NR 557 Week 2 History and Symptom Analysis Example

History and Symptom Analysis: "I Just Can't Get My Wind Today", a 78-Year-Old Home Health Patient's Breathlessness Taken From the Patient's Own Sentence Through Onset, Character and Associated Symptoms

Student Name

College of Nursing, Chamberlain University

NR 557: Health Assessment for Professional Nursing Practice

Instructor Name

Month Day, Year

History and Symptom Analysis: "I Just Can't Get My Wind Today", a 78-Year-Old Home Health Patient's Breathlessness Taken From the Patient's Own Sentence Through Onset, Character and Associated Symptoms

The Opening Line, Unedited

When I arrived for a scheduled home health visit, the patient, a 78-year-old retired bus driver who has lived for years with chronic obstructive pulmonary disease (COPD), along with heart failure, was sitting in a recliner rather than at the kitchen table where we usually talk. Asked how things were, the patient said: "I just can't get my wind today."

I have kept that sentence exactly because it carries two details a paraphrase would lose. "Today" says the change is recent, not the usual breathlessness of COPD. And "get my wind" is the patient's usual phrase; over six weeks of visits, the patient has used it to describe bad days, but never before at rest in the chair. A paraphrase such as "reports dyspnea" would lose both.

What Limited the Interview

Three things shaped what I could ask. The patient was breathless enough to stop mid-sentence twice, so questions had to be short and closed where possible. The patient's daughter, who lives nearby and had come over that morning because the patient "didn't sound right" on the phone, supplied much of the history, which is helpful but filtered through her worry. And the patient is slightly hard of hearing, so I sat close and faced them. I noted these limits in the record so that anyone reading the history would know which parts came from the daughter.

Time, Before Anything Else

Onset. The patient first noticed a cough with more sputum three days ago. Breathlessness at rest began yesterday evening. The daughter says the patient did not come to the phone yesterday afternoon, which is unusual.

Course. Worsening since yesterday evening, not improved by the patient's rescue inhaler, used four times since last night instead of the usual once or twice a day.

Pattern. Worse lying flat, so the patient slept in the recliner. The patient has slept on two pillows for months because of heart failure, but has not needed the chair before.

Character and Severity

The patient describes the breathlessness as "can't fill up," not as chest tightness. On a 0 to 10 scale, the patient rates it 7 at rest, compared with about 2 at rest on a usual day. The patient can speak in phrases of four or five words before pausing. The cough brings up thick yellow-green sputum, a change from the usual small amount of white sputum.

Associated Symptoms

Present: feeling hot and cold since yesterday; less appetite; tiredness; the daughter reports the patient seemed "muddled" this morning, asking twice what day it was, which is not usual. Absent, asked directly: chest pain, pain on breathing in, coughing up blood, leg swelling beyond the usual mild ankle swelling, calf pain, palpitations, vomiting or diarrhea. Not known: weight today; the patient has not weighed since the day before yesterday because of feeling unwell, which matters for heart failure.

What the Patient Has Tried

Rescue inhaler four times since last night with little relief; usual long-acting inhalers taken this morning; acetaminophen once last night for feeling hot. No home oxygen. No antibiotics or steroids at home.

Relevant Background

COPD for 12 years, with two admissions for exacerbations in the past three years; heart failure with reduced ejection fraction diagnosed four years ago; hypertension; former smoker of 40 pack-years, quit eight years ago. Medications include inhalers, a diuretic, a beta-blocker and an angiotensin receptor blocker. Influenza vaccine this season; pneumococcal vaccination status unclear. Lives alone with daily visits from the daughter.

Questions Still Open After the History

The history leaves four questions for the examination. First, how fast is the patient actually breathing? The patient's own sense of breathlessness and the pauses in speech suggest a raised rate, but only a count will say by how much. Second, is the problem on one side? Pneumonia usually affects one area of the lung, while a COPD flare or heart failure more often affects both sides, so the chest examination must compare right and left. Third, is there fluid overload? The worse orthopnea and the missing weight leave heart failure open. Fourth, how confused is the patient? The daughter's report is important but second-hand, and new muddled thinking during an infection in someone this age is a warning sign that needs to be tested directly.

The history also changes what I will not do at this visit. The planned medication review and education about inhaler technique can wait. A breathless patient cannot concentrate on teaching, and the priority is to decide whether today's visit ends at home or with a referral. Writing that decision down now, before the examination, makes it easier to see later whether the examination confirmed or changed it.

What the History Suggests

The history already points in a direction before any examination. Three days of cough with a change in sputum color, feeling hot and cold, new breathlessness at rest and new confusion in an older adult suggest an acute respiratory infection, possibly pneumonia, on top of COPD. Symptoms and history alone cannot reliably confirm or rule out pneumonia; a review of the clinical diagnosis of pneumonia found that no single finding from the history was sufficient, and that the examination and chest radiography were needed (Metlay et al., 1997). Two alternatives remain live: a COPD exacerbation without pneumonia, and worsening heart failure, since orthopnea has worsened and weight is unknown. The new confusion is important because in older adults it can be the first sign of serious infection.

The history also sets the priorities for the examination. I need a counted respiratory rate, oxygen saturation, temperature, blood pressure, heart rate, a careful chest examination comparing both sides, a check for leg swelling and weight, and a brief mental status assessment. The next write-up records that targeted examination. Respiratory rate, often estimated rather than counted in routine charting (Badawy et al., 2017), will be counted for a full minute, since an abnormal rate is among the earliest signs of deterioration (Cretikos et al., 2008).

Marking the daughter's contributions separately also matters for later readers, who may want to confirm details directly with the patient once the acute illness has passed.

The history took about ten minutes.

References

Badawy, J., Nguyen, O. K., Clark, C., Halm, E. A., & Makam, A. N. (2017). Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults. BMJ Quality & Safety, 26(10), 832-836. https://doi.org/10.1136/bmjqs-2017-006671

Cretikos, M. A., Bellomo, R., Hillman, K., Chen, J., Finfer, S., & Flabouris, A. (2008). Respiratory rate: The neglected vital sign. Medical Journal of Australia, 188(11), 657-659. https://doi.org/10.5694/j.1326-5377.2008.tb01825.x

Metlay, J. P., Kapoor, W. N., & Fine, M. J. (1997). Does this patient have community-acquired pneumonia? Diagnosing pneumonia by history and physical examination. JAMA, 278(17), 1440-1445. https://doi.org/10.1001/jama.1997.03550170070035