Taking a Patient's History (Nurse/Patient)

Summary

In this clinic visit, Ron Jones, a long-time smoker, seeks care for a persistent cough producing yellowish-green sputum and general fatigue. The nurse conducts a thorough assessment, including vital signs and chest examination, and educates Ron on completing antibiotics, proper inhaler use with a spacer, and smoking cessation resources. Wheezing is noted in the lower lungs, prompting the doctor to prescribe two inhalers with specific instructions on usage order for optimal effectiveness. The nurse ensures Ron understands the treatment plan, provides a smoker’s helpline, and schedules a follow-up in 10 days, emphasizing patient education and engagement in managing respiratory health.

Takeaways

• 😀 Nurse verifies patient identity and birth date to ensure safety and correct patient information.
• 😀 Patient presents with a persistent cough producing yellowish to greenish sputum, feeling generally tired.
• 😀 Patient has a history of taking antibiotics but did not complete the full course.
• 😀 Nurse educates patient on the importance of completing antibiotics to prevent recurrence and resistance.
• 😀 Patient is a long-term smoker (35 years, 2 packs/day) and expresses difficulty in quitting.
• 😀 Nurse provides smoking cessation support by offering a helpline number.
• 😀 Vital signs taken: temperature 37°C, pulse 88 bpm, blood pressure 150/84 mmHg, respirations 16/min.
• 😀 Chest auscultation reveals wheezing in the lower lungs, indicating possible airway obstruction or inflammation.
• 😀 Doctor prescribes two inhalers: a bronchodilator first, followed by an anti-inflammatory inhaler, with instruction to use a spacer.
• 😀 Nurse educates patient on proper inhaler sequence and usage for effective medication delivery.
• 😀 Follow-up plan includes completing prescribed medications, monitoring symptoms, and returning to the clinic in 10 days.
• 😀 Interaction demonstrates patient-centered care with thorough history taking, education, and clear communication.

Q & A

What was the main reason Ron Jones visited the clinic?

Ron Jones visited the clinic due to a persistent cough that had worsened over the past week and was producing yellowish to greenish sputum.

Did Ron Jones have any fever or chills?

No, he reported no fever or chills.

What was Ron's history with antibiotics?

Ron had previously taken antibiotics but stopped the course early because they did not seem to help.

Why is it important to complete the full course of antibiotics?

Completing the full course ensures that bacteria are fully eliminated, preventing them from returning stronger or resistant to treatment.

What is Ron Jones's smoking history?

He has been smoking about 2 packs per day for 35 years.

What vital signs were recorded during the visit?

Temperature: 37°C, Pulse: 88 bpm, Blood Pressure: 150/84 mmHg, Respirations: 16 per minute.

What findings were observed during the chest auscultation?

Wheezing was heard in the lower parts of the lungs.

How were the inhalers supposed to be used according to the nurse?

One inhaler is a bronchodilator to open the airways and should be used first; the second is an anti-inflammatory and should be used afterward. A spacer helps deliver the medication deep into the lungs.

What follow-up plan was recommended for Ron Jones?

He was instructed to start the inhalers at home and return to the clinic in 10 days for another course of antibiotics, with an appointment to monitor progress.

What additional support was provided to help Ron consider quitting smoking?

The nurse provided information about a smoker's helpline for counseling and support with quitting.

Why did the nurse take Ron’s vital signs and listen to his chest before the doctor saw him?

To gather preliminary clinical information, identify potential issues like wheezing or elevated blood pressure, and provide the doctor with accurate baseline findings.

How did the nurse explain the purpose of using a spacer with inhalers?

The nurse explained that the spacer helps the medication reach deep into the lungs where it is most effective.