Respiratory Physical Assessment Assignment Results | Turned In

Respiratory Physical Assessment Assignment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-October-2018 Return to Assignment Your Results Lab Pass Documentation / Electronic Health Record Document: Provider Notes Document: Provider Notes Student Documentation Model Documentation Subjective CC:"hard to take in air. My chest feels all tight and I've been wheezing... I've had to use my inhaler a lot, and it doesn't feel like it's totally working." HPI: Onset: 2 days ago at her cousin's house after exposure to cats which exacerbated her asthma and reported symptoms. Location:Chest Duration: "Minute or two" for each episode reported with a total of 10 episodes in last 2 days per patient. Characteristics/Quality: Tightness, feelings of not being able to take in air. Aggravating factors/Associated Symptoms: Cats, dust, running up a flight of stairs. Worse upon exertion and when lying down flat. Relieving factors: Proventil inhaler, resting Treatment/Medications/Remedies:Proventil Inhaler, three puffs every 4 hours for past 2 days. Albuterol 90mcg/spray MDI Severity:7-8/10 FH:Sister with asthma SH:Supervisor at Mid-American Copy & Ship, currently lives with mother and younger sister. MH:States having all the required "shots they give you when you're a kid." Hospitlized as a child and teen for asthma. ED a few months ago for foot injury that has since healed. Updates to Meds: No updates. Previous medications continued. Updates to Allergies: Updated to include seasonal allergies/hay fever along with cats & dust ROS General/Constitutional: No weigth loss, fever, chills, weakness reported. Patient does report fatigue upon exertion that subsides at rest. Respiratory:"Been hard to take in air". Chest tightness & wheezing. 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 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.