Respiratory _Transcript.pdf - Respiratory | Completed | Shadow Health Respiratory Results | Turned In Advanced Health Assessment Fall 2019 NGR 5035

Respiratory _Transcript.pdf - Respiratory | Completed |...

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Unformatted text preview: 11/14/2019 Respiratory | Completed | Shadow Health Respiratory Results | Turned In Advanced Health Assessment - Fall 2019, NGR 5035 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: Oct 17, 2019 | Patient Exam Time: 155 min All Lines (163) Interview Questions (70) Statements (10) Exam Actions (83) Objective Data Collection Education & Empathy Hello my name is F an FNP student and I will interviewing you today. Documentation Greet 10/17/19 2:22 PM EDT Hey. Can you please state your name for me and date of birth? (Clarified to Can you please confirm your name and birthday for me?.) Question 10/17/19 2:23 PM EDT My name's Tina Jones, and my birthday's February 17th. (Clarified to to confirm my name and date of birth.) How old are you Miss Jones? Question 10/17/19 2:24 PM EDT I'm 28. What brings you in today? Question 10/17/19 2:24 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 you have had to deal with this Empathize 10/17/19 2:29 PM EDT I appreciate you saying that. Tell me more about the decision to seek treatment? (Clarified to Can you tell me more about your asthma?.) 1/20 11/14/2019 Respiratory | Completed | Shadow Health Question 10/17/19 2:30 PM EDT Sure, what would you like to know? (Clarified to to ask more about my asthma.) What symptoms of asthma do you have? Question 10/17/19 2:31 PM EDT Well, I'm having breathing problems. I keep feeling tight in my chest and I've had some wheezing. Can you tell me about frequency? (No matching questions found.) Question 10/17/19 2:31 PM EDT What medical problem do you have? Question 10/17/19 2:33 PM EDT Well. . . I've had asthma since I was really little, though for a while there it wasn't really much of a problem. And I have sugar diabetes, too. What medication do you use for asthma? Question 10/17/19 2:34 PM EDT It's just a regular Proventil inhaler. How often do you use Proventil inhaler? Question 10/17/19 2:34 PM EDT When my breathing acts up, I just use two puffs from my albuterol inhaler, though lately I sometimes need three. [AUDIO COMING SOON] When did your symptoms start? Question 10/17/19 2:35 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. I'm sorry you're having difficulty with your breathing problems? Empathize 10/17/19 2:36 PM EDT 2/20 11/14/2019 Respiratory | Completed | Shadow Health Thanks for saying that. How long have you had breathing problem? Question 10/17/19 2:36 PM EDT My breathing's been acting up off and on for the past two days. How frequent are your shortness of breath episodes? Question 10/17/19 2:38 PM EDT Maybe as much as every four hours? It's a lot. How long does an episode last? Question 10/17/19 2:38 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. How many times have you had breathing problems in the last 2 days? Question 10/17/19 2:39 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. The zeros not keeping you up at night? (Clarified to Does your asthma wake you up at night?.) Question 10/17/19 2:40 PM EDT My asthma doesn't usually wake me up, but it has the past couple nights. (Clarified to if my asthma wakes me up at night.) How bad was your asthma attack? Question 10/17/19 2:40 PM EDT 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. I understand you have trouble of breathing, and I'm here to help you. Empathize 10/17/19 2:42 PM EDT 3/20 11/14/2019 Respiratory | Completed | Shadow Health Thanks for understanding. How severe is your asthma? Question 10/17/19 2:43 PM EDT 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 cannot to do because of your asthma? (Clarified to Is there anything you can't do because of your asthma?.) Question 10/17/19 2:43 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. (Clarified to if there is anything I cannot do because of my asthma.) Do you wheeze during an asthma exacerbation? Question 10/17/19 2:44 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. Are you having any chest tightness? Question 10/17/19 2:45 PM EDT 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. Have you been coughing? Question 10/17/19 2:47 PM EDT I've been coughing a lot, yeah. How long have you had the cough? Question 10/17/19 2:49 PM EDT Since my asthma acted up two days ago. How would you describe the cough? Question 10/17/19 2:50 PM EDT 4/20 11/14/2019 Respiratory | Completed | Shadow Health Um. . . I guess I'd describe it as a small, dry cough. What make your cold better? Question 10/17/19 2:50 PM EDT 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 makes your cough better? Question 10/17/19 2:51 PM EDT Drinking some water helps a little, as long as the water isn't too cold. Have you tried to treat your cough? Question 10/17/19 2:51 PM EDT I haven't taken medicine for it or anything. Is there asthma worse at night? Question 10/17/19 2:52 PM EDT It has been the past couple nights, yeah. Does lying on your back make your asthma worse? Question 10/17/19 2:53 PM EDT Just recently lying on my back has definitely made my breathing worse. To try to help your breathing you may want to elevate your head with two pillows. Educate 10/17/19 2:54 PM EDT That makes sense. Do you have any recent hospitalization for asthma? Question 10/17/19 2:55 PM EDT I haven't been to the hospital for asthma recently, but I used to go a lot growing up. Do you have any allergies? 5/20 11/14/2019 Respiratory | Completed | Shadow Health Question 10/17/19 2:56 PM EDT Yeah, I'm allergic to cats. Are you allergic to dust? Question 10/17/19 2:57 PM EDT Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust. What do you do to help your asthma with non-medication form? Question 10/17/19 2:58 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 feel that non medication forms of asthma management is helping you? (No matching questions found.) Question 10/17/19 2:59 PM EDT what forms of asthma management is helping you? (Clarified to What non-medication forms of asthma management do you use?.) Question 10/17/19 3:00 PM EDT I don't really use anything to treat my asthma other than my inhaler. [AUDIO COMING SOON] (Clarified to what nonmedication forms of asthma management I use.) Tell me about that neighborhood living condition/ (No matching questions found.) Question 10/17/19 3:01 PM EDT what is your neighborhood living condition? (Clarified to What risks are you aware of in your neighborhood?.) Question 10/17/19 3:01 PM EDT We live in a pretty safe area, and we lock the doors at night. Having my family around makes it seem safer, too. (Clarified to what risks I am aware of in my neighborhood.) Are you at work? (Clarified to Do you have a job?.) Question 10/17/19 3:02 PM EDT I'm a supervisor at Mid-American Copy & Ship. I've been working there since high school, and I've just kept moving up. (Clarified to if I have a job.) 6/20 11/14/2019 Respiratory | Completed | Shadow Health You told me that you are in school, isn't it? (Clarified to Tell me about school?.) Question 10/17/19 3:03 PM EDT School's going really well. I'm almost done with my second-to-last semester, and I feel like I've really done the best I could. (Clarified to to tell you about school.) Do I have any health care opportunities? Question 10/17/19 3:04 PM EDT I have health insurance through work. To be honest, though, I'm not exactly sure what it covers. How is environment control in your living area? (Clarified to How is your environment affecting you?.) Question 10/17/19 3:04 PM EDT Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust. (Clarified to how my environment affects me.) Call ziad environment affecting you? (No matching questions found.) Question 10/17/19 3:05 PM EDT haw is environment affecting you? (Clarified to How is your environment affecting you?.) Question 10/17/19 3:06 PM EDT Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust. (Clarified to how my environment affects me.) Is environmental control warning in your area? (No matching questions found.) Question 10/17/19 3:07 PM EDT Is there environmental control in your area? (No matching questions found.) Question 10/17/19 3:08 PM EDT Any environmental control in your area? (Clarified to Are you exposed to an environmental hazards?.) Question 10/17/19 3:08 PM EDT Um, no. (Clarified to if I am around environmental hazards.) Are there any exposure to environmental control? (No matching questions found.) Question 10/17/19 3:08 PM EDT Are there any exposure to environment ? (No matching questions found.) 7/20 11/14/2019 Respiratory | Completed | Shadow Health Question 10/17/19 3:09 PM EDT Are there any exposure (No matching questions found.) Question 10/17/19 3:09 PM EDT Any environmental issue that exacerbate your asthma? (Clarified to Does anything in your environment make your breathing worse?.) Question 10/17/19 3:17 PM EDT My asthma's almost always fine at home. . . I don't think it's anything there that's been making my asthma act up. We keep it pretty neat and tidy. (Clarified to if anything in my environment makes my breathing worse.) Any exercise activity? Question 10/17/19 3:18 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. Any possible contributing factor in your health history? Question 10/17/19 3:19 PM EDT I don't know what you mean by "contributing factors." [AUDIO COMING SOON] Do you smoke/ Question 10/17/19 3:21 PM EDT No. I think it's gross. Tell me about your family history? Question 10/17/19 3:21 PM EDT Let's see . . . there's high blood pressure and high cholesterol on both sides. . . plus my dad and his dad both had diabetes, like me. I think that's about it, though. Oh, and Grandpa Jones had colon cancer. Any Social history which is contribute in your heath history? (No matching questions found.) Question 10/17/19 3:23 PM EDT Is Social history which is contribute in your heath history? (No matching questions found.) Question 10/17/19 3:23 PM EDT 8/20 11/14/2019 Respiratory | Completed | Shadow Health is your home problems factors contribute in your heath? (No matching questions found.) Question 10/17/19 3:25 PM EDT what problems factors contribute in your heath? (No matching questions found.) Question 10/17/19 3:25 PM EDT Did you have any additional review of your respiratory system? (No matching questions found.) Question 10/17/19 3:27 PM EDT any additional review of your respiratory system? Question 10/17/19 3:27 PM EDT Yeah, I have asthma. Do you have any X-ray done? Question 10/17/19 3:28 PM EDT The last time I went to the hospital for an asthma attack, when I was still in high school, they did a chest x-ray. Any hospitalizations? Question 10/17/19 3:28 PM EDT I went to the hospital a bunch of times when I was growing up, for asthma attacks. And I went for a foot injury a few months ago, but my foot is fine now. What do you do for diabetes? Question 10/17/19 3:29 PM EDT I just watch what I eat and try to stay away from sweets. What medication are taking? Question 10/17/19 3:29 PM EDT My inhaler is the only prescription I always have, but I usually don't need it everyday, except for recently. . . I see you need more education on your diabetics medications, and this is help you for any other health exacerbation. Educate 10/17/19 3:32 PM EDT Sure, I think I understand what you mean. 9/20 11/14/2019 Respiratory | Completed | Shadow Health Okay I will review your system for Respiratory. is that okay? (No matching questions found.) Question 10/17/19 3:33 PM EDT I will review your system for Respiratory. is that okay? (No matching questions found.) Question 10/17/19 3:33 PM EDT I will review your system for Respiratory. (No matching questions found.) Question 10/17/19 3:33 PM EDT may I review your system for Respiratory. (No matching questions found.) Question 10/17/19 3:34 PM EDT may I review of system for Respiratory. (No matching questions found.) Question 10/17/19 3:34 PM EDT I'm sorry to hear that your not feeling well Empathize 10/17/19 3:36 PM EDT Thanks. I will do your physical examination is that ok? Question 10/17/19 3:37 PM EDT Sure. Inspected anterior chest wall Exam Action 10/17/19 3:38 PM EDT Inspected right side chest wall Exam Action 10/17/19 3:38 PM EDT Inspected posterior chest wall Exam Action 10/17/19 3:38 PM EDT Inspected left side chest wall Exam Action 10/17/19 3:38 PM EDT Inspected anterior chest wall Exam Action 10/17/19 3:38 PM EDT Inspected left side chest wall 10/20 11/14/2019 Respiratory | Completed | Shadow Health Exam Action 10/17/19 3:38 PM EDT Inspected posterior chest wall Exam Action 10/17/19 3:38 PM EDT Palpated chest expansion: Both sides rise symmetrically Exam Action 10/17/19 3:39 PM EDT Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:40 PM EDT Ninety-nine. Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:40 PM EDT Ninety-nine. Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:40 PM EDT Ninety-nine. Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:40 PM EDT Ninety-nine. Palpated fremitus in posterior upper chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:40 PM EDT Ninety-nine. Palpated fremitus in posterior middle chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:41 PM EDT Ninety-nine. 11/20 11/14/2019 Respiratory | Completed | Shadow Health Palpated fremitus in posterior lower chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:41 PM EDT Ninety-nine. Palpated fremitus in posterior upper chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:41 PM EDT Ninety-nine. Palpated fremitus in posterior middle chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:41 PM EDT Ninety-nine. Palpated fremitus in posterior lower chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:41 PM EDT Ninety-nine. Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:41 PM EDT Ninety-nine. Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration Exam Action 10/17/19 3:41 PM EDT Ninety-nine. Palpated chest expansion: Both sides rise symmetrically Exam Action 10/17/19 3:42 PM EDT Percussed anterior right upper lobe Exam Action 10/17/19 3:42 PM EDT Percussed anterior left upper lobe Exam Action 10/17/19 3:42 PM EDT 12/20 11/14/2019 Respiratory | Completed | Shadow Health Percussed anterior left mid-chest (upper lobe) Exam Action 10/17/19 3:43 PM EDT Percussed anterior right middle lobe Exam Action 10/17/19 3:43 PM EDT Percussed anterior right lower lobe Exam Action 10/17/19 3:43 PM EDT Percussed anterior left lower lobe Exam Action 10/17/19 3:43 PM EDT Percussed anterior right upper lobe Exam Action 10/17/19 3:43 PM EDT Percussed anterior left upper lobe Exam Action 10/17/19 3:43 PM EDT Percussed anterior left mid-chest (upper lobe) Exam Action 10/17/19 3:43 PM EDT Percussed anterior right middle lobe Exam Action 10/17/19 3:43 PM EDT Percussed anterior left lower lobe Exam Action 10/17/19 3:43 PM EDT Percussed anterior right lower lobe Exam Action 10/17/19 3:43 PM EDT Percussed anterior right lower lobe Exam Action 10/17/19 3:43 PM EDT Percussed anterior left lower lobe Exam Action 10/17/19 3:44 PM EDT Percussed anterior right middle lobe Exam Action 10/17/19 3:44 PM EDT Percussed anterior left mid-chest (upper lobe) Exam Action 10/17/19 3:44 PM EDT 13/20 11/14/2019 Respiratory | Completed | Shadow Health Percussed anterior left upper lobe Exam Action 10/17/19 3:44 PM EDT Percussed anterior right upper lobe Exam Action 10/17/19 3:44 PM EDT Percussed anterior right lower lobe Exam Action 10/17/19 3:44 PM EDT Percussed anterior right middle lobe Exam Action 10/17/19 3:44 PM EDT Auscultated breath sounds in anterior right upper lobe Exam Action 10/17/19 3:44 PM EDT Auscultated breath sounds in anterior left upper lobe Exam Action 10/17/19 3:44 PM EDT Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in anterior right middle lobe Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in anterior right lower lobe Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in anterior left lower lobe Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in anterior right upper lobe Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in anterior left upper lobe Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in anterior left mid-chest (upper lobe) Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in anterior right middle lobe Exam Action 10/17/19 3:45 PM EDT 14/20 11/14/2019 Respiratory | Completed | Shadow Health Auscultated breath sounds in anterior right lower lobe Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in anterior left lower lobe Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in posterior left upper lobe Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in posterior right upper lobe Exam Action 10/17/19 3:45 PM EDT Auscultated breath sounds in posterior right mid-back (lower lobe) Exam Action 10/17/19 3:46 PM EDT Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action 10/17/19 3:46 PM EDT Auscultated breath sounds in posterior left lower lobe Exam Action 10/17/19 3:46 PM EDT Auscultated breath sounds in posterior right lower lobe Exam Action 10/17/19 3:46 PM EDT Auscultated breath sounds in posterior right lower lobe near spine Exam Action 10/17/19 3:47 PM EDT Auscultated breath sounds in posterior left lower lobe near spine Exam Action 10/17/19 3:47 PM EDT Auscultated breath sounds in posterior right lower lobe on side Exam Action 10/17/19 3:47 PM EDT Auscultated breath sounds in posterior left lower lobe on side Exam Action 10/17/19 3:47 PM EDT Auscultated voice sounds in anterior right upper lobe Exam Action 10/17/19 3:48 PM EDT Ninety-nine. 15/20 11/14/2019 Respiratory | Completed | Shadow Health Ninety-nine. Auscultated voice sounds in anterior left upper lobe Exam Action 10/17/19 3:48 P...
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