Respiratory Results | Turned In Advanced Health Assessment

Respiratory Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Pass Documentation / Electronic Health Record Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective Ms. Jones a 28 year old female. Of African American descent. 170 cm height weight 89kg BMI 30.8 Random glucose: 224 temp: 98.5 B/p 140/81 Heart rate: 89 Resp: 20 Pulse ox: 97% right and left index finger CC. Ms. Jones States, " I came in because I'm having breathing problems, my inhaler just isn't working the way it normally does".shortness of breath and decreased effectiveness with inhaler use. HPI: onset of symptoms 2 days ago, at her cousin's house and she as cat is allergic to cats. She states "her inhaler usually it fixes the problem, and it doesn't feel totally under control. She complains of frequency as every 4 hours shortness of breath, haven't had a full asthma attack in years but her inhaler inhaler takes about when the two minutes for her breathing to go back to normal. She reports wheezing every 4 hours or so about 5 episodes of the day. Exacerbations lasting several minutes. Asthma seems to be waking her up the past two nights. The past few days asthma has been interfering with her activities of daily living. Patient HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and 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 seem to be worsened by lying flat and movement and 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 Student Documentation Model Documentation feels like she can't take in air asthma been pretty bad lately. Also reports wheezing when having an asthma attack. Patient also reports a cough which started two days ago along with the symptoms and drinking tap water makes it feel better. Haven't tried any medications for her cough. Lying on her back at night makes it worse. Current Medications: proventil 90mcg 2 puffs q 4 hours and PRN MDI for wheezing, last used this morning and uses around cats.OTC tylenol 500mg mg PO PRN for headaches, 600mg PO TID prn for cramps. Allergies: cats and dust PMHx: asthma and diabetes Soc Hx: denies cigarette smoking, last smoked marijuana at age 21 years of age.Denies use of inhaled substances Fam Hx: sister (asthma) is 14 years old, allergies (hayfever) sister Exam: Upon inspection anterior chest wall, right and left chest wall no abnormal findings. Palpation chest expansion both sides rice freely and symmetrical. Palpation of fremitus in anterior upper chest wall equal bilaterally expected vibration. Palpated permit is in anterior lower chest wall equal bilaterally and expected vibration. Palpation of fremitus posterior upper middle and lower chest wall all equal bilaterally expected vibration. Percussion of all areas on anterior and posterior wall and no areas of dullness. Auscultated breath sounds anteriorly and posteriorly all sounds present bilaterally adventitious sounds wheezing noted on expiration to all posterior lower lobes with prolonged expiration in posterior hophony - . Check patients Proventil inhaler expires 7/10/2018. proventil 200 metered doses and delivers 90 mcg of albuterol.Denies any changes in appetite. She's only allergic to dust and cats which will trigger her asthma. For asthma can be induced hurrying up the stairs. Denies any seasonal allergies at this time. no longer see's asthma specialist last scene 2 years ago even though position called in refills or her inhaler. Diagnosis of asthma at 2 and 1/2 years old. The last time patient was hospitalizedand had a chest xray for asthma was 16 years old. Denies having ever been intubated. Patient denies tracking her asthma. Denies Peak and flow regularly. Does not own a nebulizer but has use a nebulizer in the past. Patient State, " changes sheets once a week." Patient denies having triggers for asthma at home. Ms. Jones denies any pets at s any eczema or skin problems. note no sinus problems . Denies any diagnosis of GERD or COPD. Denies cigarette smoking and in health substances. Use marijuana in the past and last known use at the age of 21. Denies recently being sickness, fever, chills, N/V. Reports low energy level and denies night sweats. Deny phlegm or sputum. Deny sore throat swelling or difficulty swallowing and nasal drainage. Reports no recent illness with family members at home. Report younger sister as only one of the family with allergies and asthma. Reports no family 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 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.