NR 510 week 2 respiratory shadow health
Ms. Jones is a 28 year old well developed HPI: Ms. Jones is a pleasant 28-year-old
African American Female who presents to African American woman who presented to
the office today complaining of increased the clinic with complaints of shortness of
shortness of breath as well as increase use breath and wheezing following a near
and need of her inhaler that began two days asthma attack that she had two days ago.
ago. Ms. Jones has allergies to cats which She reports that she was at her cousin’s
exacerbate her asthma and has had recent house and was exposed to cats which
exposure to 3 cats at her cousins, she also triggered her asthma symptoms. At the time
admits to sensitivty to seasonal allergies as of the incident she notes that her wheezes
well as dust. She admits to increased cough were a 6/10 severity and her shortness of
with wheeze but denies nasal drainage or a breath was a 7-8/10 severity and lasted five
productive cough. She does not take any minutes. She did not experience any chest
medications for her allergies other than her pain or allergic symptoms. At that time she
Albuterol inhaler 90 mcg 2-3 puffs q4 hours used her albuterol inhaler and her
prn wheeze/sob, and over the counter symptoms decreased although they did not
acetaminophen and advil prn for headache completely resolve. Since that incident she
and cramping. She does report having notes that she has had 10 episodes of
increased shortnes of breath with increased wheezing and has shortness of breath
activty as well as when she is lying flat. Ms. approximately every four hours. Her last
Jones sleeps with one pillow and has no episode of shortness of breath was this
difficulty sleeping. Ms. Jones also presents morning before coming to clinic. She notes
with an elevated blood glucose and admits that her current symptoms seem to be
to non compliance with medicaiton and worsened by lying flat and movement and
regular glucose monitoring. are accompanied by a non-productive
cough. She awakens with night-time
shortness of breath twice per night. She
complains that her current symptoms are
beginning to interfere with her daily activities
and she is concerned that her albuterol
inhaler seems to be less effective than
previous. Currently she states that her
breathing is normal. Diagnosed with asthma
at age 2.5 years. She has no recent use of
spirometry, does not use a peak flow, does
not record attacks, and does not have a
home nebulizer or vaporizer. She has been
hospitalized five times for asthma, last at
age 16. She has never been intubated for
her asthma. She does not have a current
pulmonologist or allergist. Social History:
She is not aware of any environmental
exposures or irritants at her job or home.
She changes her sheets weekly and denies
dust/mildew at her home. She uses a
hypoallergenic pillow cover and her mattress
,NR 510 week 2 respiratory shadow health
is one year old. She denies current use of
tobacco, alcohol, and illicit drugs. She did
smoke marijuana for 5 or 6 years, her last
use was at age 21 years. She does not
exercise. Review of Systems: General:
Denies changes in weight, fatigue,
weakness, fever, chills, and night sweats. •
Nose/Sinuses: Denies rhinorrhea with this
episode. Denies stuffiness, sneezing,
itching, previous allergy, epistaxis, or sinus
pressure. • Gastrointestinal: No changes in
appetite, no nausea, no vomiting, no
symptoms of GERD or abdominal pain •
Respiratory: Complains of shortness of
breath and cough as above. Denies sputum,
hemoptysis, pneumonia, bronchitis,
emphysema, tuberculosis. She has a history
of asthma, last hospitalization was age 16,
last chest XR was age 16.
Objective General: Ms. Jones is a pleasant, obese 28-
year-old African American woman in no
Ms. Jones does not appear to be in any acute distress. She is alert and oriented and
distress. Her breathing is normal she is not sitting upright on exam table. She maintains
gasping or having any air hunger. Her lips eye contact throughout interview and
are pink. Ms. Jones answers questions examination. • Respiratory: Chest expansion
without difficulty and speeks normally. Her is symmetrical with respirations. Normal
bilateral posterior upper and lower lobes fremitus, symmetric bilaterally. Chest
have noted wheeze. Her pulse ox is 97% on resonant to percussion; no dullness.
room air. Her spirometer reading is FVC Bilateral expiratory wheezes in posterior
3.9/L and FEV1 3.15/L. Her inhaler is noted lower lobes. Bilateral muffled words with
to be up to date and correct dose. There is notable expiratory wheezes in posterior
no abnormality when her chest was lower lobes. No crackles. In office
inspected,palpated and percussed. spirometry: FVC 3.91 L, FEV1/FVC ratio
80.56%. SpO2: 97%.
Assessment
Mild-persistent asthma with exacerbation
Ms. Jones has increased need for her
inhaler in recent as well as when she is
exposed to allergens and with increased
activity. She also has diabetes for which she
,NR 510 week 2 respiratory shadow health
is noncompliant with medication. Ms. Jones
needs further education regarding the
necessity for blood glucose control. She
also should try to avoid exposure to
allergens that exacerbate her asthma.
Diagnostics • Obtain office oxygen
saturation Medication • NMT in office x 1 •
Plan
Initiate step-up medication therapy with
inhaled corticosteroid • Continue albuterol
Ms. Jones should be given steroids as well
inhaler Education • Encourage Ms. Jones to
as a nebulizer treatement in office and set
continue to monitor symptoms and log her
her up so she can have a unit at home. I
episodes of asthma symptoms and
would also recommend her to see a
wheezing with associated factors and bring
pulmonologist for a pulmonary fuction test.
log to next visit • Encourage to wash
Ms. Jones also needs to better control her
bedding and consider dust mite covers to
blood glucose and educate her on proper
decrease allergic nighttime symptoms •
glucose control and why it is important
Educate to increase intake of water and
especially since we are ordering her steroids
other fluids • Create Asthma Action Plan
which can cause hyperglycemia and
Referral/Consultation • Refer to allergy
diabetic patients. I would also recommend
specialist for evaluation and testing Follow-
her to see an allergist to deteremine if there
up Planning • Order PFTs to be completed
is any other cause or allergen that may
after exacerbation to have baseline
contribute to her acute respiratory issues.
available for future comparison • Instruct Ms.
She should restart her metformin and
Jones on when to seek emergent care
regularly check her blood glucose levels. I
including episodes of chest pain or
would also recommend scheduling a phone
shortness of breath unrelieved by rest,
follow up in a few days as well as an office
worsening asthma symptoms or wheezing,
appointment in a few weeks.
or the sense that rescue inhaler is not
helping • Revisit clinic in 2-4 weeks for
follow up and evaluation
Student Pre-Survey Activity Time: 1 min
Thank you for your feedback!
Lifespan Activity Time: 21 min
, NR 510 week 2 respiratory shadow health
Tina’s second cousin was diagnosed with asthma at age 5. What
would be included in your treatment plan? What factors might
concern you related to compliance?
Student Response: Asthma tends to run in families, I would instruct Tina to inform her cousin to
see a medical professional if she has trouble breathing and should see a practitioner for further
evaluation. Asthma is related to lower socioeconomial status as well as exposure to specific irritants
as young children or infants. Factors that concern me related to compliance are educational as well
as transportation to appointments and insurance.
Model Note: Younger patients with asthma are treated with the same medication as adults. Some
medication dosages are based on weight. She should use an inhaler with a spacer attached for
proper medication administration and her caregiver should always assist her. Studies have shown
that nebulizer treatments are a less efficient way to administer medication. The provider should
acknowledge that she may have an asthma attack while in school, and therefore needs a note to
allow her to use it as needed. The patient and her caregiver should be educated about the
importance of having her inhaler close-by and how to use it.
Consider that Tina’s uncle is now 68 years old and has smoked
heavily every day since he was fifteen. What would you expect to
find in his respiratory assessment? How would this affect your
oxygenation goals for this patient?
Student Response: Tina's uncle would presumably suffer from COPD and would have O2 level at
baseline due to perfusion oxygenation ratio. His respiratory assessment without complication would
be diminished breath sounds in the bases with probable rhonchi or coarseness throughout. He
would also have the probable "smokers cough" and depending on the amount of cigarettes per day
he may have a barrel chest and be sob at rest and especially on exertion with minimal activity. The
oxygenation goals for a patient with COPD differ from a patient without chronic respiratory disease.
A patient does not require as much oxygen for adequate respiratory drive. A patient with COPD may
only require a oxygen saturation of 88-92% depending on ABG levels. Increasing the amount of
oxygen in COPD patients actually decreases their stimulus to breathe or slow respirations thus
increasing the CO2 levels in the body. COPD patients become accustomed to low levels of oxygen
and function better with a lower pulse oxygenation or hypoxic drive.
Model Note: He likely has decreased breath sounds on auscultation due to emphysematous
changes to his lungs from smoking. As alveoli get destroyed from chronic inflammation and irritation,
the surface area in the lungs is decreased. This leads to less area for gas exchange and subsequent
decreased oxygen saturation. As his body adjusts to chronic oxygen deprivation, attention must be
given to how much supplemental oxygen is given. The goal with someone with severe COPD is to
keep oxygen saturation 88% to 92%. If he is given too much oxygen his drive to breathe with be
decreased and puts him at risk for death.
Ms. Jones is a 28 year old well developed HPI: Ms. Jones is a pleasant 28-year-old
African American Female who presents to African American woman who presented to
the office today complaining of increased the clinic with complaints of shortness of
shortness of breath as well as increase use breath and wheezing following a near
and need of her inhaler that began two days asthma attack that she had two days ago.
ago. Ms. Jones has allergies to cats which She reports that she was at her cousin’s
exacerbate her asthma and has had recent house and was exposed to cats which
exposure to 3 cats at her cousins, she also triggered her asthma symptoms. At the time
admits to sensitivty to seasonal allergies as of the incident she notes that her wheezes
well as dust. She admits to increased cough were a 6/10 severity and her shortness of
with wheeze but denies nasal drainage or a breath was a 7-8/10 severity and lasted five
productive cough. She does not take any minutes. She did not experience any chest
medications for her allergies other than her pain or allergic symptoms. At that time she
Albuterol inhaler 90 mcg 2-3 puffs q4 hours used her albuterol inhaler and her
prn wheeze/sob, and over the counter symptoms decreased although they did not
acetaminophen and advil prn for headache completely resolve. Since that incident she
and cramping. She does report having notes that she has had 10 episodes of
increased shortnes of breath with increased wheezing and has shortness of breath
activty as well as when she is lying flat. Ms. approximately every four hours. Her last
Jones sleeps with one pillow and has no episode of shortness of breath was this
difficulty sleeping. Ms. Jones also presents morning before coming to clinic. She notes
with an elevated blood glucose and admits that her current symptoms seem to be
to non compliance with medicaiton and worsened by lying flat and movement and
regular glucose monitoring. are accompanied by a non-productive
cough. She awakens with night-time
shortness of breath twice per night. She
complains that her current symptoms are
beginning to interfere with her daily activities
and she is concerned that her albuterol
inhaler seems to be less effective than
previous. Currently she states that her
breathing is normal. Diagnosed with asthma
at age 2.5 years. She has no recent use of
spirometry, does not use a peak flow, does
not record attacks, and does not have a
home nebulizer or vaporizer. She has been
hospitalized five times for asthma, last at
age 16. She has never been intubated for
her asthma. She does not have a current
pulmonologist or allergist. Social History:
She is not aware of any environmental
exposures or irritants at her job or home.
She changes her sheets weekly and denies
dust/mildew at her home. She uses a
hypoallergenic pillow cover and her mattress
,NR 510 week 2 respiratory shadow health
is one year old. She denies current use of
tobacco, alcohol, and illicit drugs. She did
smoke marijuana for 5 or 6 years, her last
use was at age 21 years. She does not
exercise. Review of Systems: General:
Denies changes in weight, fatigue,
weakness, fever, chills, and night sweats. •
Nose/Sinuses: Denies rhinorrhea with this
episode. Denies stuffiness, sneezing,
itching, previous allergy, epistaxis, or sinus
pressure. • Gastrointestinal: No changes in
appetite, no nausea, no vomiting, no
symptoms of GERD or abdominal pain •
Respiratory: Complains of shortness of
breath and cough as above. Denies sputum,
hemoptysis, pneumonia, bronchitis,
emphysema, tuberculosis. She has a history
of asthma, last hospitalization was age 16,
last chest XR was age 16.
Objective General: Ms. Jones is a pleasant, obese 28-
year-old African American woman in no
Ms. Jones does not appear to be in any acute distress. She is alert and oriented and
distress. Her breathing is normal she is not sitting upright on exam table. She maintains
gasping or having any air hunger. Her lips eye contact throughout interview and
are pink. Ms. Jones answers questions examination. • Respiratory: Chest expansion
without difficulty and speeks normally. Her is symmetrical with respirations. Normal
bilateral posterior upper and lower lobes fremitus, symmetric bilaterally. Chest
have noted wheeze. Her pulse ox is 97% on resonant to percussion; no dullness.
room air. Her spirometer reading is FVC Bilateral expiratory wheezes in posterior
3.9/L and FEV1 3.15/L. Her inhaler is noted lower lobes. Bilateral muffled words with
to be up to date and correct dose. There is notable expiratory wheezes in posterior
no abnormality when her chest was lower lobes. No crackles. In office
inspected,palpated and percussed. spirometry: FVC 3.91 L, FEV1/FVC ratio
80.56%. SpO2: 97%.
Assessment
Mild-persistent asthma with exacerbation
Ms. Jones has increased need for her
inhaler in recent as well as when she is
exposed to allergens and with increased
activity. She also has diabetes for which she
,NR 510 week 2 respiratory shadow health
is noncompliant with medication. Ms. Jones
needs further education regarding the
necessity for blood glucose control. She
also should try to avoid exposure to
allergens that exacerbate her asthma.
Diagnostics • Obtain office oxygen
saturation Medication • NMT in office x 1 •
Plan
Initiate step-up medication therapy with
inhaled corticosteroid • Continue albuterol
Ms. Jones should be given steroids as well
inhaler Education • Encourage Ms. Jones to
as a nebulizer treatement in office and set
continue to monitor symptoms and log her
her up so she can have a unit at home. I
episodes of asthma symptoms and
would also recommend her to see a
wheezing with associated factors and bring
pulmonologist for a pulmonary fuction test.
log to next visit • Encourage to wash
Ms. Jones also needs to better control her
bedding and consider dust mite covers to
blood glucose and educate her on proper
decrease allergic nighttime symptoms •
glucose control and why it is important
Educate to increase intake of water and
especially since we are ordering her steroids
other fluids • Create Asthma Action Plan
which can cause hyperglycemia and
Referral/Consultation • Refer to allergy
diabetic patients. I would also recommend
specialist for evaluation and testing Follow-
her to see an allergist to deteremine if there
up Planning • Order PFTs to be completed
is any other cause or allergen that may
after exacerbation to have baseline
contribute to her acute respiratory issues.
available for future comparison • Instruct Ms.
She should restart her metformin and
Jones on when to seek emergent care
regularly check her blood glucose levels. I
including episodes of chest pain or
would also recommend scheduling a phone
shortness of breath unrelieved by rest,
follow up in a few days as well as an office
worsening asthma symptoms or wheezing,
appointment in a few weeks.
or the sense that rescue inhaler is not
helping • Revisit clinic in 2-4 weeks for
follow up and evaluation
Student Pre-Survey Activity Time: 1 min
Thank you for your feedback!
Lifespan Activity Time: 21 min
, NR 510 week 2 respiratory shadow health
Tina’s second cousin was diagnosed with asthma at age 5. What
would be included in your treatment plan? What factors might
concern you related to compliance?
Student Response: Asthma tends to run in families, I would instruct Tina to inform her cousin to
see a medical professional if she has trouble breathing and should see a practitioner for further
evaluation. Asthma is related to lower socioeconomial status as well as exposure to specific irritants
as young children or infants. Factors that concern me related to compliance are educational as well
as transportation to appointments and insurance.
Model Note: Younger patients with asthma are treated with the same medication as adults. Some
medication dosages are based on weight. She should use an inhaler with a spacer attached for
proper medication administration and her caregiver should always assist her. Studies have shown
that nebulizer treatments are a less efficient way to administer medication. The provider should
acknowledge that she may have an asthma attack while in school, and therefore needs a note to
allow her to use it as needed. The patient and her caregiver should be educated about the
importance of having her inhaler close-by and how to use it.
Consider that Tina’s uncle is now 68 years old and has smoked
heavily every day since he was fifteen. What would you expect to
find in his respiratory assessment? How would this affect your
oxygenation goals for this patient?
Student Response: Tina's uncle would presumably suffer from COPD and would have O2 level at
baseline due to perfusion oxygenation ratio. His respiratory assessment without complication would
be diminished breath sounds in the bases with probable rhonchi or coarseness throughout. He
would also have the probable "smokers cough" and depending on the amount of cigarettes per day
he may have a barrel chest and be sob at rest and especially on exertion with minimal activity. The
oxygenation goals for a patient with COPD differ from a patient without chronic respiratory disease.
A patient does not require as much oxygen for adequate respiratory drive. A patient with COPD may
only require a oxygen saturation of 88-92% depending on ABG levels. Increasing the amount of
oxygen in COPD patients actually decreases their stimulus to breathe or slow respirations thus
increasing the CO2 levels in the body. COPD patients become accustomed to low levels of oxygen
and function better with a lower pulse oxygenation or hypoxic drive.
Model Note: He likely has decreased breath sounds on auscultation due to emphysematous
changes to his lungs from smoking. As alveoli get destroyed from chronic inflammation and irritation,
the surface area in the lungs is decreased. This leads to less area for gas exchange and subsequent
decreased oxygen saturation. As his body adjusts to chronic oxygen deprivation, attention must be
given to how much supplemental oxygen is given. The goal with someone with severe COPD is to
keep oxygen saturation 88% to 92%. If he is given too much oxygen his drive to breathe with be
decreased and puts him at risk for death.
