Respiratory _ Provider_Note_Completed _ Shadow Health

Respiratory _ Provider_Note_Completed _ Shadow Health Respiratory Results | Turned In Advanced Health Assessment - July 2020, NURP 500/530 Return to Assignment (/assignments//) Your Results Reopen (/assignment_attempts//reopen Lab Pass (/assignment_attempts//lab_pass.p Overview Transcript Subjective Data Collection Documentation / Electronic Health Record Document: Provider Notes Objective Data Collection Education & Empathy Documentation Document: Provider Notes Student Documentation Model Documentation Subjective Identifying and Reliability: Ms Jones is an obese 28 year-old female who is presenting to the office today with an an asthma exacerbation. She is the primary and only source of personal and medical data. Pleasant, cooperative, and readily open to freely disseminate health information. Good eye contact, well-groomed, good posture, and communicate clearly with logical flow of ideas. Gneral Survey: Upon entering the patient's examination room, patient was found to be sitting straight and erect, good posture, well-groomed, well- nourished with a pleasant demeanor and manner of communicating. Reason for Visit: "Breathing Problems and my inhaler just isn't working the way it normally does" HPI: Miss Tina Jones is a 28 year old African American woman who walked into the clinic complaining of shortness of breath and wheezing after nearly having a "bad" asthma attack 2 days ago. Patient reports allergies to cats which triggered her asthma symptoms while she was visiting her cousin's house. Initially at the time of the asthma attack or shortness of breath severity was 7-8/10, wheezing severity was initially a 6/10. It lasted for five minutes following the use of her rescue inhaler Proventil. Patient reports only chest tightness at the time which has continued to the present with no increase of tightness. Patient denies all other allergic symptoms during the exacerbation of her asthma. The inhaler had a mild to moderate effect, not fully resolving the asthma. symptoms. Patient reports that since the initial exacerbation, she has had 10 similar asthma episodes consisting of shortness of breath, "not able to get enough air" into her lungs, chest tightness, even through the night, Awakening her from sleep. Her symptoms are worse than when laying supine, including coughing fits each time she lays down, which easily resolved once sitting up. Instead of using the prescribed two Puffs of her inhaler, the patient has been using three Puffs each exacerbation with minimal to moderate relief. Most recent episode was this morning prior to her arrival. Asthma exacerbations are aggravated by exposure to cats, perhaps Dusk, and currently exacerbated by exertion and laying supine with a subsequent Patient concerned her inhaler is ineffective. Her asthma has been HPI: Ms. Jones is a pleasant 28-year-old African American wom who presented to the clinic with complaints of shortness of brea and wheezing following a near asthma attack that she had two d ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the ti of the incident she notes that her wheezes were a 6/10 severity her shortness of breath was a 7-8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms se to be worsened by lying flat and movement and are accompanie a non-productive cough. She awakens with night-time shortness breath twice per night. She complains that her current symptom beginning to interfere with her daily activities and she is concern that her albuterol inhaler seems to be less effective than previou Currently she states that her breathing is normal. Diagnosed wit asthma at age 2.5 years. She has no recent use of spirometry, d not use a peak flow, does not record attacks, and does not have home nebulizer or vaporizer. She has been hospitalized five time 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 irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillo cover and her mattress is one year old. She denies current use o tobacco, alcohol, and illicit drugs. She did smoke marijuana for 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 vomiti 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 Sasuthpmpao,rltast hospitalization was age 16, last chest XR was age 16. ……………………………………….CONTINUED………………………………………….