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Respiratory Shadowhealth Tina Jones Documentation
Family Nurse Practitioner Ii (NUR 535)
Southern Connecticut State University
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Respiratory Results | Turned In
Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
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Subjective Data Collection
Objective Data Collection
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Document: Provider Notes
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Student Documentation Model Documentation
HPI: Ms. Jones is a pleasant 28-year-old African American wom who presented to the clinic with complaints of shortness of bre and wheezing following a near asthma attack that she had two ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the of the incident she notes that her wheezes were a 6/10 severity her shortness of breath was a 7-8/10 severity and lasted ûve 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 fou hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms s to be worsened by lying üat and movement and are accompan a non-productive cough. She awakens with night-time shortne breath twice per night. She complains that her current symptom beginning to interfere with her daily activities and she is concer that her albuterol inhaler seems to be less effective than previo Currently she states that her breathing is normal. Diagnosed w asthma at age 2 years. She has no recent use of spirometry, not use a peak üow, does not record attacks, and does not hav home nebulizer or vaporizer. She has been hospitalized ûve tim asthma, last at age 16. She has never been intubated for her asthma. She does not have a current pulmonologist or allergist
Social History: She is not aware of any environmental exposure irritants at her job or home. She changes her sheets weekly an denies dust/mildew at her home. She uses a hypoallergenic pil cover and her mattress is one year old. She denies current use tobacco, alcohol, and illicit drugs. She did smoke marijuana for 6 years, her last use was at age 21 years. She does not exercis
Review of Systems: General: Denies changes in weight, fatigue weakness, fever, chills, and night sweats.
- Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuûness, sneezing, itching, previous allergy, epistaxis, or sinu pressure.
- Gastrointestinal: No changes in appetite, no nausea, no vomit no symptoms 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 was age 16, last chest XR was age 16.
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented sitting upright on exam table. She maintains eye contact throug interview and examination.
- Respiratory: Chest expansion is symmetrical with respirations Normal fremitus, symmetric bilaterally. Chest resonant to percu no dullness. Bilateral expiratory wheezes in posterior lower lob Bilateral muüed words with notable expiratory wheezes in pos lower lobes. No crackles. In oûce spirometry: FVC 1 FEV1/F ratio 87% SpO2: 97%.
Subjective
Objective
Assessment
asthma exacerbation.
Asthma exacerbation
Respiratory Shadowhealth Tina Jones Documentation
Course: Family Nurse Practitioner Ii (NUR 535)
University: Southern Connecticut State University
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