Shadow health Respiratory Tina jones Documentation
Documentation / Electronic Health Record
Document: Provider Notes
Document: Provider Notes
Student Documentation
Model Documentation
Subjective
Ms. Tina Jones is a 28 year old African American female who reports to the clinic with complaints of “having breathing problems” with decreased effectiveness from her inhaler. She states that it’s been “hard to take in air”, her chest feels tight, she’s been wheezing and has a new, frequent, nonproductive cough. These symptoms started two days ago, worsening at night when she’s lying down or when she over exerts herself. She states she changes her bedding and dust weekly. Typically cats or dust triggers her asthma reaction. She states her symptoms began while visiting her cousin who has cats. She only visits her a few times a year. Her most recent experience of shortness of breath was this morning before arrival at the clinic. Currently she states that her “breathing feels okay” but during her asthma attacks she would rate the severity at a 7 or 8 out of 10 and with the attack lasting about five minutes total. She uses her albuterol inhaler to treat symptoms, however lately the inhaler hasn’t been as effective at treating the symptoms as it has previously. She has not been hospitalized for asthma since she was a child. She was diagnosed with asthma at age 2. She treats her asthma with an inhaler only, along with attempting to stay away from cats. She doesn’t keep an asthma diary or use spirometry, peak flow or nebulizer. She denies use of tobacco or alcohol. She hasn’t used marijuanna since she was 21 years old. Does not see a specialist for asthma. Review of Systems General: Not getting adequate sleep due to asthma symptoms resulting in low energey levels, denies fever, chills, night sweats Nose: Denies congestion, sneezing, runny nose, or environmental allergies besides dust G.I.: No changes in appetite, no N/V, no complaints of abdominal pain Respiratory: Complaints of new onset SOB with wheezing and nonproductive cough, denies pneumonia, bronchitis, emphysema, TB. History of asthma since childhood, no recent hospitalization for asthma.
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 for 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 exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, 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. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, 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.
Objective
Ms. Tina Jones is an 28 year old African American female. She is alert and oriented times 4 and is dressed appropriately for the setting. She is currently not under any distress. Chest expansion is symmetric bilaterally with respirations, Chest resonant to percussion with no dullness, normal fremitus, bilateral wheezes heard in posterior lower lobes. Bilateral muffled “99” ascultated in lower posterial lobes. Incentive spirometer results: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%.
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on exam table. She maintains eye contact throughout interview and…
