Chamberlain College of Nursing| Respiratory Results Transcript | Turned In| Shadow Health| NR 509

5/11/2018 Respiratory | Completed | Shadow Health


Respiratory Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Overview
Transcript
Transcript
Started: May 11, 2018 | Patient Exam Time: 168 min
Subjective Data Collection
All Lines (177) Interview Questions (91) Statements (21) Exam Actions (65)
Objective Data Collection
Greet
Education & Empathy Hello my name sara an FNP student and I will be interviewing you
05/11/18 12:39 PM
today.
CDT
Documentation

Student Pre-Survey
Hey.
Lifespan

Question
Review Questions
Can you please state your name for me? 05/11/18 12:39 PM
Self-Reflection CDT



Tina Jones.


Question
Your date of birth? 05/11/18 12:39 PM
CDT



February 17th.


Question
Year of birth please? (Clarified to What year were you born.) 05/11/18 12:40 PM
CDT


I was born in . . . [Ms. Jones reports correct birth year.] [AUDIO
COMING SOON]




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,5/11/2018 Respiratory | Completed | Shadow Health

How old are you ms. Jones? (Clarified to how old are you.) Question
05/11/18 12:40 PM
CDT



I'm 28.


Question
What brings you in today? 05/11/18 12:41 PM
CDT


I came in because I've been having breathing problems, and my
inhaler just isn't working the way it normally does.


Question
Why did you decide to seek treatment? 05/11/18 12:42 PM
CDT


I came in because I've been having breathing problems, and my
inhaler just isn't working the way it normally does.


Empathize
I'm sorry to hear that you're having breathing problems. 05/11/18 12:42 PM
CDT



Thanks for saying that.


Question
What medical problems do you have? 05/11/18 12:43 PM
CDT


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.


Question
What medication do you use for asthma? 05/11/18 12:53 PM
CDT



It's just a regular Proventil inhaler.


Question
How often do you use your Proventil inhaler? 05/11/18 12:53 PM
CDT



I've been using it probably every. . . four hours or so, I'd say.


When did your symptoms start?




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Question
05/11/18 12:53 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.


Empathize
I'm sorry you're having difficulty with your breathing problems. 05/11/18 12:56 PM
CDT



Thanks.


Question
How long have you had breathing problems? 05/11/18 12:56 PM
CDT



My breathing's been acting up off and on for the past two days.


Question
How frequent are your shortness of breath episodes? 05/11/18 12:57 PM
CDT



Maybe as much as every four hours? It's a lot.


Question
And how long do your shortness of breath episodes last? (Clarified to
05/11/18 12:57 PM
how long does an episode last.) CDT


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.


Question
How long did you last episode last? 05/11/18 1:00 PM
CDT


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.


Question
How many times have you had breathing problems in the past 2
05/11/18 1:02 PM
days? CDT




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