Personal Narrative : Dyspnea On Exertion

D.Z., a 65-year-old man, is admitted to a medical floor for exacerbation of his chronic obstructive pulmonary disease (COPD; emphysema). He has a past medical history of hypertension, which has been well controlled by Enalapril (Vasotec) for the past 6 years. He has had pneumonia yearly for the past 3 years, and has been a 2-pack-a-day smoker for 38 years. He appears as a cachectic man who is experiencing difficulty breathing at rest. He reports cough productive of thick yellow-green sputum. D.Z. seems irritable and anxious; he complains of sleeping poorly and states that lately feels tired most of the time. His vital signs (VS) are 162/84, 124, 36, 102 F, SaO2 88%. His admitting diagnosis is an acute

History of Present Illness: Mr. Olson is a very pleasant 57-year-old gentleman with multiple medical problems to include severe COPD, who is here today for an initial consultation for his shortness of breath. He is followed by a pulmonologist Dr. William Goodman, at the Veteran Affairs Administration. His last evaluation there was in February 2015. Mr. Olson states he has had ongoing dyspnea on exertion over the last two years. He complains of minimal cough. He does note some sinus problems for which he is on Flovent. In the past, he has had pulmonary function testing that did demonstrate reversible airflow obstruction, therefore he likely has some component of asthma overlay. He states that occasionally has chest tightness and chest heaviness. He has gained about 25 pounds over the last year. He is currently using Spiriva, albuterol as needed as well as Symbicort. He is also using supplemental oxygen at 2.5L per minute at night as well as on an as needed basis during the day. Mr. Olson admits to continued tobacco use with about a half pack to a pack a day. He states that when he is feeling depressed, he will smoke more.

Patient is a high school counselor. He participates in physical activities by running 2 to 3 times a week, playing golf, and volunteering at a nursing home. The patient is married with one daughter and one son. He does not use tobacco and periodically drinks at

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.

My patient is 79-year old, male that was brought the University of Kentucky medical center emergency department via ambulance on January 14, 2017. The patient was smoking while using home oxygen, when he fell asleep. The EMS responded to a home fire.

A cousin of mine, Susan, approached me after her father received open heart surgery. Susan’s father, age 59, has been a chronic smoker since the age of 19. What went from two cigarettes a day quickly become two packs a day, with no end in sight. During July of 2015 he complained of feeling dizziness, shortness of breath,

History of cardiomyopathy. The most recent echocardiogram was done in 2014 showing improved ejection fraction at 55%. He feels asymptomatic, at this time. He did have recent testing with Dr. Dourdoufis. I will request those notes and review them when they arrive. He will certainly let myself or Dr. Dourdoufis know or seek care if necessary if his symptoms change acutely.

Mr. Hightower is a 52 year old male with a PMH Type 2 DM, Hyperlipidemia, and HTN. He is a new patient to your office stating he stopped his meds several months ago and he cannot remember what he took in the past. His BP is 150/90. HR 88, RR 20 BMI 35. HGB A1C is 9.6, Total chol 225, LDLs 183, HDL 35. CBC, CHem, LFTs are wnl except for glucose of 124. Discuss the focused pertinent physical exam for this patient as well as what further diagnostics are needed in providing evidenced based care. What medications are important to start for this patient to treat his co-morbidities. Include the follow-up for this gentleman along with pertinent diagnostics needed at

HISTORY OF PRESENT ILLNESS: David Lockman is here for followup for his traumatic saw injury to his right knee. He is about two and half weeks out now. He was seen, I believe a week or so ago or two weeks ago perhaps, by one of my partners. He was sent for therapy, although he has had some delay in therapy. He just started therapy. He did get a blood clot, I believe recently, and is now on Xarelto for that. He states that the swelling in his leg is much better, at this point. He does continue to smoke, however. I believe he is a half a pack or one pack per day smoker. Again, I went over smoking cessation with him, as well as the risks of uncontrolled bleeding with the Xarelto that he currently on. He understands this, so he should

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

The patient had a medical history of hypertension, hyperlipidemia, coronary artery disease, myocardial infarction in 2010, COPD, pulmonary embolism, prostate cancer, gastro esophageal reflux disease, and small bowel adhesions. The patient had an echocardiogram six months ago with an ejection fraction of 45%. Individuals with “an EF of 25% to 50% have an intermediate risk for the development of postoperative low cardiac output

Mr. Joseph presents with a productive cough of brownish-green phlegm, ankle swelling, orthopnea (using six pillows for comfort), dyspnea (when walking one block), fever, and chills. His chest x-ray is read as borderline cardiomegaly, chronic bronchitis with bibasilar pneumonia. Mr. Joseph's laboratory values are unremarkable, with only the salicylate level increased. His arterial blood gas reveals partly compensated respiratory acidosis. An

Lung function tests have revealed normal spirometry, gas transfer and static lung volumes. There appears to be a fall in pre-bronchodilator FEV1, but not so FVC and TLCO comparing back to 2007??. Maximal respiratory pressures are reduced indicative of respiratory muscle/diaphragm weakness. This is consistent with what has previously been observed and the previous diagnosis of mild left hemidiaphragm weakness. I note from Tony Dortimer’s most recent letter that the coronary angiogram

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

In this assignment, I will reflect upon an incident within the clinical practice involving a smoker patient . For the purpose of this assignment, Gibbs’ Reflective Cycle (1988) has been used to guide the reflection on the incident. The patient's name, in relation to confidentiality will not be used according to NMC confidentiality.