NR-511 Differential Diagnosis & Primary Care Practicum-Respiratory-Shadow_Health.pdf

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Identifying and Reliability: Ms Jones is an obese 28 year-old female who is presenting to the office today with an an asthma exacerbation. She is the primary and only source of personal and medical... data. Pleasant, cooperative, and readily open to freely disseminate health information. Good eye contact, well-groomed, good posture, and communicate clearly with logical flow of ideas. Gneral Survey: Upon entering the patient's examination room, patient was found to be sitting straight and erect, good posture, well-groomed, wellnourished with a pleasant demeanor and manner of communicating. Reason for Visit: "Breathing Problems and my inhaler just isn't working the way it normally does" HPI: Miss Tina Jones is a 28 year old African American woman who walked into the clinic complaining of shortness of breath and wheezing after nearly having a "bad" asthma attack 2 days ago. Patient reports allergies to cats which triggered her asthma symptoms while she was visiting her cousin's house. Initially at the time of the asthma attack or shortness of breath severity was 7-8/10, wheezing severity was initially a 6/10. It lasted for five minutes following the use of her rescue inhaler Proventil. Patient reports only chest tightness at the time which has continued to the present with no increase of tightness. Patient denies all other allergic symptoms during the exacerbation of her asthma. The inhaler had a mild to moderate effect, not fully resolving the asthma. symptoms. Patient reports that since the initial exacerbation, she has had 10 similar asthma episodes consisting of shortness of breath, "not able to get enough air" into her lungs, chest tightness, even through the night, Awakening her from sleep. Her symptoms are worse than when laying supine, including coughing fits each time she lays down, which easily resolved once sitting up. Instead of using the prescribed two Puffs of her inhaler, the patient has been using three Puffs each exacerbation with minimal to moderate relief. Most recent episode was this morning prior to her arrival. Asthma exacerbations are aggravated by exposure to cats, perhaps Dusk, and currently exacerbated by exertion and laying supine with a subsequent [Show More]

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