Respiratory Physical Assessment Assignment _ Completed _ Shadow Health Transcript.pdf - Respiratory Physical Assessment Assignment | Completed | Shadow

Respiratory Physical Assessment Assignment _ Completed _ Shadow Health Transcript.pdf

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Unformatted text preview: 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Respiratory Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: Nov 08, 2018 | Patient Exam Time: 442 min All Lines (193) Interview Questions (100) Statements (10) Exam Actions (83) Objective Data Collection Education & Empathy Hi Tina, what brings you in to the clinic today? Documentation Student Pre-Survey Greet 11/08/18 10:04 PM CST Hey. Lifespan Review Questions Hey.... what brings you in today? Self-Reflection Question 11/08/18 10:04 PM CST I came in because I've been having breathing problems, and my inhaler just isn't working the way it normally does. can you tell me what you mean by breathing problems? Question 11/08/18 10:05 PM CST 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. I am sorry to hear that you have been having these issues. I will do my best to help you feel better. Empathize 11/08/18 10:11 PM CST I appreciate you telling me that. 1/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health how long have you been having the breathing issues (Clarified to How long ago did your breathing problems start?.) Question 11/08/18 10:16 PM CST All of these breathing problems started two days ago, at my cousin's house. (Clarified to how long ago my breathing problems started.) where are you feeling the discomfort Question 11/08/18 10:25 PM CST My chest has been feeling tight, but it doesn't hurt or anything. How long does the chest tightness last Question 11/08/18 10:28 PM CST Once my asthma starts to act up, I just use my inhaler, and then I feel better within a minute or two. How often are you having to use your inhaler in a day (Clarified to how many times have you used your inhaler in the past two days.) Question 11/08/18 10:29 PM CST I've been needing my inhaler about every four hours, I'd say. (Clarified to how many times I have used my inhaler in the past two days.) what inhaler are you using Question 11/08/18 10:30 PM CST It's just a regular Proventil inhaler. what is the dosage of the proventil Question 11/08/18 10:30 PM CST 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 would you rate the chest tightness? Question 11/08/18 10:33 PM CST It doesn't hurt. . . it's just hard to breathe, but there's no pain. what severity would you rate it at? Question 11/08/18 10:33 PM CST 2/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health It doesn't hurt. . . it's just hard to breathe, but there's no pain. how difficult is it to breathe 0-10? Question 11/08/18 10:33 PM CST Yeah, I have asthma. would you rate difficulty 0-10? Question 11/08/18 10:34 PM CST At its worst it's been like a 7 or 8 out of 10, probably. how would you describe the difficulty breathing? Question 11/08/18 10:36 PM CST Oh, hmm, gosh--that's always hard to describe. I think I'm friendly, and I'd say I'm pretty driven. I'd say I'm funny too. that has nothing to do with my question, but thanks for that! (No matching questions found.) Question 11/08/18 10:37 PM CST that has nothing to do with my question, but thanks for that! Educate 11/08/18 10:37 PM CST Alright, thanks for letting me know. so your breathing feels tight in your chest? Question 11/08/18 10:37 PM CST It's not so bad right this second, but it's been pretty tight lately, like I can't take in air. what seems to make your breathing worse Question 11/08/18 10:38 PM CST Usually it acts up around cats. . . sometimes dust, or running quickly up a flight of stairs. But the past couple days my breathing has just been getting bad on its own, it seems like. what seems to help your breathing the past two days (Clarified to What has made your breathing better.) Question 11/08/18 10:40 PM CST 3/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Really just my inhaler. (Clarified to what has made my breathing better.) Have you had a fever Question 11/08/18 10:42 PM CST No, I haven't had a fever. have you been coughing Question 11/08/18 10:42 PM CST I've been coughing a lot, yeah. have you had any sputum Question 11/08/18 10:42 PM CST No, nothing's coming up. have you had any recent hospitalizations Question 11/08/18 10:46 PM CST I had to go to the ER for a foot injury a few months ago, but it's all better now. does anyone else in your family have breathing problems Question 11/08/18 10:46 PM CST My baby sister has asthma, too, but no one else in the family has lung problems, I don't think. are your immunizations up to date Question 11/08/18 10:48 PM CST Yeah, I'm pretty sure. tdap (No matching questions found.) Question 11/08/18 10:48 PM CST is your tdap up to date (No matching questions found.) Question 11/08/18 10:49 PM CST is your mmr vaccination up to date 4/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Question 11/08/18 10:49 PM CST I got all the required vaccines when I was a kid, but I don't remember the specifics. have you had a pertussis vaccination Question 11/08/18 10:49 PM CST I don't remember that specific one, but I know I got all the required shots they give you when you're a kid. where are you working Question 11/08/18 10:52 PM CST I'm a supervisor at Mid-American Copy & Ship. I've been working there since high school, and I've just kept moving up. do you smoke Question 11/08/18 10:55 PM CST No. I think it's gross. have you been around anyone who smokes Question 11/08/18 10:55 PM CST Some of my friends smoke when we go out drinking. But I don't smoke, and nobody at home smokes. when was the last time you were around smoke (No matching questions found.) Question 11/08/18 10:55 PM CST when was the last time you were around cigarette smoke (No matching questions found.) Question 11/08/18 10:55 PM CST have you been around smoke lately (Clarified to Have you been around smoke in the last few days?.) Question 11/08/18 10:56 PM CST No, nobody at home smokes. (Clarified to if I have been around smoke in the past few days.) have you traveled lately Question 11/08/18 10:57 PM CST 5/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health I really haven't travelled that much...I've always wanted to go to France but I've never even been out of the country. I'm always busy with work or school anyway though. We used to go on some family vacations when I was younger, but they were usually just to see some family in other states. do you have any other symptoms Question 11/08/18 11:01 PM CST Other than what I've told you? I don't think so. It's just needing my inhaler so much and the cough that's been bothering me. have you been taking any new medications Question 11/08/18 11:03 PM CST No, all I really use is my inhaler. no over the counter medications (Clarified to Have you taken overthe-counter medicine for your cough?.) Question 11/08/18 11:03 PM CST I'm not taking anything for it. . . unless you count my inhaler. (Clarified to if I have taken overthecounter medicine for my cough.) any new allergies Question 11/08/18 11:03 PM CST No, not that I know of. have you been ill recently Question 11/08/18 11:04 PM CST No, I'm usually healthy. when was the last time you were sick Question 11/08/18 11:05 PM CST I don't really remember. I rarely get sick. have you had any weight loss Question 11/08/18 11:06 PM CST Not that I've noticed. 6/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health any fever Question 11/08/18 11:06 PM CST No, I haven't had a fever. any chills Question 11/08/18 11:06 PM CST No, I haven't. have you felt weak Question 11/08/18 11:06 PM CST No, I wouldn't say I feel weak. have you felt fatigued Question 11/08/18 11:06 PM CST Yeah, my energy's been pretty low because I haven't been sleeping as well as usual. why haven't you been sleeping well (No matching questions found.) Question 11/08/18 11:07 PM CST is your breathing worse at night Question 11/08/18 11:07 PM CST Um. . . I guess I've been pretty much just sitting as still as possible because my breathing's been getting bad when I move around too much. And it also feels like when I lie down to go to bed it gets worse. I'm glad that you realize when your breathing is getting worse and that you give yourself time to recover. Empathize 11/08/18 11:16 PM CST I appreciate you saying that. what position have you been sleeping in (Clarified to How have you been sleeping?.) Question 11/08/18 11:16 PM CST Normally I sleep pretty well, but the past two nights my sleep's been pretty bad. (Clarified to how I have been sleeping.) 7/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health what position have you been sleeping in (Clarified to Do you sleep in a bed?.) Question 11/08/18 11:16 PM CST Yeah, of course. (Clarified to if I sleep in a bed.) how much sleep have you been getting Question 11/08/18 11:17 PM CST Probably like six or seven hours. do wake feeling rested Question 11/08/18 11:17 PM CST I feel a little tired, since my asthma's been waking me up. have you had any throat irritation Question 11/08/18 11:18 PM CST My throat has been fine. any soreness in your throat Question 11/08/18 11:18 PM CST My throat has been fine. can you describe your breathing the past two days Question 11/08/18 11:19 PM CST 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. do you feel like you've had fluid in your lungs Question 11/08/18 11:20 PM CST Yeah, I have asthma. have you noticed any enlarged lymph nodes Question 11/08/18 11:25 PM CST 8/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health No, not that I noticed. any abnormal sweating Question 11/08/18 11:26 PM CST No more than normal, I guess. any heat intolerance Question 11/08/18 11:26 PM CST I get kinda warm sometimes, but I don't have a huge problem with it. any cold intolerance Question 11/08/18 11:26 PM CST I'm kinda hot-blooded, so I don't notice the cold too much. have you had hives Question 11/08/18 11:26 PM CST The doctor said I got hives when I took it, but I don't know where the rash was. Probably all over. any recent headaches Question 11/08/18 11:27 PM CST Yeah, I get them a lot when I'm studying. when was your last headache Question 11/08/18 11:27 PM CST I don't know exactly when it was. I don't remember any really bad ones recently. any dizziness Question 11/08/18 11:28 PM CST No, I'm not dizzy. any syncope (No matching questions found.) 9/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Question 11/08/18 11:28 PM CST have you felt faint (Clarified to do you ever feel faint.) Question 11/08/18 11:28 PM CST Um, not that I remember. (Clarified to if I ever feel faint.) any numbness anywhere Question 11/08/18 11:28 PM CST No, I don't think so. any tingling anywhere Question 11/08/18 11:29 PM CST No, I haven't noticed any tingling. any chest pain (Clarified to have you been having chest pain.) Question 11/08/18 11:29 PM CST My chest has been feeling tight, but it doesn't hurt or anything. (Clarified to if I have been having chest pain.) have you been feeling any chest pressure (Clarified to Do you feel pressure in your chest.) Question 11/08/18 11:29 PM CST It just feels like I can't really take in air when I breathe, sort of like breathing makes my chest tighter. . . it doesn't hurt or anything, though. (Clarified to if I feel pressure in my chest.) have you had any heart palpitations Question 11/08/18 11:30 PM CST My heart is fine, thank God! do you have any edema anywhere Question 11/08/18 11:31 PM CST I don't think so. 10/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health do you have swelling anywhere Question 11/08/18 11:31 PM CST No, nothing has been swelling. do you have any shortness of breath Question 11/08/18 11:31 PM CST Yeah, my breathing's been pretty bad the past couple days. have you been taking your metformin (Clarified to When were you on metformin.) Question 11/08/18 11:33 PM CST When I was 24, right after I was first diagnosed. (Clarified to when I took metformin.) do you still take metformin Question 11/08/18 11:34 PM CST No, not anymore. You really should be taking something to control your blood glucose levels Educate 11/08/18 11:34 PM CST Thanks for telling me. Inspected anterior chest wall Exam Action 11/08/18 11:35 PM CST Inspected left side chest wall Exam Action 11/08/18 11:36 PM CST Inspected anterior chest wall Exam Action 11/08/18 11:36 PM CST Inspected right side chest wall Exam Action 11/08/18 11:36 PM CST Inspected anterior chest wall Exam Action 11/08/18 11:36 PM CST 11/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Inspected right side chest wall Exam Action 11/08/18 11:37 PM CST Inspected anterior chest wall Exam Action 11/08/18 11:37 PM CST Inspected left side chest wall Exam Action 11/08/18 11:37 PM CST Inspected posterior chest wall Exam Action 11/08/18 11:38 PM CST Inspected right side chest wall Exam Action 11/08/18 11:38 PM CST Inspected anterior chest wall Exam Action 11/08/18 11:38 PM CST Palpated chest expansion: Both sides rise symmetrically Exam Action 11/08/18 11:40 PM CST Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:41 PM CST Ninety-nine. Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:41 PM CST Ninety-nine. Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:41 PM CST Ninety-nine. Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:41 PM CST Ninety-nine. 12/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:41 PM CST Ninety-nine. Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:42 PM CST Ninety-nine. Palpated fremitus in posterior upper chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:42 PM CST Ninety-nine. Palpated fremitus in posterior upper chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:42 PM CST Ninety-nine. Palpated fremitus in posterior middle chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:42 PM CST Ninety-nine. Palpated fremitus in posterior middle chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:42 PM CST Ninety-nine. Palpated fremitus in posterior lower chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:42 PM CST Ninety-nine. Palpated fremitus in posterior lower chest wall: Equal bilaterally, expected vibration Exam Action 11/08/18 11:42 PM CST Ninety-nine. 13/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Percussed anterior right upper lobe Exam Action 11/08/18 11:43 PM CST Percussed anterior left upper lobe Exam Action 11/08/18 11:43 PM CST Percussed anterior left mid-chest (upper lobe) Exam Action 11/08/18 11:43 PM CST Percussed anterior right middle lobe Exam Action 11/08/18 11:43 PM CST Percussed anterior right lower lobe Exam Action 11/08/18 11:43 PM CST Percussed anterior left lower lobe Exam Action 11/08/18 11:43 PM CST Percussed posterior left upper lobe Exam Action 11/08/18 11:43 PM CST Percussed posterior right upper lobe Exam Action 11/08/18 11:43 PM CST Percussed posterior right mid-back (lower lobe) Exam Action 11/08/18 11:43 PM CST Percussed posterior left mid-back (lower lobe) Exam Action 11/08/18 11:43 PM CST Percussed posterior left lower lobe Exam Action 11/08/18 11:44 PM CST Percussed posterior right lower lobe Exam Action 11/08/18 11:44 PM CST Percussed posterior right lower lobe on side Exam Action 11/08/18 11:44 PM CST 14/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Percussed posterior left lower lobe on side Exam Action 11/08/18 11:44 PM CST Percussed posterior left lower lobe near spine Exam Action 11/08/18 11:44 PM CST Percussed posterior right lower lobe near spine Exam Action 11/08/18 11:44 PM CST Auscultated breath sounds in anterior right upper lobe Exam Action 11/08/18 11:45 PM CST Auscultated breath sounds in anterior left upper lobe Exam Action 11/08/18 11:45 PM CST Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 11/08/18 11:45 PM CST Auscultated breath sounds in anterior right middle lobe Exam Action 11/08/18 11:46 PM CST Auscultated breath sounds in anterior left lower lobe Exam Action 11/08/18 11:46 PM CST Auscultated breath sounds in anterior right lower lobe Exam Action 11/08/18 11:46 PM CST Auscultated breath sounds in posterior left upper lobe Exam Action 11/08/18 11:46 PM CST Auscultated breath sounds in posterior right upper lobe Exam Action 11/08/18 11:47 PM CST Auscultated breath sounds in posterior right mid-back (lower lobe) Exam Action 11/08/18 11:47 PM CST Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action 11/08/18 11:48 PM CST Auscultated breath sounds in posterior left lower lobe Exam Action 11/08/18 11:48 PM CST 15/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Auscultated breath sounds in posterior right lower lobe Exam Action 11/08/18 11:48 PM CST Auscultated breath sounds in posterior right lower lobe on side Exam Action 11/08/18 11:48 PM CST Auscultated breath sounds in posterior left lower lobe on side Exam Action 11/08/18 11:48 PM CST Auscultated breath sounds in posterior left lower lobe near spine Exam Action 11/08/18 11:48 PM CST Auscultated breath sounds in posterior right lower lobe near spine Exam Action 11/08/18 11:48 PM CST Auscultated breath sounds in posterior left lower lobe near spine Exam Action 11/08/18 11:53 PM CST Auscultated breath sounds in posterior left lower lobe Exam Action 11/08/18 11:54 PM CST Auscultated voice sounds in anterior right upper lobe Exam Action 11/08/18 11:54 PM CST Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior left upper lobe Exam Action 11/08/18 11:54 PM CST Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior left mid-chest (upper lobe) Exam Action 11/08/18 11:55 PM CST Ninety-nine. 16/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Ninety-nine. Auscultated voice sounds in anterior right middle lobe Exam Action 11/08/18 11:55 PM CST Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior right lower lobe Exam Action 11/08/18 11:55 PM CST Ninety-nine. Ninety-nine. Auscultated voice sounds in anterior left lower lobe Exam Action 11/08/18 11:55 PM CST Ninety-nine. Auscultated voice sounds in posterior left upper lobe Exam Action 11/08/18 11:55 PM CST Ninety-nine. Auscultated voice sounds in posterior right upper lobe Exam Action 11/08/18 11:55 PM CST Ninety-nine. Auscultated voice sounds in posterior right mid-back (lower lobe) Exam Action 11/08/18 11:55 PM CST Ninety-nine. Ninety-nine. 17/24 11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health Auscultated voice sounds in posterior left mid-back (lower lobe) Exam Action 11/08/18 11:55 PM CST Ninety-nine. Ninety-nine. Auscultated voice sounds in posterior left lower lobe Exam Action 11/08/18 11:56 PM CST Ninety-nine. Auscultated voice sounds in posterior right l...
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