Tina jones respiratory shadow health transcript
Transcript
Started: Jul 22, 2022 | Total Time: 168 min
All Lines (154)Interview Questions (72)Statements (2)Exam Actions (80)
Hi Ms Jones, I’m xx and I’m going to examine you today.
Greet
07/22/22 1:55 PM MDT
Hey.
Can you verify your name and date of birth?
Question
07/22/22 1:55 PM MDT
My name’s Tina Jones, and my birthday’s February 17th.
What brings you in today?
Question
07/22/22 1:56 PM MDT
I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does.
I’m sorry to hear you’re going through that.
Empathize
07/22/22 1:56 PM MDT
Thanks for understanding.
Can you please describe what’s going on with your inhaler? (No matching questions found.)
Question
07/22/22 1:57 PM MDT
Can you please describe what breathing problems you’re having? (Clarified to Can you describe your breathing problems?.)
Question
07/22/22 1:57 PM MDT
It feels like it’s been hard to take in air. My chest feels all tight and I’ve been wheezing… I’ve had to use my inhaler a lot, and it doesn’t feel like it’s totally working. (Clarified to to describe my breathing problems.)
Do you know what are causing your asthma to flare up? (Clarified to What started your recent asthma problems?.)
Question
07/22/22 1:58 PM MDT
This all started at my cousin’s house. She has cats, and I’m allergic, so my asthma always goes crazy when I’m there. (Clarified to what triggered my recent asthma problems.)
When was your most recent asthma exacerbation?
Question
07/22/22 1:59 PM MDT
The last time I had real trouble breathing was early this morning. But it’s been going on for the past two days.
How many puffs of your inhaler do you use when your asthma symptoms flare up?
Question
07/22/22 2:01 PM MDT
Sometimes I have to take three puffs of the 90 mcg albuterol inhaler instead of two, and the past couple days, always three. [AUDIO COMING SOON]
How often are you around cats?
Question
07/22/22 2:01 PM MDT
Not often. Just at my cousin’s house. . . and I’m only there a few times a year.
What else triggers your asthma besides cats?
Question
07/22/22 2:01 PM MDT
For the last two days, it seems worse at night when I’m lying down, or when I’m moving around too much. Typically it’s stuff like cats or dust that gets to me.
Do you have any other respiratory illnesses?
Question
07/22/22 2:02 PM MDT
No, just the asthma.
How long have you had asthma?
Question
07/22/22 2:02 PM MDT
I’ve had asthma a long time. . . since I was really little.
How do you manage your asthma?
Question
07/22/22 2:03 PM MDT
I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
How is your breathing currently?
Question
07/22/22 2:03 PM MDT
My breathing feels okay right this second, but I’ve definitely been having problems recently with it.
How severe is your asthma?
Question
07/22/22 2:03 PM MDT
My asthma used to be really scary. I haven’t had a full attack in years, and if you had asked me before this I would have said my asthma wasn’t that bad anymore, but the last couple days I’ve had a lot of trouble breathing.
What other symptoms have you had besides trouble breathing?
Question
07/22/22 2:04 PM MDT
Other than what I’ve told you? I don’t think so. It’s just needing my inhaler so much and the cough that’s been bothering me.
Tell me more about your cough
Question
07/22/22 2:05 PM MDT
Um. . . I guess I’d describe it as a small, dry cough.
When did this cough start?
Question
07/22/22 2:05 PM MDT
Two days ago, a little while after I first started having these asthma problems.
Do you have any sputum with this cough?
Question
07/22/22 2:05 PM MDT
No, nothing’s coming up.
How often do you cough?
Question
07/22/22 2:06 PM MDT
I’ve been coughing pretty much all the time.
What are your allergies?
Question
07/22/22 2:06 PM MDT
I’m allergic to cats.
Any other allergy besides cats? (Clarified to Are you allergic to anything besides cats?.)
Question
07/22/22 2:06 PM MDT
Yeah, I’m allergic to penicillin. (Clarified to if I am allergic to anything besides cats.)
When did you have an allergic reaction to penicillin? (Clarified to Have you had an allergic reaction to penicillin?.)
Question
07/22/22 2:07 PM MDT
Yeah, but it was a long time ago, when I was little. . . the doctor told me not to take it again after that. (Clarified to if I have had a reaction to penicillin.)
What happens when you take penicillin?
Question
07/22/22 2:08 PM MDT
I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.
How severe was your reaction to penicillin?
Question
07/22/22 2:08 PM MDT
It was a long time ago, so I don’t remember that well, but I don’t think it was that serious. I just got a rash–like, hives–I think. . . then the doctor said not to take penicillin again, so I didn’t.
Do you have any environmental allergies?
Question
07/22/22 2:09 PM MDT
No, unless cats count.
Can you describe what happens when you’re around cats?
Question
07/22/22 2:09 PM MDT
Whenever I’m around cats, I start sneezing, my eyes get itchy, my nose runs. . . and my asthma starts to act up.
How do your treat your allergy to cats?
Question
07/22/22 2:10 PM MDT
I try not to be around cats at all, but when I have to be around them and my breathing gets bad, I use my inhaler. . . but I don’t totally feel better until I go home and take a shower.
You mentioned your asthma flares up when you’re around dust. What happens when you’re around dust?
Question
07/22/22 2:10 PM MDT
If I’m around a lot of dust, I can get sneezy, or I can start wheezing.
Do you smoke?
Question
07/22/22 2:11 PM MDT
No. I think it’s gross.
Do you use any recreational drugs?
Question
07/22/22 2:11 PM MDT
No.
Do you use marijuana?
Question
07/22/22 2:11 PM MDT
Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
When was the last time you used marijuana?
Question
07/22/22 2:12 PM MDT
I haven’t smoked pot since I was twenty or twenty-one.
Are you around secondhand smoke?
Question
07/22/22 2:12 PM MDT
Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes.
How often are you around your friends that smoke? (Clarified to How often are you around people who smoke?.)
Question
07/22/22 2:12 PM MDT
Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes. (Clarified to how often I am around secondhand smoke.)
Does anyone in your family have asthma?
Question
07/22/22 2:13 PM MDT
It’s just me and my baby sister that have asthma, but she really doesn’t have problems with it.
Did your parents or grandparents have asthma?
Question
07/22/22 2:13 PM MDT
Yeah. Both Nana and Poppa died about five years ago.
I’m so sorry to hear that
Empathize
07/22/22 2:14 PM MDT
Thanks for saying that.
What did your father die of?
Question
07/22/22 2:14 PM MDT
He died in a car accident.
What happened in the car accident?
Question
07/22/22 2:15 PM MDT
He was driving to work and it was raining…and his car hydroplaned. And hit a tree. So it was really sudden.
How did your grandfather die?
Question
07/22/22 2:16 PM MDT
Well, Grandpa Jones died of colon cancer, and Poppa died of a heart attack.
Does your family have a history of lung cancer?
Question
07/22/22 3:19 PM MDT
The only cancer that I know of in our family is colon cancer–Grandpa Jones died of that.
Does your family have a history of respiratory illness?
Question
07/22/22 3:19 PM MDT
My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think.
Do you have a history of bronchitis, pneumonia or emphysema?
Question
07/22/22 3:20 PM MDT
Nope, never.
Inspected anterior chest wall
Exam Action
07/22/22 3:22 PM MDT
Inspected left side chest wall
Exam Action
07/22/22 3:22 PM MDT
Inspected posterior chest wall
Exam Action
07/22/22 3:22 PM MDT
Inspected right side chest wall
Exam Action
07/22/22 3:23 PM MDT
Inspected anterior chest wall
Exam Action
07/22/22 3:23 PM MDT
Palpated chest expansion: Both sides rise symmetrically
Exam Action
07/22/22 3:23 PM MDT
Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration
Exam Action
07/22/22 3:23 PM MDT
Ninety-nine.
Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration
Exam Action
07/22/22 3:23 PM MDT
Ninety-nine.
Palpated chest expansion: Both sides rise symmetrically
Exam Action
07/22/22 3:37 PM MDT
Percussed anterior left upper lobe
Exam Action
07/22/22 3:41 PM MDT
Percussed anterior right upper lobe
Exam Action
07/22/22 3:41 PM MDT
Percussed anterior left mid-chest (upper lobe)
Exam Action
07/22/22 3:41 PM MDT
Percussed anterior right middle lobe
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07/22/22 3:41 PM MDT
Percussed anterior right lower lobe
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07/22/22 3:41 PM MDT
Percussed anterior left lower lobe
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07/22/22 3:41 PM MDT
Percussed posterior right upper lobe
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07/22/22 3:42 PM MDT
Percussed posterior left upper lobe
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07/22/22 3:42 PM MDT
Percussed posterior left mid-back (lower lobe)
Exam Action
07/22/22 3:42 PM MDT
Percussed posterior right mid-back (lower lobe)
Exam Action
07/22/22 3:42 PM MDT
Percussed posterior right lower lobe
Exam Action
07/22/22 3:42 PM MDT
Percussed posterior left mid-back (lower lobe)
Exam Action
07/22/22 3:42 PM MDT
Percussed posterior left lower lobe
Exam Action
07/22/22 3:42 PM MDT
Percussed posterior left lower lobe on side
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07/22/22 3:42 PM MDT
Percussed posterior left lower lobe near spine
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07/22/22 3:42 PM MDT
Percussed posterior right lower lobe
Exam Action
07/22/22 3:42 PM MDT
Percussed posterior right lower lobe near spine
Exam Action
07/22/22 3:42 PM MDT
Percussed posterior right lower lobe on side
Exam Action
07/22/22 3:42 PM MDT
Percussed posterior right lower lobe on side
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07/22/22 3:42 PM MDT
Auscultated breath sounds in anterior left upper lobe
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07/22/22 3:43 PM MDT
Auscultated breath sounds in anterior right upper lobe
Exam Action
07/22/22 3:43 PM MDT
Auscultated breath sounds in anterior right middle lobe
Exam Action
07/22/22 3:43 PM MDT
Auscultated breath sounds in anterior left upper lobe
Exam Action
07/22/22 3:43 PM MDT
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Exam Action
07/22/22 3:43 PM MDT
Auscultated breath sounds in anterior left lower lobe
Exam Action
07/22/22 3:43 PM MDT
Auscultated breath sounds in anterior right lower lobe
Exam Action
07/22/22 3:43 PM MDT
Auscultated breath sounds in posterior left upper lobe
Exam Action
07/22/22 3:44 PM MDT
Auscultated breath sounds in posterior right upper lobe
Exam Action
07/22/22 3:44 PM MDT
Auscultated breath sounds in posterior right mid-back (lower lobe)
Exam Action
07/22/22 3:44 PM MDT
Auscultated breath sounds in posterior left mid-back (lower lobe)
Exam Action
07/22/22 3:44 PM MDT
Auscultated breath sounds in posterior left lower lobe
Exam Action
07/22/22 3:44 PM MDT
Auscultated breath sounds in posterior right lower lobe
Exam Action
07/22/22 3:45 PM MDT
Auscultated breath sounds in posterior left lower lobe on side
Exam Action
07/22/22 3:45 PM MDT
Auscultated breath sounds in posterior left lower lobe near spine
Exam Action
07/22/22 3:46 PM MDT
Auscultated breath sounds in posterior right lower lobe near spine
Exam Action
07/22/22 4:01 PM MDT
Auscultated breath sounds in posterior right lower lobe on side
Exam Action
07/22/22 4:01 PM MDT
Auscultated breath sounds in posterior right lower lobe
Exam Action
07/22/22 4:01 PM MDT
Auscultated breath sounds in posterior left lower lobe
Exam Action
07/22/22 4:01 PM MDT
Auscultated breath sounds in posterior right mid-back (lower lobe)
Exam Action
07/22/22 4:01 PM MDT
Auscultated breath sounds in posterior left mid-back (lower lobe)
Exam Action
07/22/22 4:01 PM MDT
Auscultated breath sounds in posterior left upper lobe
Exam Action
07/22/22 4:01 PM MDT
Auscultated breath sounds in posterior left mid-back (lower lobe)
Exam Action
07/22/22 4:01 PM MDT
Auscultated breath sounds in anterior left upper lobe
Exam Action
07/22/22 4:02 PM MDT
Auscultated breath sounds in anterior right upper lobe
Exam Action
07/22/22 4:02 PM MDT
Auscultated breath sounds in anterior right middle lobe
Exam Action
07/22/22 4:02 PM MDT
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Exam Action
07/22/22 4:02 PM MDT
Auscultated breath sounds in anterior left lower lobe
Exam Action
07/22/22 4:02 PM MDT
Auscultated breath sounds in anterior right lower lobe
Exam Action
07/22/22 4:02 PM MDT
Auscultated breath sounds in anterior left lower lobe
Exam Action
07/22/22 4:03 PM MDT
Auscultated breath sounds in anterior right lower lobe
Exam Action
07/22/22 4:04 PM MDT
Auscultated voice sounds in anterior right upper lobe
Exam Action
07/22/22 4:04 PM MDT
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior right upper lobe
Exam Action
07/22/22 4:05 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior left upper lobe
Exam Action
07/22/22 4:05 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior left mid-chest (upper lobe)
Exam Action
07/22/22 4:06 PM MDT
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior right middle lobe
Exam Action
07/22/22 4:06 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior left lower lobe
Exam Action
07/22/22 4:06 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior right lower lobe
Exam Action
07/22/22 4:06 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in posterior right upper lobe
Exam Action
07/22/22 4:06 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in posterior right mid-back (lower lobe)
Exam Action
07/22/22 4:09 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in posterior right lower lobe
Exam Action
07/22/22 4:10 PM MDT
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe
Exam Action
07/22/22 4:10 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in posterior right lower lobe on side
Exam Action
07/22/22 4:10 PM MDT
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in posterior right lower lobe near spine
Exam Action
07/22/22 4:10 PM MDT
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe near spine
Exam Action
07/22/22 4:10 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe on side
Exam Action
07/22/22 4:11 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior left lower lobe
Exam Action
07/22/22 4:15 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior right lower lobe
Exam Action
07/22/22 4:15 PM MDT
Ninety-nine.
Ninety-nine.
Ninety-nine.
Check pulse oximetry using right hand
Exam Action
07/22/22 4:20 PM MDT
Checked pulse oximetry using left hand
Exam Action
07/22/22 4:20 PM MDT
Ms. Jones can you please blow into the spirometer?
Question
07/22/22 4:22 PM MDT
Checked spirometer
Exam Action
07/22/22 4:22 PM MDT
Checked patient’s inhaler
Exam Action
07/22/22 4:23 PM MDT
Do you see an asthma specialist?
Question
07/22/22 4:25 PM MDT
I used to go to Dr. Dewitt, but she moved her practice recently. Luckily she’s still been able to call in refills of my inhaler, but I haven’t actually been in to see her in about two years.
Have you had any hospitalizations?
Question
07/22/22 4:26 PM MDT
I went to the hospital a bunch of times when I was growing up, for asthma attacks. And I went for a foot injury a few months ago, but my foot is fine now.
At the time of your asthma attack, how severe was it?
Question
07/22/22 7:03 PM MDT
My asthma used to be really scary. I haven’t had a full attack in years, and if you had asked me before this I would have said my asthma wasn’t that bad anymore, but the last couple days I’ve had a lot of trouble breathing.
What number on a scale of 0 to 10 would you rate the severity? (Clarified to How would you rate the severity of your asthma on a scale from one to ten?.)
Question
07/22/22 7:04 PM MDT
At its worst it’s been like a 7 or 8 out of 10, probably. (Clarified to how I would rate my asthma on a scale.)
How you rate your shortness of breath from a scale of 0 to 10?
