Shadow Health Respiratory Tina Jones Documentation Documentation / Electronic Health Record

Shadow Health Respiratory Tina Jones Documentation
Documentation / Electronic Health Record

Document: Provider Notes
Student Documentation Model Documentation
Subjective

Table of Contents

Ms. Tina Jones is a 28-year-old African American woman who presents to the clinic with complaints of experiencing breathing difficulties with reduced effectiveness from her inhaler. She mentions difficulty in breathing, tightness in her chest, wheezing, and a new, frequent, nonproductive cough. These symptoms began two days ago, worsen at night or with physical exertion, and are aggravated by lying down. Ms. Jones reports changing her bedding and dusting weekly.

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Typically, her asthma is triggered by cats or dust, and she recently visited her cousin, who has cats, where her symptoms began. She rates the severity of her asthma attacks at 7 or 8 out of 10, lasting about five minutes. She uses an albuterol inhaler, which has been less effective lately. She hasn’t been hospitalized for asthma since childhood when she was diagnosed at age 2. She manages her asthma with an inhaler and tries to avoid cats. She doesn’t maintain an asthma diary or use spirometry, peak flow, or a nebulizer. She denies tobacco or alcohol use and hasn’t used marijuana since age 21. She doesn’t see a specialist for asthma.

Review of Systems General:

Difficulty sleeping due to asthma symptoms, resulting in low energy levels; denies fever, chills, or night sweats. Nose: No congestion, sneezing, runny nose, or allergies besides dust. G.I.: No changes in appetite, no nausea/vomiting, and no abdominal pain. Respiratory: Reports new onset shortness of breath with wheezing and nonproductive cough; denies pneumonia, bronchitis, emphysema, or tuberculosis. History of asthma since childhood, with no recent hospitalization for asthma.

Tina Jones Cardiovascular Shadow Health Objective Data Collection

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 two days ago. She reports exposure to cats at her cousin’s house triggered her asthma symptoms, with wheezing at a 6/10 severity and shortness of breath at a 7-8/10 severity, lasting five minutes. She used her albuterol inhaler, which partially relieved the symptoms. Since then, she’s had 10 episodes of wheezing and shortness of breath every four hours. Her last episode was this morning. Symptoms worsen when lying flat and with movement, accompanied by a non-productive cough. She experiences nighttime shortness of breath twice per night, and her symptoms now interfere with daily activities. She is concerned about the decreasing effectiveness of her albuterol inhaler.

Social History:

No awareness of environmental exposures or irritants at home or work. Weekly bedding changes and no dust/mildew at home. Uses a hypoallergenic pillow cover, and her mattress is one year old. Denies current tobacco, alcohol, or illicit drug use. Former marijuana use for 5-6 years, last at age 21. No regular exercise.

Review of Systems:

General: Denies weight changes, fatigue, weakness, fever, chills, and night sweats. Nose/Sinuses: No rhinorrhea with this episode, denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. Gastrointestinal: No changes in appetite, no nausea, no vomiting, no GERD symptoms, or abdominal pain. Respiratory: Reports shortness of breath and cough as described, denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, or tuberculosis. History of asthma with last hospitalization at age 16; last chest XR at age 16.

Objective

Ms. Tina Jones is a 28-year-old African American female who is alert, oriented times 4, and appropriately dressed for the setting. She appears to be at ease and not in any distress. Chest expansion is symmetric bilaterally during respirations, and percussion over the chest reveals resonance with no dullness. Normal fremitus is observed, and bilateral wheezes are auscultated in the posterior lower lobes. Bilateral muffled “99” sounds are heard in the lower posterior lobes. Incentive spirometer results: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%.

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%. Dont wait until the last minute. Provide your requirements and let our native nursing writers deliver your assignments ASAP. Start My Order

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%.

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Shadow Health Respiratory Tina Jones Documentation Documentation / Electronic Health Record