Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved.
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
Student Documentation Model Documentation
Subjective
CC:”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.”
HPI:
Onset: 2 days ago at her cousin’s house after
exposure to cats which exacerbated her asthma and
reported symptoms.
Location:Chest
Duration: “Minute or two” for each episode reported
with a total of 10 episodes in last 2 days per patient.
Characteristics/Quality: Tightness, feelings of not
being able to take in air.
Aggravating factors/Associated Symptoms: Cats,
dust, running up a flight of stairs. Worse upon
exertion and when lying down flat.
Relieving factors: Proventil inhaler, resting
Treatment/Medications/Remedies:Proventil Inhaler,
three puffs every 4 hours for past 2 days. Albuterol
90mcg/spray MDI
Severity:7-8/10
FH:Sister with asthma
SH:Supervisor at Mid-American Copy & Ship,
currently lives with mother and younger sister.
MH:States having all the required “shots they give
you when you’re a kid.” Hospitlized as a child and
teen for asthma. ED a few months ago for foot injury
that has since healed.
Updates to Meds: No updates. Previous medications
continued.
Updates to Allergies: Updated to include seasonal
allergies/hay fever along with cats & dust
ROS
General/Constitutional: No weigth loss, fever, chills,
weakness reported. Patient does report fatigue upon
exertion that subsides at rest.
Respiratory:”Been hard to take in air”. Chest
tightness & wheezing.
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.
Denie