative.

The categories of the health history addressed are name- H.M., age- 68, gender- female, race- white, reason for seeking care-seven days of exceptional shortness of breath and increased volume of sputum, and awakens two or three times per night coughing and short of breath, which turned a greenish color, present health-COPD exacerbation, past health-Had three or four bouts of bronchitis in the past year that she treated at home, 30-pack-year history of smoking; smokes half a pack per day now to “clear out lungs” in the morning, cannot climb one flight of stairs without stopping; walks down the flat driveway 10 yards without difficulty. The categories that have not been addressed are allergies, current medications, family history, and complete review of systems.

Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Symmetric chest expansion. Breathing nonlabored.

Data: Pulmonary function testing shows normal lung volumes. No obstruction is noted on spirometry. Th DLCO is mildly diminished.

Patient TM is a 61-year-old female patient with PMH of COPD, Hypertension, asthma and type II Diabetic who presents to the clinic with a complaint of Shortness of breath for the past 2 Days. The patient states that the SOB was sudden in onset and progressive. It was 8/10 in severity. Occurs with minimal activity. The patient states that he has been using his rescue inhalers but is not getting any relief. The patient states she has severe exacerbations of COPD around once or twice a year. She states that she is coughing up a small amount of clear sputum with no foul smell. Denies fever. Denies chest pain no palpitations. The patient TM is a chronic smoker. She has three pack years history of

History of Present Illness: Mr. Knowlton is a very pleasant 81-year-old man who was referred for cough and shortness of breath. He had pulmonary function testing that demonstrated a mild restrictive ventilatory defect with significant reduction in his diffusing capacity of carbon monoxide. Mr. Knowlton states that his exertional dyspnea has been present over the last year or so. He notes that he has particular difficulty with incline and steps. He states that with one set of stairs, he is significant winded and sits down to rest before he can walk again. He has noted that this dyspnea has been a progressive decline. He also states that he has an associated cough over the last three to four months that his occasionally

Patient is a 10 year-old male admitted into the hospital for Chronic Asthma. Patient is experiencing shortness of breath, fatigue, nausea, and tightness in chest area. Patient has a history of Chronic Asthma since birth. .

Ineffective breathing pattern related to decreased oxygen saturation, poor tissue perfusion, obesity, decreased air entry to bases of both lungs, gout and arthritic pain, decreased cardiac output, disease process of COPD, and stress as evidenced by shortness of breath, BMI > 30 abnormal breathing patterns (rapid, shallow breathing), abnormal skin colour (slightly purplish), excessive diaphoresis, nasal flaring and use of accessory muscles, statement of joint pain, oxygen saturations of 85-95% 2L NP, immobility 95% of the day, and adventitious sounds throughout lungs (crackles) secondary to CHF, hypertension, pain caused by gout and arthritis, and obesity