Tina Jones Respiratory Doccumentation - Respiratory Results | Completed Advanced Health Assessment - MU

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Respiratory Results | Completed Advanced Health Assessment - MU - January 2021, nurs_612_20w_21/sp Return to Assignment (/assignments/458629/) Documentation / Electronic Health Record Document: Pr... ovider Notes Student Documentation Model DocumentationSubjective (No Documentation Made) HPI: Ms. Jones is a pleasant 28-year-old African American womanwho presented to the clinic with complaints of shortness of breath andwheezing following a near asthma attack that she had two days ago.She reports that she was at her cousin’s house and was exposed tocats which triggered her asthma symptoms. At the time of the incidentshe notes that her wheezes were a 6/10 severity and her shortness ofbreath was a 7-8/10 severity and lasted five minutes. She did notexperience any chest pain or allergic symptoms. At that time sheused her albuterol inhaler and her symptoms decreased althoughthey did not completely resolve. Since that incident she notes that shehas had 10 episodes of wheezing and has shortness of breathapproximately every four hours. Her last episode of shortness ofbreath was this morning before coming to clinic. She notes that hercurrent symptoms seem to be worsened by lying flat and movementand are accompanied by a non-productive cough. She awakens withnight-time shortness of breath twice per night. She complains that hercurrent symptoms are beginning to interfere with her daily activitiesand she is concerned that her albuterol inhaler seems to be lesseffective than previous. Currently she states that her breathing isnormal. Diagnosed with asthma at age 2.5 years. She has no recentuse of spirometry, does not use a peak flow, does not record attacks,and does not have a home nebulizer or vaporizer. She has beenhospitalized five times for asthma, last at age 16. She has never beenintubated for her asthma. She does not have a current pulmonologistor allergist. Social History: She is not aware of any environmental exposures orirritants at her job or home. She changes her sheets weekly anddenies dust/mildew at her home. She uses a hypoallergenic pillowcover and her mattress is one year old. She denies current use oftobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6years, 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. Deniesstuffiness, sneezing, itching, previous allergy, epistaxis, or sinuspressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, nosymptoms 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 wasage 16, last chest XR was age 16. Your Res [Show More]

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