W2_SH_[Dr. Documentation]-ASTHMA-Respiratory | Completed | Shadow Health

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W2_SH_[Dr. Documentation]-ASTHMA-Respiratory | Completed | Shadow Health Respiratory Results | Turned In Advanced Health Assessment - Chamberlain, NR509-June-2018 Return to Assignment Your... Results Lab Pass Overview Transcript Documentation / Electronic Health Record Subjective Data Collection Document: Provider Notes Objective Data Collection Education & Empathy Documentation Student Pre-Survey Lifespan Review Questions Self-Reflection 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 ……………………………………….. …………………………………………………..CONTINUED………………………………………….. [Show More]

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