ASTHMA-Respiratory | Completed | Shadow Health

ASTHMA-Respiratory | Completed | Shadow Health Respiratory Results | Turned In Advanced Health Assessment - Chamberlain, NR509-June-2018 Return to Assignment Your Results Documentation / Electronic Health Record 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 athma exacerbation. She is the primary and only source of personal and medical data. Pleasent, cooperative and readily open to freely dissiminate health information. Good eyeye contact, well-groomed, good posture, and comunicates clearly with logical flow of ideas. General 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 pleasent demeanor and manner of communicating. Reason for Visit: "Breathing problems and my inhaler just isn't working the way it normally does." HPI: Ms. Tina Jones is a 28-year-old African American woman who walked in to the clinic complianing of SOB and wheezing after nearly haveing a "bad" asthma attack two days ago. Pt. reports allergies to cats which triggered her asthma symptoms while she was visitn her cousins house. Initially, at the time of the climax of her near asthma attack, her SOB severity was a 7-8/10, wheezing severity was initially a 6/10. It lasted for 5 minutes, following the use of her rescue inhaler Provenol. Pt. reports only chest tightness at the time, which has continued to the present with no increase in tightness. Pt. denies all other allergic symptoms during the exaccerbation of her asthma. The inhalor had amild to moderate effect, not fully resolving the asthma symptoms. Pt. reports that since the initial exacerbation, she has had ten similar asthma episodes consisting of SOB, "not able to get enough air in" to her lungs, chest tightness all occur every 4 hours, even through the night, awakinging her from sleep. Her symptomsare worsoned when laying supine, including coughing fits each time she lays down, which easily resolves once sitting backup. Instead of using the prescribed 2 puffs of albuterol, pt. has been using 3 puffs each exacerbation with minimal to moderate relief. Most recent episode was this morning prior to her arrival. Asthma exacerbations are aggrevated by exposure to cats, perhaps dust, and currently exacerbated by exertion and laying supine with a subsequent coughing fit. occur Cough is non-productive. Pt. concerned her new albuterol inhaler is ineffective compared to previous device. Her asthma has been slowly interferring with her life the past year or so, while still being manageable. Over the past 2 days, her asthma has interferred with her daily life, including her response that if she had not had these past two days off of work, she "would have called in sick for sure." Pt. feels minimal asthma symptoms curretly, following her albuterol use over an hour ago. Diagnosed with asthma at 2.5-years-old, She frequented hospital visits and including five hospitalizations before she was 16-years-old. Since then she hasn't been hospitalized. Pt. denies spirometry inhalor, peak flow meter use, as well as any other asthma medication use. Pt. doesn't keep asthma record of exacerbations and triggers; denies asthma medication usage excet for albuterolresuce inhaler. Pt. not currrently beingmanaged by a pulmonologist or someone for her allergies. Pt. denies using a vaporizer or nebulizer at home. PMH: Pt. reports Type 2 Diabetes, possible borderline hypertension (no actual dx). Allergies: Cats: Develops itchy, watery eyes; an itchy, "runny nose"; an itchy, sometimes a sore throat, and often an asthma exacerbation - SOB, DOE, wheezing, coughing, and chest tightness. Dust: Develops a rash, no tiching. Penicillin: "Rash, like, hives."