Shadow health respiratory assessment transcript

Shadow health respiratory assessment transcript

Pre Brief

Tina had an asthma episode 2 days ago. 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 ten episodes of wheezing and has shortness of breath approximately every four hours. Tina presents with continued shortness of breath and wheezing. Be sure to ask pertinent questions during the interview about related body systems. This case study will provide the opportunity to carefully assess lung sounds during the physical examination. Be sure to appropriately document your findings using correct medical terminology.

Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved.

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Shadow Health Respiratory Assessment Transcript Pre-Brief

Patient Background and Reason for Visit:
Tina had an asthma attack 2 days ago. She used her albuterol inhaler, but her symptoms didn’t completely go away. Since then, she’s had ten wheezing episodes and shortness of breath every four hours. Tina is here due to ongoing breathing difficulties and wheezing.

Introduction:
Sara, an FNP student, will interview Tina today.

Basic Information:
– Name: Tina Jones
– Date of Birth: February 17th
– Age: 28

Symptoms and Current Condition:
Tina has been having breathing issues and her inhaler isn’t helping as usual.
She has a history of asthma since childhood and allergies.
Tina mentioned experiencing wheezing and tightness, especially at a friend’s house with cats.
Her breathing hasn’t been fully under control lately.

Breathing Problems:
Breathing problems started about two days ago.
She experiences wheezing and shortness of breath every four hours, around five times a day.

Severity and Impact:
Tina’s breathing has worsened recently.
She hasn’t had a full-blown asthma attack in years, but these past days have been challenging.

Triggers and Management:
Avoids triggers, especially things that worsen her breathing.
In the past, inhaler use usually helped, but not recently.

Symptoms During Episodes:
Tina wheezes a little during breathing issues.
Lying on her back makes breathing worse.

Physical Examination:
Inspected chest wall from different angles.
Palpated chest expansion symmetrically.
Checked for vibrations during speaking.
Conducted percussion and auscultation on various chest areas.

Medications:
Tina takes albuterol for asthma.
She usually doesn’t need it daily, but has been using it every four hours recently.

Prescription and Usage:
Prescribed to use two puffs, confirmed with Pharmacy.
Tina uses it about every four hours.

Other Medications:
No other prescription medications.
Occasionally uses over-the-counter medications for cramps.

Over-the-Counter Medication Usage:
Takes a couple of over-the-counter pills for cramps.
Takes up to three doses a day.

Allergies and Medical History:
Tina is allergic to cats but has no known drug allergies.
She has a history of asthma and allergies but no other known medical issues.

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Hello my name sara an FNP student and I will be interviewing you today.
Hey.
Can you please state your name for me?
Tina Jones.
Your date of birth?
February 17th.
Year of birth please? (Clarified to What year were you born.)
I was born in . . . [Ms. Jones reports correct birth year.] [AUDIO
COMING SOON]

How old are you ms. Jones? (Clarified to how old are you.)
I’m 28.
What brings you in today?
I came in because I’ve been having breathing problems, and my
inhaler just isn’t working the way it normally does.
Why did you XXX
I XXX normally does.

BRIAN FOSTER CHEST PAIN SHADOW HEALTH ASSESSMENT

I’m XXX.
XXX  that. Shadow health respiratory assessment transcript.
What XXX?
Well. . . I’ve hadxxxx since I was really little, though for a while
there it wasn’t really much of a problem. And I have xxxx,
too.
What XXX?
It’s XXX.

ESTHER PARK ABDOMINAL PAIN SHADOW HEALTH 

How XXX?
I’ve XXX.
XXX start?
I don’t know if I’d call it an asthma attack, but XXX house. She has cats, and I’m
allergic, so I’m used to it being a problem there, but usually the
inhaler fixes it. . . it doesn’t feel totally under control, though.
I’m sorry you’re having difficulty with your breathing problems.
Thanks.
How XXX  problems?
My breathing’s been acting up off and on for the past two days.
How XXX?

DANNY RIVERA SHADOW HEALTH PEDIATRIC PHYSICAL ASSESSMENT 

Maybe XXX? It’s a lot.
And how XXX? (Clarified to
how long does an episode last.)
I haven’t had a XXX normal. .
. that’s not what’s been happening recently, though.
How xxxx?
I haven’t had a xxx, but usually once I use xxx
it only takes a minute or two for my xxxck to normal. .
. that’s not what’s been happening recently, though.
How manyxxxx

Well. . . it’s kind of hard to count because my breathing’s been at
least a little bad most of the past two days, but it’s really acted up,
like with wheezing and everything, probably every four hours or so–
like five times each day.
Is your     ?
My
How     xxx.)
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.
How xxx?
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.
Is there xxx?
There usually xxxx. . . I
guess I try to avoid things that make my breathing worse, but that’s
about it. The past couple days, though, it’s been hard to do anything.
Do you wheeze during an asthma exacerbation?
During a full attack, I would wheeze a lot, like I couldn’t breathe at all,
but until the past couple days, I would usually just wheeze a little
when I had breathing problems.
Are you having any chest tightness? Shadow health respiratory assessment transcript.
It’s not so bad right this second, but it’s been pretty tight lately, like I
can’t take in air.
Have you xxx?
I’ve been xxxxa lot, yeah.
How long have you had the xxxx?
Since my asthma acted up two days ago.
How would you describe the xxx?
Um. . . I guess I’d describe it asxxx.
What makes your xxxbetter?
Drinking some water helps a little, as long as the water isn’t too cold.
Have you tried txxx your xxx?
I haven’txxx.
Is your xxx?
It has been the past cxxx, yeah.
Does lxxx worse?
Just recently lying on my back has definitely made my breathing
worse.
To try to help your breathing you may want to elevate your head with
two pillows.
OK, I understand.
Inspected anterior chest wall
Inspected anterior chest wall
Inspected left side chest wall
Inspected anterior chest wall
Inspected right side chest wall
Inspected anterior chest wall
Palpated chest expansion: Both sides rise symmetrically
Palpated fremitus in anterior upper chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Palpated fremitus in anterior lower chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Palpated fremitus in posterior upper chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Palpated fremitus in posterior middle chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Palpated fremitus in posterior lower chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Percussed anterior left upper lobe
Percussed anterior right upper lobe
Percussed anterior left mid-chest (upper lobe)
Percussed anterior right middle lobe
Percussed anterior left lower lobe
Percussed anterior right lower lobe
Percussed posterior right upper lobe
Percussed posterior left upper lobe
Percussed posterior right mid-back (lower lobe)
Percussed posterior left mid-back (lower lobe)
Percussed posterior right lower lobe
Percussed posterior left lower lobe. Shadow health respiratory assessment transcript.
Percussed posterior left lower lobe on side
Percussed posterior left lower lobe near spine
Percussed posterior right lower lobe near spine
Percussed posterior right lower lobe on side
Auscultated breath sounds in anterior left upper lobe
Auscultated breath sounds in anterior right upper lobe
Auscultated breath sounds in anterior right middle lobe
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Auscultated breath sounds in anterior left lower lobe
Auscultated breath sounds in anterior right lower lobe
Auscultated breath sounds in posterior right upper lobe
Auscultated breath sounds in posterior left upper lobe
Auscultated breath sounds in posterior left mid-back (lower lobe)
Auscultated breath sounds in posterior right mid-back (lower lobe)
Auscultated breath sounds in posterior right lower lobe
Auscultated breath sounds in posterior left lower lobe
Auscultated breath sounds in posterior left lower lobe on side
Auscultated breath sounds in posterior left lower lobe near spine
Auscultated breath sounds in posterior right lower lobe near spine
Auscultated breath sounds in posterior right lower lobe on side
Auscultated voice sounds in anterior left upper lobe
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior right upper lobe
Ninety-nine.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 10/23
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Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior left upper lobe
Auscultated voice sounds in anterior left mid-chest (upper lobe)
Ninety-nine.
Auscultated xxx
Auscultated xxxx
Ninety-nine.
Auscultated voice sounds in anterior left lower lobe
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated xxxx
Ninety-nine.
Auscultated voice sounds in posterior left upper lobe
Shadow health respiratory assessment transcript
Ninety-nine.
Auscultated voice sounds in posterior right mid-back (lower lobe)
Ninety-nine.
Auscultated voice sounds in posterior left mid-back (lower lobe)
Ninety-nine.
Auscultated voice sounds in posterior right lower lobe
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe on side
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe near spine
Ninety-nine.
Auscultated voice sounds in posterior right lower lobe near spine
Ninety-nine.
Shadow health respiratory assessment transcript
Auscultated voice sounds in posterior right lower lobe on side
Ninety-nine.
Checked pulse xxx
Check pulse xx
Checked xxxx
Checked xxx
Always make sure yourxxxx
Sure, I think I understand what you mean.
Make sure to read all instructions and store as indicated (No
matching questions found.)
Make sure to read all instructions and store as indicated
Alright, thanks for letting me know.
Always shake well before using.
Thanks for telling me.
Also after every complete use you should always rinse out your
mouth with water.
Shadow health respiratory assessment transcript.
That makes sense.
What medications do you take?
My xxx is the only prescription I always have, but I usually don’t
need it everyday, except for recently. . .
When did you last use your xxx?
I had to use it early this morning.
How is your xxx prescribed?
Yes.
How often is your xxx?
Yes.
How many times have you use xxx?
I’ve been needing my xxx about every four hours, I’d say.
How many xxxx 4 hours? (Clarified to how xxxx are you prescribed.)
I’m supposed to just do twoxxx [Nurse confirmed with Pharmacy:
xxx]
How many xxx are you doing?
I’m supposed to just do xxx. [Nurse confirmed with Pharmacy:
xxx]

Make sure to follow thexxx instructions as prescribed
Thanks for telling me.
Are you taking any other medications?
No, all I really use is xxx.
You take any over-the-counter medications?
I take xxx, but not
often.
How much xxxdo you take?
I just take a couple. I usually get them at night from reading–
squinting I guess–and so I take one and go to bed. [Nurse confirmed
with Pharmacyxxx ]
How much xxx do you take for cramps?
I take three at a time. And I’d bet I take it up to three times a day.
[Nurse confirmed with Pharmacy: xxx]
Do you have xxxx?
Yeah, I’mxxx.
Do you have axxx?
No, not that I know of.
When didxxx

This all started at my cousin’s house. Shexxxxalways goes crazy when I’m there.
Does being around dust trigger asthma?
Yeah, being around a lot of dust, especially hanging out in a really
dusty house, can make my asthma act up.
Sorry to hear that about your asthma
Thanks for understanding.
Does cxxxa?
Only when I’m in a rush and have to hurry up them.
Do you have xxxx? (Clarified to do you have
seasonal allergies.)
A little while ago, I had some seasonal allergies, but it didn’t really
bother my asthma, and it’s better now.
Does xxxe?
Well. . . sometimes when txxx often.
Do you xxx?
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.

Since you have asthma it is important to follow up on a regular basis
with your asthma specialist
Alright, thanks for letting me know.
How xxx?
I’ve had xxxle.
How xxxx?
My xxx.
Have you everxxx?
I xxx?
I used to go to thexxxt not since I
was sixteen.
Have yoxxx?
You mean like, did they ever have to put me on a breathing machine?
No, I haven’t had an asthma attack that serious.
Do you use a xxx?
Not really. . .
Do you cxxx?

I’ve heard of that, but no, I don’t do it.
Do you use xxx
No, but I have before.
We may cxxx
That makes sense.
Also a way to track your asthma symptoms and episodes. (No
matching questions found.)
Also a way to track your     s and episodes.
OK, I understand.

Sending you home with a peak flow meter and document regularly.
I’ve heard of that, but no, I don’t do it.
We will also teach you how to use nebulizer at home.
Sure, I think I understand what you mean.
How often do you change your sheets?
I change my bedding once a week, I’d say.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 18/23
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Do you have pets at home?
No. . . I’m too busy to take care of a dog, and I can’t have cats
because of my allergies.
Does    ?
No, nobody at home    .
If exposed to secondhand smoke it is definitely a Asthma trigger.
Alright, thanks for letting me know.
Have you ever had eczema?
No, I don’t have that kind of skin problem.
history of sinus problems? (Clarified to do you have a history of sinus
problems?.)
I don’t really have a problem with my sinuses.
Do you have xxx?
I don’t know what that is, so I guess probably not?
Have you ever been   xxx
Have you xxx?
Shadow health respiratory assessment transcript
No, I’ve never done that. I think it’s gross.
I’m glad you think that
Thanks for understanding.
Smoking is a known trigger for asthma
OK, I understand.
Have you xxx
Well, I used to xx. . . but I don’t do that anymore.
When was the xxx?
I haven’t sxxx.
Have you ever experimented with xxxx?
No, no way. That’s a nasty thing to do.
Have you been sick recently?
No, I’m usually healthy.
Have you had any xxx?
No, I haven’t had a xxx.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 21/23
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Have you had any nausea or vomiting?
I haven’t had thrown up, or even had an upset stomach, in a long
time.
Have you had chills?
No, I haven’t.
Are you fatigued?
I feel tired, yeah, probably because I haven’t been able to sleep very
well.
Do you have any xx?
I don’t getxxx, but sometimes I wake up hot and have to kick off
my xxx.
Sometimexxxybe an indication of being sick
That makes sense.
Have you been cxxx anything?
No, nothing’s coming up.
Have you had any problemsxxx?
Nope.
Do you have any nasal drainage?
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 22/23
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No, my nose has been fine.
Has anyone been sick at home?
No, no one at home has been sick.
Does anyone in your family have asthma?
It’s just me and my baby sister that have asthma, but she really
doesn’t have problems with it.
Does anyone in your family have allergies?
My sister has hay fever, I think, and it sometimes makes her asthma
get pretty bad.
Does anyone in your family have eczema?
No. . .
Do you have a family history of sinus problems?
I don’t think anyone in the family has sinus problems.
Are you in any pain right now?
It doesn’t hurt. . . it’s just hard to breathe, but there’s no pain.
Is there pain when you wheeze? (No matching questions found.)
are you in pain when you wheeze?
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 23/23
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Right now it doesn’t sound too bad, but I’ve definitely been
wheezing the past couple days.
Any changes in your appetite?
I wouldn’t say it’s changed recently, but I do feel hungry a lot.
When was your last chest x-ray?
The last time I went to the hospital for an asthma attack, when I was
still in high school, they did a chest x-ray.
Comments
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shadow health respiratory transcript

APPROACH

Overview
| Transcript
| Subjective Data Collection
| Objective Data Collection
| Education & Empathy
| Documentation / Electronic Health Record
| Student Pre-Survey
| Lifespan Activity
| Review Questions
| Self-Reflection Activity

SAMPLE Shadow Health Respiratory Assessment

Model Documentation