11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health

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Respiratory Physical Assessment Assignment Results | Turned In

Advanced Health Assessment - Chamberlain, NR509-October-2018

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Your Results

Lab Pass

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation Model Documentation

https://www.qwivy.com/file/37017336/Respiratory-Physical-Assessment-Assignment-Documentation-Completed-Shadow-Healthpdf/

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Student Pre-Survey

Lifespan

Review Questions

Self-Reflection

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Model

Documentation

Student

Documentation

11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health

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Subjective

CC:"hard to take in air. My chest feels all tight and

I've been wheezing... I've had to use my inhaler a lot,

and it doesn't feel like it's totally working."

HPI:

Onset: 2 days ago at her cousin's house after

exposure to cats which exacerbated her asthma and

reported symptoms.

Location:Chest

Duration: "Minute or two" for each episode reported

with a total of 10 episodes in last 2 days per patient.

Characteristics/Quality: Tightness, feelings of not

being able to take in air.

Aggravating factors/Associated Symptoms: Cats,

dust, running up a flight of stairs. Worse upon

exertion and when lying down flat.

Relieving factors: Proventil inhaler, resting

Treatment/Medications/Remedies:Proventil Inhaler,

three puffs every 4 hours for past 2 days. Albuterol

90mcg/spray MDI

Severity:7-8/10

FH:Sister with asthma

SH:Supervisor at Mid-American Copy & Ship,

currently lives with mother and younger sister.

MH:States having all the required "shots they give

you when you're a kid." Hospitlized as a child and

teen for asthma. ED a few months ago for foot injury

that has since healed.

Updates to Meds: No updates. Previous medications

continued.

Updates to Allergies: Updated to include seasonal

allergies/hay fever along with cats & dust

ROS

General/Constitutional: No weigth loss, fever, chills,

weakness reported. Patient does report fatigue upon

exertion that subsides at rest.

Respiratory:"Been hard to take in air". Chest

tightness & wheezing.

HPI: Ms. Jones is a pleasant 28-year-old African

American woman who presented to the clinic with

complaints of shortness of breath and wheezing

following a near asthma attack that she had two

days ago. She reports that she was at her cousin’s

house and was exposed to cats which triggered her

asthma symptoms. At the time of the incident she

notes that her wheezes were a 6/10 severity and her

shortness of breath was a 7-8/10 severity and lasted

five minutes. She did not experience any chest pain

or allergic symptoms. At that time she used her

albuterol inhaler and her symptoms decreased

although they did not completely resolve. Since that

incident she notes that she has had 10 episodes of

wheezing and has shortness of breath approximately

every four hours. Her last episode of shortness of

breath was this morning before coming to clinic. She

notes that her current symptoms seem to be

worsened by lying flat and movement and are

accompanied by a non-productive cough. She

awakens with night-time shortness of breath twice

per night. She complains that her current symptoms

are beginning to interfere with her daily activities and

she is concerned that her albuterol inhaler seems to

be less effective than previous. Currently she states

that her breathing is normal. Diagnosed with asthma

at age 2.5 years. She has no recent use of

spirometry, does not use a peak flow, does not

record attacks, and does not have a home nebulizer

or vaporizer. She has been hospitalized five times

for asthma, last at age 16. She has never been

intubated for her asthma. She does not have a

current pulmonologist or allergist.

Social History: She is not aware of any

environmental exposures or irritants at her job or

home. She changes her sheets weekly and denies

dust/mildew at her home. She uses a hypoallergenic

pillow cover and her mattress is one year old. She

denies current use of tobacco, alcohol, and illicit

drugs. She did smoke marijuana for 5 or 6 years, her

last use was at age 21 years. She does not exercise.

Review of Systems: General: Denies changes in

weight, fatigue, weakness, fever, chills, and night

sweats.

• Nose/Sinuses: Denies rhinorrhea with this episode.

Denies stuffiness, sneezing, itching, previous allergy,

epistaxis, or sinus pressure.

• Gastrointestinal: No changes in appetite, no

nausea, no vomiting, no symptoms of GERD or

abdominal pain

• Respiratory: Complains of shortness of breath and

cough as above. Denies sputum, hemoptysis,

pneumonia, bronchitis, emphysema, tuberculosis.

She has a history of asthma, last hospitalization was

age 16, last chest XR was age 16.

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