NURS 5220 / NURS5220 Tina Jones Respiratory Transcript GRADED A+

7/25/2020 Respiratory | Completed | Shadow Health


Respiratory Results | Turned In
Advanced Health Assessment - Summer 2020, N5121
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Overview
Transcript
Transcript
Started: Jul 25, 2020 | Total Time: 45 min
Subjective Data Collection
All Lines (99) Interview Questions (43) Statements (6) Exam Actions (50)
Objective Data Collection

Education & Empathy Hey.

Documentation
Question
What brings you in today
07/25/20 6:48 PM MD


I came in because I've been having breathing problems, and my inhaler just isn't working the
way it normally does.


Thanks for understanding.


Question
Tell me about your asthma
07/25/20 6:49 PM MD


Sure, what would you like to know?


Question
Any exacerbation (Clarified to Are there any aggravating factors?.)
07/25/20 6:50 PM MD


If I move around or try to be too active, I cough more. (Clarified to if there are aggravating
factors.)


Question
Tell me about your asthma attacks
07/25/20 6:50 PM MD


I guess the main thing with an asthma attack was I would have my usual breathing problems--
my chest would get tight, I couldn't take in air, I would wheeze--but then I'd also get all sweaty,
and it wouldn't stop, even once I used my inhaler. I haven't felt that bad in years, but I'm
worried I will if I don't get my asthma under control.


Sure, I think I understand what you mean.


Thanks.


Question
How often does this happen
07/25/20 6:51 PM MD


Maybe as much as every four hours? It's a lot.


Question
How long does it last (Clarified to How long does your wheezing usually last?.)
07/25/20 6:51 PM MD

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Sometimes it can take a few minutes for me to realize I need my inhaler, then once I use it the
wheezing usually gets better. . . I'd say it takes about a minute to work at most after that. So
five minutes total, at the longest? (Clarified to how long my wheezing lasts.)


Question
How many times a week (Clarified to How many times a week do you have an asthma attack?.)
07/25/20 6:51 PM MD


I haven't had a full attack in years, though lately my asthma's definitely been worse than usual.
(Clarified to how many times a week I have an asthma attack.)


Question
When did it start getting worse (Clarified to When did your shortness of breath start?.)
07/25/20 6:52 PM MD


All of these breathing problems started two days ago, at my cousin's house. (Clarified to when
my shortness of breath started.)


Question
Are you allergic to pets
07/25/20 6:52 PM MD


Yeah, I'm allergic to cats.


Were there any cats at your cousin's house (Clarified to How many cats are at your cousin's Question
house?.) 07/25/20 6:52 PM MD


My cousin has three cats, so my allergies are especially bad at her house. (Clarified to how
many cats my cousin has.)


Question
When was the last time you had an attack
07/25/20 6:52 PM MD


I don't know if I would say it was an attack, but my asthma got really bad two days ago. That's
how all this started. I haven't had a full attack in years, though. . . not since high school.


Question
Any triggers (Clarified to Have you had any asthma triggers recently?.)
07/25/20 6:53 PM MD


Two days ago, at my cousin's house. She has three of them, and my asthma always goes
crazy when I'm there. (Clarified to if I have been around asthma triggers.)


Question
Are you allergic to environmental factors
07/25/20 6:53 PM MD


No, unless cats count.


Question
Are you allergic to dust
07/25/20 6:56 PM MD


Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust.


Question
Does dust trigger allergies (Clarified to Do you have a reaction to dust?.)
07/25/20 6:56 PM MD


If I'm around a lot of dust, I can get sneezy, or I can start wheezing. (Clarified to if I have a
reaction to dust.)


Question
Does exercise aggravate your asthma
07/25/20 6:56 PM MD




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