W2_SH_[Transcript}]-Asthma-Respiratory | Completed | Shadow Health.pdf - Respiratory | Completed | Shadow Health 2)22 PM Respiratory Results | Turned In

W2_SH_[Transcript}]-Asthma-Respiratory | Completed | Shadow Health.pdf

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Unformatted text preview: Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Respiratory Results | Turned In Advanced Health Assessment - Chamberlain, NR509-June-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: Jul 21, 2018 | Patient Exam Time: 738 min All Lines (297) Interview Questions (216) Statements (23) Exam Actions (58) Objective Data Collection Education & Empathy Tina, it's good to see you again. If you don't remember me, I'm Scott, your nurse practitioner. I'll be doing your examination today. Documentation Student Pre-Survey Greet 07/21/18 11:17 PM CDT Hey. Lifespan Review Questions What brings you in today? Self-Reflection Question 07/21/18 11:18 PM CDT I came in because I've been having breathing problems, and my inhaler just isn't working the way it normally does. Tell me about the breathing issues your experiencing? Question 07/21/18 11:18 PM CDT It feels like it's been 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. To make sure I understand, you feel like you can't get enough air? (No matching questions found.) Question 07/21/18 11:19 PM CDT Page 1 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM You can't get enough air in to your lungs? (No matching questions found.) Question 07/21/18 11:19 PM CDT I'm sorry, thats a terrible feeling. Empathize 07/21/18 11:20 PM CDT Thanks for saying that. I know that we have been through these same set of questions, so I'm sorry I'm going to ask them again. I'm not really insulting your intelligence, although it may seem like I am. Educate 07/21/18 11:22 PM CDT Alright, thanks for letting me know. When did your breathing issues begin? Question 07/21/18 11:22 PM CDT All of these breathing problems started two days ago, at my cousin's house. Were you around cats? Question 07/21/18 11:22 PM CDT Two days ago, at my cousin's house. She has three of them, and my asthma always goes crazy when I'm there. Because your allergic to cats, right? Question 07/21/18 11:22 PM CDT Definitely. Cats make my asthma go crazy. How long were you exposed to these cats? (No matching questions found.) Question 07/21/18 11:23 PM CDT Has your asthma gotten worse since you were exposed to the cats? Question 07/21/18 11:23 PM CDT Page 2 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM No, my asthma has definitely got better since I was little. It used to be really bad--I would get asthma attacks all the time. Just lately, though, it's been worse than usual. Did anything make you asthma feel better? (No matching questions found.) Question 07/21/18 11:24 PM CDT Your inhaler didn't help your asthma? (Clarified to what do you do if your inhaler doesn't work.) Question 07/21/18 11:24 PM CDT I guess I don't really have a backup plan; it's always worked in the past, though lately I've needed more puffs than usual. How many puffs do you need? Question 07/21/18 11:25 PM CDT Sometimes I have to take three puffs instead of two, and the past couple days, always three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] How many times did you use your inhaler the past two days? (Clarified to how many times have you used your inhaler in the past two days.) Question 07/21/18 11:25 PM CDT I've been needing my inhaler about every four hours, I'd say. What have you done to treat your asthma? (Clarified to how do you manage your asthma.) Question 07/21/18 11:26 PM CDT I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Why didn't you avoid the cats this time? Question 07/21/18 11:26 PM CDT I haven't been sleeping as well because my asthma has been getting a little worse at night, and it's been waking me up, too. How many times to you wake up with asthma? Question 07/21/18 11:27 PM CDT Page 3 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM I feel like I've woken up at least twice each night with breathing problems the past two nights. Are you able to fall back asleep? (No matching questions found.) Question 07/21/18 11:27 PM CDT Have you been sick lately? Question 07/21/18 11:28 PM CDT No, I'm usually healthy. Have you been exposed to any dust lately? Question 07/21/18 11:28 PM CDT No. . . I'm not around dust much. It mostly happens if I'm at someone's house and they don't keep it very clean, and that hasn't happened in a while. How often have you been having trouble breathing? Question 07/24/18 11:37 AM CDT Maybe as much as every four hours? It's a lot. When is the last time you were hospitalized because of an asthma attack? Question 07/24/18 11:39 AM CDT I used to go to the hospital a lot for asthma attacks, but not since I was sixteen. What have you done to avoid hospitalizations due to asthma? (No matching questions found.) Question 07/24/18 11:41 AM CDT That's awesome - to be able to avoid going to the hospital since 16 years old. Empathize 07/24/18 11:42 AM CDT I appreciate you saying that. Page 4 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM How have you been treating your asthma? Question 07/24/18 11:42 AM CDT I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. How often have you been using your inhaler lately? Question 07/24/18 11:42 AM CDT I don't usually use it every day, but I've used it a bunch the past couple days. How many times a day do you sue your inhaler? Question 07/24/18 11:43 AM CDT I don't usually use it every day, but I've used it a bunch the past couple days. How many puffs do you need to help you breath better? (Clarified to How many inhaler puffs do you need.) Question 07/24/18 11:44 AM CDT Sometimes I have to take three puffs instead of two, and the past couple days, always three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] How many inhaler puffs are you prescribed? Question 07/24/18 11:44 AM CDT I'm supposed to just do two puffs. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] How effective has your inhaler been? (No matching questions found.) Question 07/24/18 11:45 AM CDT Is your inhaler been functioning abnormally lately? Question 07/24/18 11:46 AM CDT I don't usually use it every day, but I've used it a bunch the past couple days. Page 5 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Do you use any other medications for your asthma? Question 07/24/18 11:46 AM CDT My inhaler is the only prescription I always have, but I usually don't need it everyday, except for recently. . . Do you take any other medications? (Clarified to are you taking other medications.) Question 07/24/18 11:47 AM CDT No, all I really use is my inhaler. Have you ever been prescribed with a corticosteroid? Question 07/24/18 11:48 AM CDT Yeah, when I was diagnosed they gave me a medicine to try. What medication did they give you when you were first diagnosed with asthma? (Clarified to how old were you when you were diagnosed with asthma.) Question 07/24/18 11:48 AM CDT My doctor told me when I was pretty little... I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. Which medication did your doctor first diagnosed with asthma? (No matching questions found.) Question 07/24/18 11:49 AM CDT Which medications have you tried for asthma in the past? Question 07/24/18 11:50 AM CDT It's just a regular Proventil inhaler. Do you get asthma symptoms when you exercise? (Clarified to Do you have asthma when you exercise.) Question 07/24/18 11:51 AM CDT Well, I don't exercise, really. I mean, I'm active -- I'm on my feet all day -- but I don't go running or stuff like that. I bet I'd get winded pretty fast, and I'd probably need my inhaler. Page 6 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Do you get winded while going up a flight of stairs? (Clarified to Do you get short of breath when you go up a flight of stairs?.) Question 07/24/18 11:51 AM CDT Only when I'm in a rush and have to hurry up them. Do you have shortness of breath while doing normal activities around the house? Question 07/24/18 11:53 AM CDT It's definitely been harder to move around without worrying my asthma was going to act up again. Have you ever had an asthma attack that was so severe that you nearly died? (Clarified to How many asthma attacks have you had.) Question 07/24/18 11:54 AM CDT I haven't had a full attack, but I've had a lot of breathing problems-probably. . . ten times since I was at my cousin's house two days ago. I'm sorry, that's rough and a but scary. Empathize 07/24/18 12:00 PM CDT Thanks for saying that. Are you experiencing any chest pain? Question 07/24/18 12:00 PM CDT My chest has been feeling tight, but it doesn't hurt or anything. Do you feel increased tightness when you take a slow deep breath? (No matching questions found.) Question 07/24/18 12:01 PM CDT Do you have an increase in chest tightness when you take a deep breath? (Clarified to do you have pain when you breathe.) Question 07/24/18 12:01 PM CDT No, my chest feels tight when I have breathing problems, but it doesn't hurt. On a scale from 0 to 10, ten being the worst chest tightness you've ever felt, how would you rate your chest tightness right now? Question 07/24/18 12:02 PM CDT Page 7 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM It doesn't hurt. . . it's just hard to breathe, but there's no pain. Have you had any coughing fits lately? Question 07/24/18 12:04 PM CDT I've been coughing a lot, yeah. When do you usually cough the most? Question 07/24/18 12:04 PM CDT I've been coughing all day, but. . . I guess it gets a little worse at night. Does your coughing get worse any time you lay down? Question 07/24/18 12:11 PM CDT Yeah, it's like, as soon as I lie down in bed the cough gets worse. It's making it harder to sleep. When did your asthma symptoms start? Question 07/24/18 12:41 PM CDT I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. How many times have you had breathing problems in the past two days? Question 07/24/18 12:43 PM CDT Well. . . it's kind of hard to count because my breathing's been at least a little bad most of the past two days, but it's really acted up, like with wheezing and everything, probably every four hours or so--like five times each day. Is you asthma keeping you up at night? Question 07/24/18 12:43 PM CDT My asthma doesn't usually wake me up, but it has the past couple nights. Page 8 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM How many times do you wake up during the night? Question 07/24/18 12:44 PM CDT I feel like I've woken up at least twice each night with breathing problems the past two nights. How severe is your asthma? Question 07/24/18 12:44 PM CDT My asthma used to be really scary. I haven't had a full attack in years, and if you had asked me before this I would have said my asthma wasn't that bad anymore, but the last couple days I've had a lot of trouble breathing. Is there anything you can't do because of your asthma? Question 07/24/18 12:45 PM CDT There usually isn't anything I can't do because of my asthma. . . I guess I try to avoid things that make my breathing worse, but that's about it. The past couple days, though, it's been hard to do anything. Have you missed work because of your asthma? (Clarified to Have you had to miss work because of your asthma?.) Question 07/24/18 12:45 PM CDT Luckily I haven't been expected in at work the past two days, or else I probably would have had to call in sick. . . my asthma's never kept me home from work before this, though. Have you had to miss school because of your asthma? (Clarified to Have you had to miss work because of your asthma?.) Question 07/24/18 12:46 PM CDT Luckily I haven't been expected in at work the past two days, or else I probably would have had to call in sick. . . my asthma's never kept me home from work before this, though. Has your chest been tight these past two days? (Clarified to how many days has your chest felt tight in the past week.) Question 07/24/18 12:47 PM CDT Just the past two days, since I was around those cats. Page 9 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM How bad is your chest tightness right now? Question 07/24/18 12:47 PM CDT It's not so bad right this second, but it's been pretty tight lately, like I can't take in air. Why is your chest tightness feeling a little better right this second? Question 07/24/18 12:48 PM CDT It's not so bad right this second, but it's been pretty tight lately, like I can't take in air. Did you do anything to help relieve your chest tightness? (No matching questions found.) Question 07/24/18 12:48 PM CDT How do you relieve your chest tightness? Question 07/24/18 12:50 PM CDT Once my asthma starts to act up, I just use my inhaler, and then I feel better within a minute or two. How would you describe your cough? Question 07/24/18 12:51 PM CDT Um. . . I guess I'd describe it as a small, dry cough. Have you tried anything to treat your cough? Question 07/24/18 12:51 PM CDT I haven't taken medicine for it or anything. Does laying down on your back make your cough worse? Question 07/24/18 12:52 PM CDT Yeah, it's like, as soon as I lie down in bed the cough gets worse. It's making it harder to sleep. Page 10 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Try to make sure that when you lay down, you elevate your shoulders, neck and head at a slight angle. Use two pillows or you can buy a wedge on Amazon that will sit you up ever so slightly - like 20 degrees to 30 degrees. This will help your cough calm down at night, allow you to get a better nights sleep. It even helps with those who have heart failure, congestion sometimes, and obstructive sleep apnea. Educate 07/24/18 12:58 PM CDT That makes sense. It sounds like you need more rest. I'm sorry you've struggled sleeping ad breathing at night. I hope this helps. (No matching questions found.) Question 07/24/18 12:58 PM CDT It sounds like you need more rest. I'm sorry you've struggled sleeping ad breathing at night. I hope this helps. Empathize 07/24/18 12:59 PM CDT Thanks for understanding. Have you had any congestions lately? Question 07/24/18 12:59 PM CDT No, congestion isn't the problem. Any sinus pain? Question 07/24/18 12:59 PM CDT Nope. Any headaches lately? Question 07/24/18 12:59 PM CDT Yeah, I get them a lot when I'm studying. Are your headaches related to your asthma? (Clarified to is your asthma related to your allergies.) Question 07/24/18 1:00 PM CDT I guess so. . . it's worst around cats, and sometimes I also get breathing problems when I'm around a lot of dust. Page 11 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Do you have seasonal allergies? Question 07/24/18 1:00 PM CDT A little while ago, I had some seasonal allergies, but it didn't really bother my asthma, and it's better now. What makes your asthma worse? Question 07/24/18 1:01 PM CDT For the last two days, it seems worse at night when I'm lying down, or when I'm moving around too much. Typically it's stuff like cats or dust that gets to me. What is the most severe cause of your allergies? Question 07/24/18 1:02 PM CDT No, never anything severe, unless my asthma acting up around cats counts. Ok, I'm going to do a physical examination, if that's all right with you? Question 07/24/18 1:03 PM CDT Sure. Inspected anterior chest wall Exam Action 07/24/18 1:05 PM CDT Inspected right side chest wall Exam Action 07/24/18 1:05 PM CDT Inspected posterior chest wall Exam Action 07/24/18 1:05 PM CDT Inspected left side chest wall Exam Action 07/24/18 1:06 PM CDT Page 12 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Inspected posterior chest wall Exam Action 07/24/18 1:06 PM CDT Inspected left side chest wall Exam Action 07/24/18 1:06 PM CDT Inspected anterior chest wall Exam Action 07/24/18 1:06 PM CDT Palpated chest expansion: Both sides rise symmetrically Exam Action 07/24/18 1:06 PM CDT Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration Exam Action 07/24/18 2:36 PM CDT Ninety-nine. Percussed anterior right upper lobe Exam Action 07/24/18 2:54 PM CDT Percussed anterior right upper lobe Exam Action 07/24/18 2:54 PM CDT Percussed anterior left upper lobe Exam Action 07/24/18 2:54 PM CDT Percussed anterior left mid-chest (upper lobe) Exam Action 07/24/18 2:54 PM CDT Percussed anterior right middle lobe Percussed anterior right lower lobe Exam Action 07/24/18 2:54 PM CDT Exam Action 07/24/18 2:54 PM CDT Page 13 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Percussed anterior left lower lobe Exam Action 07/24/18 2:54 PM CDT Percussed posterior left upper lobe Exam Action 07/24/18 2:55 PM CDT Percussed posterior right upper lobe Exam Action 07/24/18 2:55 PM CDT Percussed posterior right mid-back (lower lobe) Exam Action 07/24/18 2:55 PM CDT Percussed posterior left mid-back (lower lobe) Exam Action 07/24/18 2:55 PM CDT Percussed posterior left lower lobe Exam Action 07/24/18 2:55 PM CDT Percussed posterior right lower lobe Exam Action 07/24/18 2:55 PM CDT Percussed posterior right lower lobe on side Exam Action 07/24/18 2:55 PM CDT Percussed posterior left lower lobe on side Exam Action 07/24/18 2:55 PM CDT Percussed posterior left lower lobe near spine Exam Action 07/24/18 2:55 PM CDT Percussed posterior right lower lobe near spine Exam Action 07/24/18 2:55 PM CDT Auscultated breath sounds in anterior right upper lobe Exam Action 07/24/18 2:57 PM CDT Page 14 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Auscultated breath sounds in anterior left upper lobe Exam Action 07/24/18 2:57 PM CDT Auscultated breath sounds in anterior right upper lobe Exam Action 07/24/18 2:59 PM CDT Auscultated breath sounds in anterior left upper lobe Exam Action 07/24/18 2:59 PM CDT Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 07/24/18 2:59 PM CDT Auscultated breath sounds in anterior right middle lobe Exam Action 07/24/18 2:59 PM CDT Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 07/24/18 3:11 PM CDT Auscultated breath sounds in anterior right middle lobe Exam Action 07/24/18 3:14 PM CDT Auscultated breath sounds in anterior right lower lobe Exam Action 07/24/18 3:14 PM CDT Auscultated breath sounds in anterior left lower lobe Exam Action 07/24/18 3:15 PM CDT Auscultated voice sounds in anterior right upper lobe Exam Action 07/24/18 3:46 PM CDT Ninety-nine. Ninety-nine. Ninety-nine. Page 15 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Ninety-nine. Page 16 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior left upper lobe Exam Action 07/24/18 3:47 PM CDT Ninety-nine. Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior left mid-chest (upper lobe) Exam Action 07/24/18 3:47 PM CDT Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior right middle lobe Exam Action 07/24/18 3:48 PM CDT Ninety-nine. Auscultated voice sounds in anterior right lower lobe Exam Action 07/24/18 3:48 PM CDT Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior left lower lobe Exam Action 07/24/18 3:48 PM CDT Page 17 of 39 Respiratory | Completed | Shadow Health 7/26/18, 2)22 PM Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior right lower lobe Exam Action 07/24/18 3:48 PM CDT Ninety-nine. Ninety-nine. Auscultated voice sounds in posterior left upper lobe Exam Action 07/24/18 3:48 PM CDT Ninety-nine. Ninety-nine. Auscultated voice sounds in posterior right upper lobe Exam Action 07/24/18 3:48 PM ...
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