Respiratory _ Completed _ Shadow Health Transcript.pdf - Shadow Health will be performing planned maintenance this Friday from 7:00am until 7:30am

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Unformatted text preview: Shadow Health will be performing planned maintenance this Friday, from 7:00am until 7:30am Eastern. During this time assignment attempts will be disabled. Thank you for helping us to improve your Shadow Health experience! Respiratory Results | Turned In Advanced Health Assessment - September 2019, 2019SEP NUR-516-NG001 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: Sep 21, 2019 | Patient Exam Time: 90 min All Lines (171) Interview Questions (78) Statements (23) Exam Actions (70) Objective Data Collection Education & Empathy Hello, Miss Jones. My name is Tricia and I will be your nurse practitioner today. Documentation Lifespan Greet 09/21/19 2:44 PM EDT Hey. Review Questions Self-Reflection What brings you in today? Question 09/21/19 2:45 PM EDT I came in because I've been having breathing problems, and my inhaler just isn't working the way it normally does. I'm sorry to hear that, Miss Jones. That is serious and we will definitely get that address today. Empathize 09/21/19 2:46 PM EDT Thanks for understanding. When did your symptoms occur? Question 09/21/19 2:46 PM EDT I don't know if I'd call it an asthma attack, but my asthma started acting up two days ago at my cousin's house. She has cats, and I'm allergic, so I'm used to it being a problem there, but usually the inhaler fixes it. . . it doesn't feel totally under control, though. Have you had shortness of breath? Question 09/21/19 2:47 PM EDT Yeah, my breathing's been pretty bad the past couple days. How many attacks are you having? (Clarified to How many asthma attacks have you had?.) Question 09/21/19 2:47 PM EDT 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. (Clarified to how many asthma attacks I have had.) When were you diagnosed with asthma? Question 09/21/19 2:48 PM EDT 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. That must have been very difficult at such a young age. Empathize 09/21/19 2:48 PM EDT I appreciate you saying that. What medication are you taking for your asthma? Question 09/21/19 2:48 PM EDT It's just a regular Proventil inhaler. How often do you normally use your inhaler? Question 09/21/19 2:49 PM EDT Usually not often, like two or three times a week, but I've used it a bunch the past couple days. And you said you are allergic to cats, correct? Definitely. Cats make my asthma go crazy. Question 09/21/19 2:49 PM EDT What other allergies do you have? Question 09/21/19 2:50 PM EDT Well, besides cats, I'm allergic to penicillin. Do you have any seasonal allergies? Question 09/21/19 2:50 PM EDT A little while ago, I had some seasonal allergies, but it didn't really bother my asthma, and it's better now. I'm glad to hear that that is under control now. Empathize 09/21/19 2:50 PM EDT Thanks for saying that. Where you were hospitalized for your asthma? Question 09/21/19 2:51 PM EDT I went a bunch of times when I was little, for asthma attacks. Is there any other medication you take for asthma? Question 09/21/19 2:51 PM EDT No, all I really use is my inhaler. How else do you deal with your asthma attacks? Question 09/21/19 2:51 PM EDT I guess the main thing with an asthma attack was I would have my usual breathing problems--my chest would get tight, I couldn't take in air, I would wheeze--but then I'd also get all sweaty, and it wouldn't stop, even once I used my inhaler. I haven't felt that bad in years, but I'm worried I will if I don't get my asthma under control. You said that your cousin's cats brought on this recent attack, correct? (No matching questions found.) Question 09/21/19 2:52 PM EDT Did your cousin's cats bring on these new symptoms? (No matching questions found.) Question 09/21/19 2:52 PM EDT Has anything made these attacks worse? (No matching questions found.) How long do these new episodes last? (Clarified to How long does an episode last?.) Question 09/21/19 2:53 PM EDT Question 09/21/19 2:53 PM EDT I haven't had a full attack in years, but usually once I use my inhaler it only takes a minute or two for my breathing to go back to normal. . . that's not what's been happening recently, though. (Clarified to how long an episode lasts.) How often are you getting these attacks? Question 09/21/19 2:54 PM EDT Just sometimes...maybe once a week? Whenever I read for a long time. How many attacks have you had in the past 2 days? (Clarified to How many times have you had breathing problems in the past two days?.) Question 09/21/19 2:54 PM EDT 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. (Clarified to how many times I have had breathing problems in the past two days.) 5 times Is a lot. That must make you so uncomfortable. Empathize 09/21/19 2:55 PM EDT Thanks. Have you experienced coughing during these attacks? (Clarified to Do you experience any cough when you have an asthma attack?.) Question 09/21/19 2:56 PM EDT Well, it's not that coughing makes me short of breath. . . it's more that my breathing's been bad, and I'm coughing. (Clarified to if I cough when I have an asthma attack.) What brought on the recent asthma attacks? (No matching questions found.) Question 09/21/19 2:56 PM EDT How long does each episode last? Question 09/21/19 2:57 PM EDT I haven't had a full attack in years, but usually once I use my inhaler it only takes a minute or two for my breathing to go back to normal. . . that's not what's been happening recently, though. Have these attacks disrupted your daily life? Empathize 09/21/19 2:57 PM EDT I appreciate you telling me that. Have these attacks disrupted your daily life? (No matching questions found.) Question 09/21/19 2:57 PM EDT Do these asthma attacks wake you up at night? (No matching questions found.) Question 09/21/19 2:58 PM EDT Is there anything you can't do because of your asthma? Question 09/21/19 2:58 PM EDT 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 been wheezing during your asthma attacks? Question 09/21/19 2:59 PM EDT During a full attack, I would wheeze a lot, like I couldn't breathe at all, but until the past couple days, I would usually just wheeze a little when I had breathing problems. Do you have any tightness in your chest during an asthma attack? (Clarified to When you have an asthma attack do you have tightness in your chest?.) Question 09/21/19 3:00 PM EDT Yeah, my chest feels tight, like I can't take in air, and I start to wheeze. (Clarified to if my chest feels tight during an asthma attack.) Do you also have shortness of breath? Empathize 09/21/19 3:01 PM EDT Thanks for understanding. Do you also have shortness of breath? (Clarified to Do you currently have shortness of breath?.) Question 09/21/19 3:01 PM EDT My breathing feels okay right this second, but I've definitely been having problems recently with it. (Clarified to if I have shortness of breath right now.) Do you have any chest pain? Question 09/21/19 3:02 PM EDT My chest has been feeling tight, but it doesn't hurt or anything. How long have you had a cough? Question 09/21/19 3:02 PM EDT Since my asthma acted up two days ago. How else do you manage your asthma? Question 09/21/19 3:02 PM EDT I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Do you use any tobacco products? Question 09/21/19 3:03 PM EDT No. I think it's gross. Do you exercise regularly? Question 09/21/19 3:03 PM EDT It's really not my thing. I get some exercise by being on my feet at work and walking around campus, that sort of thing. But jumping around in spandex is not my idea of a good time. I can empathize with that. I don't enjoy it either. Empathize 09/21/19 3:03 PM EDT I appreciate you saying that. Do you do anything at home to prevent your asthma attacks? (No matching questions found.) Please describe your cough Question 09/21/19 3:04 PM EDT Question 09/21/19 3:04 PM EDT Um. . . I guess I'd describe it as a small, dry cough. Is your asthma Better or Worse during the day? (No matching questions found.) Question 09/21/19 3:04 PM EDT Is your asthma worse during the day? (Clarified to Is your asthma worse at a certain time of day?.) Question 09/21/19 3:05 PM EDT My breathing's been getting even worse at night. (Clarified to if my asthma is worse at a certain time of day.) Do you think lying down makes it worse? (Clarified to Does lying down make your asthma worse?.) Question 09/21/19 3:05 PM EDT Just recently lying on my back has definitely made my breathing worse. (Clarified to if lying down makes my asthma worse.) Are you having any other medical issues? (Clarified to Do you have other health conditions?.) Question 09/21/19 3:06 PM EDT Other than my asthma problems, there's just my diabetes. (Clarified to if I have other medical problems.) Does anyone in your family have asthma? Question 09/21/19 3:06 PM EDT It's just me and my baby sister that have asthma, but she really doesn't have problems with it. Have you ever had any other respiratory issues? Question 09/21/19 3:06 PM EDT No, just the asthma. Your family health history can often influence your own health. Educate 09/21/19 3:08 PM EDT Sure, I think I understand what you mean. Have you ever had the flu? Question 09/21/19 3:09 PM EDT I can't even remember the last time I had the flu. I don't get sick very often. Have you ever had bronchitis? Question 09/21/19 3:09 PM EDT Nope, never. Have you ever suffered from emphysema? Question 09/21/19 3:10 PM EDT The closest I ever came to depression was after Dad died...I just felt sad all the time. Losing a loved one can definitely be a difficult period In your life. Empathize 09/21/19 3:10 PM EDT Thanks for saying that. Are you currently having any other respiratory issues? (Clarified to Do you have a history of other respiratory disease?.) Question 09/21/19 3:10 PM EDT No, just the asthma. (Clarified to if I have had other respiratory problems.) Do you have any other respiratory issues now? (Clarified to Do you have any other breathing problems?.) Question 09/21/19 3:11 PM EDT 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. (Clarified to if I have any other breathing problems.) What is the name of your inhaler? Question 09/21/19 3:11 PM EDT It's just a regular Proventil inhaler. What dosage is your inhaler? Sometimes I have to take three puffs of the 90 mcg albuterol inhaler instead of two, and the past couple days, always three. [AUDIO COMING SOON] Question 09/21/19 3:11 PM EDT Do you do anything at home to control your asthma? (No matching questions found.) Have you changed anything in your environment? Question 09/21/19 3:12 PM EDT Question 09/21/19 3:12 PM EDT No, I'm a creature of habit. I eat the same foods all the time. What else do you do to manage your asthma? Question 09/21/19 3:14 PM EDT I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. When was the last time you used your inhaler? Question 09/21/19 3:14 PM EDT I had to use it early this morning. How many puffs of your inhaler did you use this morning? Question 09/21/19 3:15 PM EDT Sometimes I have to take three puffs of the 90 mcg albuterol inhaler instead of two, and the past couple days, always three. [AUDIO COMING SOON] Is being around dust also trigger your asthma? (Clarified to Does being around dust trigger your asthma?.) Question 09/21/19 3:15 PM EDT Yeah, being around a lot of dust, especially hanging out in a really dusty house, can make my asthma act up. (Clarified to if dust triggers my asthma.) Do you get short of breath when climbing stairs? Question 09/21/19 3:16 PM EDT Only when I'm in a rush and have to hurry up them. Does climbing stairs trigger your asthma? Only when I'm in a rush and have to hurry up them. Question 09/21/19 3:16 PM EDT Do changes in weather make your asthma worse? Question 09/21/19 3:16 PM EDT Not that I've noticed. Sometimes exercise can trigger asthma attacks Educate 09/21/19 3:17 PM EDT That makes sense. Does anything at work trigger your asthma? Question 09/21/19 3:17 PM EDT Well. . . sometimes when there's dust at work it can make my asthma act up, but that doesn't happen very often. Do you see a pulmonary doctor for your asthma? (Clarified to Do you have an asthma doctor?.) Question 09/21/19 3:18 PM EDT I used to go to Dr. Dewitt, but she moved her practice recently. Luckily she's still been able to call in refills of my inhaler, but I haven't actually been in to see her in about two years. (Clarified to if I have a doctor for my asthma.) Seeing a specialist, like an asthma doctor can better help to manage your symptoms. Educate 09/21/19 3:19 PM EDT Alright, thanks for letting me know. Have you ever been hospitalized for your asthma? Question 09/21/19 3:19 PM EDT I went a bunch of times when I was little, for asthma attacks. Did you ever need a breathing tube at that time? (Clarified to Did you ever need a breathing machine?.) Yeah, they put me on a nebulizer at the hospital a couple times when I went in for asthma. (Clarified to if I have ever been put on a breathing machine.) Can you keep an asthma diary? Question 09/21/19 3:20 PM EDT Question 09/21/19 3:20 PM EDT Not really. . . It is helpful for you to record the number and duration of your asthma attacks. Educate 09/21/19 3:21 PM EDT Thanks for telling me. Have you ever use a nebulizer at home? (Clarified to Do you use a nebulizer?.) Question 09/21/19 3:21 PM EDT No, but I have before. (Clarified to if I use a nebulizer.) Do you change your bedding regularly Question 09/21/19 3:22 PM EDT Of course! I did not mean to offend you. I apologize. Empathize 09/21/19 3:23 PM EDT I appreciate you telling me that. The reason I asked about your bedding is that you mentioned that your asthma is worse at night. Many times environmental factors can trigger asthma attacks. Educate 09/21/19 3:24 PM EDT OK, I understand. Do you have pets? Question 09/21/19 3:24 PM EDT No. . . I'm too busy to take care of a dog, and I can't have cats because of my allergies. Pets can be a job in themselves. Empathize 09/21/19 3:24 PM EDT Thanks. Have you ever had any sinus issues? Question 09/21/19 3:25 PM EDT I don't really have a problem with my sinuses. Do you suffer from headaches? Question 09/21/19 3:25 PM EDT Yeah, I get them a lot when I'm studying. What do you take for your headaches? Question 09/21/19 3:26 PM EDT I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON] Does the acetaminophen help with your headaches? Question 09/21/19 3:26 PM EDT Yeah. Usually I'll take a Tylenol and go to bed, and that'll get rid of it. It is important that you hydrate yourself when you're taking certain medications. Educate 09/21/19 3:26 PM EDT Alright, thanks for letting me know. Have you been sick recently? Question 09/21/19 3:27 PM EDT No, I'm usually healthy. Have you had a fever recently? No, I haven't had a fever. Have you had chills? Question 09/21/19 3:27 PM EDT Question 09/21/19 3:28 PM EDT No, I haven't. Have you been feeling tired or fatigued? (Clarified to Have you been feeling more tired lately?.) Question 09/21/19 3:28 PM EDT Yeah, my energy's been pretty low because I haven't been sleeping as well as usual. (Clarified to if I have been more tired recently.) Have you had any night sweats? Question 09/21/19 3:28 PM EDT I don't get sweaty, but sometimes I wake up hot and have to kick off my sheets. Do you have a productive cough? Educate 09/21/19 3:29 PM EDT Thanks for telling me. Do you have a productive cough? Question 09/21/19 3:29 PM EDT No, nothing's coming up. Coughing up phlegm it's a way of your body expelling any type of irritants from your lungs. Educate 09/21/19 3:31 PM EDT That makes sense. Have you had any difficulty swallowing? Question 09/21/19 3:31 PM EDT Nope. Have you had any post nasal drip? Question 09/21/19 3:31 PM EDT No, I haven't noticed that happening. Have you had itchy eyes? Question 09/21/19 3:32 PM EDT My eyes are okay right now, but when I'm around cats they get pretty red and itchy. The reason I asked all these questions is that your immune system often response to allergens. Most of the time these symptoms are itchy eyes, runny nose and sore throat. But some people may also have that reaction from their lungs affecting breathing and Airway. Educate 09/21/19 3:36 PM EDT Sure, I think I understand what you mean. I'm going to perform a physical assessment on you now so that I can determine the extent of the symptoms that you are having. Educate 09/21/19 3:37 PM EDT OK, I understand. Inspected anterior chest wall Exam Action 09/21/19 3:37 PM EDT Inspected left side chest wall Exam Action 09/21/19 3:37 PM EDT Inspected posterior chest wall Exam Action 09/21/19 3:37 PM EDT Inspected right side chest wall Exam Action 09/21/19 3:37 PM EDT Inspected anterior chest wall Exam Action 09/21/19 3:38 PM EDT Palpated chest expansion: Both sides rise symmetrically Exam Action 09/21/19 3:38 PM EDT Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration Ninety-nine. Exam Action 09/21/19 3:38 PM EDT Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration Exam Action 09/21/19 3:39 PM EDT Ninety-nine. Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration Exam Action 09/21/19 3:39 PM EDT Ninety-nine. Palpated fremitus in posterior upper chest wall: Equal bilaterally, expected vibration Exam Action 09/21/19 3:39 PM EDT Ninety-nine. Palpated fremitus in posterior middle chest wall: Equal bilaterally, expected vibration Exam Action 09/21/19 3:39 PM EDT Ninety-nine. Palpated fremitus in posterior lower chest wall: Equal bilaterally, expected vibration Exam Action 09/21/19 3:39 PM EDT Ninety-nine. Palpated fremitus in posterior lower chest wall: Equal bilaterally, expected vibration Exam Action 09/21/19 3:39 PM EDT Ninety-nine. Percussed anterior right upper lobe Exam Action 09/21/19 3:40 PM EDT Percussed anterior left upper lobe Exam Action 09/21/19 3:40 PM EDT Percussed anterior right middle lobe Exam Action 09/21/19 3:40 PM EDT Percussed anterior left mid-chest (upper lobe) Exam Action 09/21/19 3:40 PM EDT Percussed anterior right lower lobe Exam Action 09/21/19 3:40 PM EDT Percussed anterior left lower lobe Exam Action 09/21/19 3:40 PM EDT Percussed posterior left upper lobe Exam Action 09/21/19 3:40 PM EDT Percussed posterior right upper lobe Exam Action 09/21/19 3:40 PM EDT Percussed posterior left mid-back (lower lobe) Exam Action 09/21/19 3:40 PM EDT Percussed posterior right mid-back (lower lobe) Exam Action 09/21/19 3:40 PM EDT Percussed posterior left lower lobe Exam Action 09/21/19 3:40 PM EDT Percussed posterior right lower lobe Exam Action 09/21/19 3:40 PM EDT Percussed posterior left lower lobe on side Exam Action 09/21/19 3:40 PM EDT Percussed posterior left lower lobe near spine Exam Action 09/21/19 3:40 PM EDT Percussed posterior right lower lobe near spine Exam Action 09/21/19 3:41 PM EDT Percussed posterior right lower lobe near spine Exam Action 09/21/19 3:41 PM EDT Percussed posterior left lower lobe near spine Exam Action 09/21/19 3:41 PM EDT Percussed posterior right lower lobe near spine Exam Action 09/21/19 3:41 PM EDT Percussed posterior right lower lobe on side Exam Action 09/21/19 3:41 PM EDT Auscultated breath sounds in anterior right upper lobe Exam Action 09/21/19 3:41 PM EDT Auscultated breath sounds in anterior left upper lobe Exam Action 09/21/19 3:41 PM EDT Auscultated breat...
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