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Your patient is William, a 64-year-old African American male who presented to your clinic today as a new patient. His chief complaint is a cough. He reports that yesterday, he woke up with a cough and wheezing. He has been using his albuterol nebulizer every 2-3 hours since then. Today, he has increased sputum production and reports his sputum has gone from clear to yellow/green. The patient reports a history of COPD. He was diagnosed four years ago. He reports he is a current one-pack-a-day smoker. Denies alcohol or drug use. Other medical history includes well-controlled hypertension. Current medications include an albuterol inhaler and nebulizer that he uses only as needed. Reports before this illness had not been used in 1 month. The last COPD exacerbation was over a year ago. Denies other problems today.

PHM: COPD, HTN

SUBJECTIVE ROS: Negative for fever, chills, chest pain, N/V/D.

OBJECTIVE VS today: BP 136/84, HR 92, RR 22, Temp 98.4, O2 93%

Exam:
- General: Sitting comfortably with no obvious distress.
- HEENT: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed. Eyes - Visual acuity is intact.
- Respiratory: Expiratory wheezing noted posteriorly through all fields; no crackles or rales noted.
- CV: Regular rate and rhythm. No edema.

What additional subjective information do you need to ask the patient about his COPD?

Answer :

Additional subjective information needed includes details about William's symptoms, triggers, medication adherence, activity level, and previous exacerbations to manage his COPD effectively.

To better understand William's COPD, it is essential to ask additional subjective information. Focus on the following:

  1. History of symptoms: Ask about the duration, frequency, and severity of his cough, wheezing, and shortness of breath.
  2. Trigger factors: Inquire about any known triggers, including environmental factors, recent infections, or exposure to smoke or pollutants.
  3. Medication use: Discuss his usage of the albuterol inhaler and nebulizer, and whether there have been any recent changes in medication adherence or effectiveness.
  4. Activity level: Assess how his COPD affects his daily activities and if there have been any recent changes in exercise tolerance or physical limitations.
  5. Previous exacerbations: Details about the frequency, severity, and treatment of past exacerbations can provide insight into his COPD management.

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