Respiratory Results | Turned In

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