Tina Jones _ Respiratory Results_Turned In | NR 509 Respiratory_Transcript

Respiratory Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results L La ab b P Pa as ss s Started: May 11, 2018 | Patient Exam Time: 168 min Transcript Greet 05/11/18 12:39 PM CDT Question 05/11/18 12:39 PM CDT Question 05/11/18 12:39 PM CDT Question 05/11/18 12:40 PM CDT Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Student Pre-Survey Lifespan Review Questions Self-Reflection I In nt te er rv viie ew w Q Qu ue es st tiio on ns s ( (9 91 1) ) S St ta at te em me en nt ts s ( (2 21 1) ) E Ex xa am m A Ac ct tiio on ns s ( (6 65 5) ) Hello my name sara an FNP student and I will be interviewing you today. Hey. Can you please state your name for me? Tina Jones. Your date of birth? February 17th. Year of birth please? (Clarified to What year were you born.) I was born in . . . [Ms. Jones reports correct birth year.] [AUDIO COMING SOON] A Allll L Liin ne es s ( (1 17 77 7) )5/11/2018 Respiratory | Completed | Shadow Health Question 05/11/18 12:40 PM CDT Question 05/11/18 12:41 PM CDT Question 05/11/18 12:42 PM CDT Empathize 05/11/18 12:42 PM CDT Question 05/11/18 12:43 PM CDT Question 05/11/18 12:53 PM CDT Question 05/11/18 12:53 PM CDT How old are you ms. Jones? (Clarified to how old are you.) I'm 28. What brings you in today? I came in because I've been having breathing problems, and my inhaler just isn't working the way it normally does. Why did you decide to seek treatment? 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 you're having breathing problems. Thanks for saying that. What medical problems do you have? 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? It's just a regular Proventil inhaler. How often do you use your Proventil inhaler? I've been using it probably every. . . four hours or so, I'd say. When did your symptoms start?5/11/2018 Respiratory | Completed | Shadow Health Question 05/11/18 12:53 PM CDT Empathize 05/11/18 12:56 PM CDT Question 05/11/18 12:56 PM CDT Question 05/11/18 12:57 PM CDT Question 05/11/18 12:57 PM CDT Question 05/11/18 1:00 PM CDT Question 05/11/18 1:02 PM CDT 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. Thanks. How long have you had breathing problems? My breathing's been acting up off and on for the past two days. How frequent are your shortness of breath episodes? Maybe as much as every four hours? It's a lot. And how long do your shortness of breath episodes last? (Clarified to how long does an episode last.) 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 long did you last episode last? 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 past 2 days?5/11/2018 Respiratory | Completed | Shadow Health Question 05/11/18 1:04 PM CDT Question 05/11/18 1:05 PM CDT Question 05/11/18 1:06 PM CDT Question 05/11/18 1:07 PM CDT Question 05/11/18 1:09 PM CDT Question 05/11/18 1:10 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 your asthma keeping you up at night? My asthma doesn't usually wake me up, but it has the past couple nights. How severe are your symptoms? (Clarified to How bad was your asthma attack.) 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. How severe is your asthma? 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? 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. Do you wheeze during an asthma exacerbation? 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? It's not so bad right this second, but it's been pretty tight lately, like I can't take in air.5/11/2018 Respiratory | Completed | Shadow Health Question 05/11/18 1:10 PM CDT Question 05/11/18 1:11 PM CDT Question 05/11/18 1:11 PM CDT Question 05/11/18 1:11 PM CDT Question 05/11/18 1:12 PM CDT Question 05/11/18 1:13 PM CDT Question 05/11/18 1:14 PM CDT Educate 05/11/18 1:14 PM CDT Have you been coughing? I've been coughing a lot, yeah. How long have you had the cough? Since my asthma acted up two days ago. How would you describe the cough? Um. . . I guess I'd describe it as a small, dry cough. What makes your cough better? Drinking some water helps a little, as long as the water isn't too cold. Have you tried to treat your cough? I haven't taken medicine for it or anything. Is your asthma worse at night? It has been the past couple nights, yeah. Does lying on your back make your asthma worse? 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.5/11/2018 Respiratory | Completed | Shadow Health Exam Action 05/11/18 1:36 PM CDT Exam Action 05/11/18 1:43 PM CDT Exam Action 05/11/18 1:43 PM CDT Exam Action 05/11/18 1:44 PM CDT Exam Action 05/11/18 1:44 PM CDT Exam Action 05/11/18 1:44 PM CDT Exam Action 05/11/18 1:46 PM CDT Exam Action 05/11/18 1:48 PM CDT Exam Action 05/11/18 1:48 PM CDT Exam Action 05/11/18 1:50 PM CDT OK, I understand. Inspected anterior chest wall Inspected anterior chest wall Inspected left side chest wall Inspected anterior chest wall Inspected right side chest wall Inspected anterior chest wall Palpated chest expansion: Both sides rise symmetrically Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration Ninety-nine. Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration Ninety-nine. Palpated fremitus in posterior upper chest wall: Equal bilaterally, expected vibration - - - - - - - Continued