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
Ms. Jones is a 28 year old well developed minutes. She did not experience any chest
African American Female who presents to pain or allergic symptoms. At that time she
the office today complaining of increased used her albuterol inhaler and her
shortness of breath as well as increase use symptoms decreased although they did not
and need of her inhaler that began two days completely resolve. Since that incident she
ago. Ms. Jones has allergies to cats which notes that she has had 10 episodes of
exacerbate her asthma and has had recent wheezing and has shortness of breath
exposure to 3 cats at her cousins, she also approximately every four hours. Her last
admits to sensitivty to seasonal allergies as episode of shortness of breath was this
well as dust. She admits to increased cough morning before coming to clinic. She notes
with wheeze but denies nasal drainage or a that her current symptoms seem to be
productive cough. She does not take any worsened by lying flat and movement and
medications for her allergies other than her are accompanied by a non-productive
Albuterol inhaler 90 mcg 2-3 puffs q4 hours cough. She awakens with night-time
prn wheeze/sob, and over the counter shortness of breath twice per night. She
acetaminophen and advil prn for headache complains that her current symptoms are
and cramping. She does report having beginning to interfere with her daily activities
increased shortnes of breath with increased and she is concerned that her albuterol
activty as well as when she is lying flat. Ms. inhaler seems to be less effective than
Jones sleeps with one pillow and has no previous. Currently she states that her
difficulty sleeping. Ms. Jones also presents breathing is normal. Diagnosed with asthma
with an elevated blood glucose and admits at age 2.5 years. She has no recent use of
to non compliance with medicaiton and spirometry, does not use a peak flow, does
regular glucose monitoring. 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
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.
General: Ms. Jones is a pleasant, obese 28-
Objective
year-old African American woman in no
acute distress. She is alert and oriented and
Ms. Jones does not appear to be in any
sitting upright on exam table. She maintains
distress. Her breathing is normal she is not
eye contact throughout interview and
gasping or having any air hunger. Her lips
examination. • Respiratory: Chest expansion
are pink. Ms. Jones answers questions
is symmetrical with respirations. Normal
without difficulty and speeks normally. Her
fremitus, symmetric bilaterally. Chest
bilateral posterior upper and lower lobes
resonant to percussion; no dullness.
have noted wheeze. Her pulse ox is 97% on
Bilateral expiratory wheezes in posterior
room air. Her spirometer reading is FVC
lower lobes. Bilateral muffled words with
3.9/L and FEV1 3.15/L. Her inhaler is noted
notable expiratory wheezes in posterior
to be up to date and correct dose. There is
lower lobes. No crackles. In office
no abnormality when her chest was
spirometry: FVC 3.91 L, FEV1/FVC ratio
inspected,palpated and percussed.
80.56%. SpO2: 97%.
Assessment
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 Mild-persistent asthma with exacerbation
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
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.
Review Questions Activity Time: 14 min
If Tina had mentioned that she was just diagnosed with pneumonia,
what would you have expected to find during percussion?
Correct: Dull percussion sounds are expected over the areas of diffuse infiltrate (accumulation of
fluid and by products of inflammation) in a patient with pneumonia.
Hyperresonance
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
Ms. Jones is a 28 year old well developed minutes. She did not experience any chest
African American Female who presents to pain or allergic symptoms. At that time she
the office today complaining of increased used her albuterol inhaler and her
shortness of breath as well as increase use symptoms decreased although they did not
and need of her inhaler that began two days completely resolve. Since that incident she
ago. Ms. Jones has allergies to cats which notes that she has had 10 episodes of
exacerbate her asthma and has had recent wheezing and has shortness of breath
exposure to 3 cats at her cousins, she also approximately every four hours. Her last
admits to sensitivty to seasonal allergies as episode of shortness of breath was this
well as dust. She admits to increased cough morning before coming to clinic. She notes
with wheeze but denies nasal drainage or a that her current symptoms seem to be
productive cough. She does not take any worsened by lying flat and movement and
medications for her allergies other than her are accompanied by a non-productive
Albuterol inhaler 90 mcg 2-3 puffs q4 hours cough. She awakens with night-time
prn wheeze/sob, and over the counter shortness of breath twice per night. She
acetaminophen and advil prn for headache complains that her current symptoms are
and cramping. She does report having beginning to interfere with her daily activities
increased shortnes of breath with increased and she is concerned that her albuterol
activty as well as when she is lying flat. Ms. inhaler seems to be less effective than
Jones sleeps with one pillow and has no previous. Currently she states that her
difficulty sleeping. Ms. Jones also presents breathing is normal. Diagnosed with asthma
with an elevated blood glucose and admits at age 2.5 years. She has no recent use of
to non compliance with medicaiton and spirometry, does not use a peak flow, does
regular glucose monitoring. 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
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.
General: Ms. Jones is a pleasant, obese 28-
Objective
year-old African American woman in no
acute distress. She is alert and oriented and
Ms. Jones does not appear to be in any
sitting upright on exam table. She maintains
distress. Her breathing is normal she is not
eye contact throughout interview and
gasping or having any air hunger. Her lips
examination. • Respiratory: Chest expansion
are pink. Ms. Jones answers questions
is symmetrical with respirations. Normal
without difficulty and speeks normally. Her
fremitus, symmetric bilaterally. Chest
bilateral posterior upper and lower lobes
resonant to percussion; no dullness.
have noted wheeze. Her pulse ox is 97% on
Bilateral expiratory wheezes in posterior
room air. Her spirometer reading is FVC
lower lobes. Bilateral muffled words with
3.9/L and FEV1 3.15/L. Her inhaler is noted
notable expiratory wheezes in posterior
to be up to date and correct dose. There is
lower lobes. No crackles. In office
no abnormality when her chest was
spirometry: FVC 3.91 L, FEV1/FVC ratio
inspected,palpated and percussed.
80.56%. SpO2: 97%.
Assessment
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 Mild-persistent asthma with exacerbation
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
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.
Review Questions Activity Time: 14 min
If Tina had mentioned that she was just diagnosed with pneumonia,
what would you have expected to find during percussion?
Correct: Dull percussion sounds are expected over the areas of diffuse infiltrate (accumulation of
fluid and by products of inflammation) in a patient with pneumonia.
Hyperresonance
