Shadow Health 653Respiratory- Tina Jones Subjective Data: Subjective Data Collection Score: 21 of 21 (100.0%)

Your Results Lab Pass (/assignment_attempts//lab_pass.p Overview Transcript Subjective Data Collection: 21 of 21 (100.0%) Subjective Data Collection Objective Data Collection Education & Empathy Documentation Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Indicates an item that you found. Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yiel better patient data. The following details are facts of t patient's case. Chief Complaint Established chief complaint Reports increased breathing problems and shortness of breath Reports decreased effectiveness of inhaler History of Presenting Illness Asked about onset of symptoms Reports symptoms began two days ago Asked about frequency and duration of SOB episodes Reports exacerbations lasting several minutes Reports exacerbated breathing about every 4 hours since original episode Reports waking up twice a night with asthma the past 2 nights Asked about severity of symptoms Describes asthma severity as "not full attack," but worse than usual Reports asthma has been interfering with activities of daily life Asked about character of symptoms Reports recent wheezing Reports chest tightness Denies chest pain Asked about cough Reports cough Cough has persisted since original asthma exacerbation 2 days ago Describes cough as "dry" Describes cough as "small" and not severe Reports cough slightly relieved by drinking water Has not treated cough with medication or home remedies Asked about aggravating factors Reports symptoms worse at night Reports symptoms increase when lying flat on back Reports symptoms aggravated by movement Medical History Confirmed use of medications Confirms medications (no new medications reported) Followed up about inhaler use Uses an inhaler to treat asthma symptoms Inhaler is Proventil Reports most recent inhaler use was this morning Reports using inhaler every 4 hours or so since exacerbation Prescribed usage is 2 puffs Reports needing more than 2 puffs to resolve asthma symptoms Confirmed allergies Confirms allergies (no new allergies reported) Followed up on exposure to allergy and asthma triggers Reports cat allergy triggered recent episodes Reports dust as a known trigger Reports activity such as walking up stairs as a known trigger Denies seasonal pattern Denies changes in weather as a trigger Reports minimal exposure to asthma triggers at work Asked detailed questions about asthma history No current asthma doctor Diagnosed with asthma in childhood Age of diagnosis was 2 1/2 years old Asked about hospitalizations for asthma Reports prior hospitalizations for asthma Reports last hospitalization was age 16 Estimates 5 total hospitalizations for asthma Reports she has never been intubated Followed up about non-medication forms of asthma management Denies record keeping of asthma exacerbation or shortness of breath episodes Denies using peak flow meter Denies nebulizer use Social Determinants of Health Asked about environmental control Reports living situation is tidy and free of dust Reports hypoallergenic bedding hygiene Reports avoiding animals and has no pets at home Reports avoiding exposure to secondhand smoke Social History Asked about exercise and activity level Reports general low activity level Reports diminished activity due to asthma Asked about possible contributing factors in health history Denies history of eczema Denies history of sinus problems Denies history of GERD, heartburn, or indigestion Denies history of COPD or emphysema Asked about smoking, inhalants, or tobacco Denies history of tobacco use, including cigarettes Reports past history of marijuana 653Respiratory- Tina Jones Subjective Data: Subjective Data Collection Score: 21 of 21 (100.0%)