NR 509 Week 2: Shadow Health Respiratory Physical Assessment

Shadow Health Respiratory Assessment Pre Brief

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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.


| 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
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.”
Onset: 2 days ago at her cousin’s house after
exposure to cats which exacerbated her asthma and
reported symptoms.
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
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
Updates to Allergies: Updated to include seasonal
allergies/hay fever along with cats & dust
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
• 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.

Student Documentation Model Documentation
Ms. Jones is a 28 year old African American women
who appears to be her stated age. She is found
sitting upright on the exam table and does not
appear to be in any acute distress.
General/Constitutional: Reports of fatigue with
exertion due to SOB that subsides with rest. Patient
observed at rest, does not appear to be fatigued or
SOB at current.
Respiratory: Chest appear symmetric upon
inspection with expansion palpated equal bilaterally
along with tactile fremitus. All areas of the chest wall
are resonant with no areas of dullness noted. Breath
sounds are present in all areas. Adventitious
wheezing auscultated bilaterally in posterior upper
and lower lobes. Negative bronchophony
auscultated. Spirometry read: FEV1 3.15, FVC 3.91;
ratio = 81%. SpO2: 97% per bilaterally pointer
fingers on room air. Inhaler noted to be correct dose
and up to date.
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
• Respiratory: Chest expansion is symmetrical with
respirations. Normal fremitus, symmetric bilaterally.
Chest resonant to percussion; no dullness. Bilateral
expiratory wheezes in posterior lower lobes. Bilateral
muffled words with notable expiratory wheezes in
posterior lower lobes. No crackles. In office
spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.
SpO2: 97%.
Diagnosis 1 (Code): Mild to Moderate persistent
asthma with acute exacerbation (J45.41). Ms. Jones
has an increased need for her inhaler during times of
increased activity and while lying flat, exacerbated
by recent exposure to allergens. Notable wheezing
auscultated bilaterally in patients posterior lobes
along with unproductive cough reported.
Diagnosis 2 (Code): Primary Spontaneous
pneumothorax (J93.11). Ms. Jones has reported a
feeling of chest discomfort described as “tightness”
more than pain along with accompanied shortness of
Diagnosis 3 (Code): Acute bronchitis, unspecified
(J20.9). Ms. Jones has reported having a cough
along with shortness of breath. Wheezing was
auscultated in patients bilateral, posterior lobes.
Denies coughing up mucus and has been afebrile.
Mild-persistent asthma with exacerbation
Plan for Diagnosis 1: Mild – Moderate persistant
asthma with acute exacerbation
Diagnostics: Obtained spirometry reading and SpO2
reading during office visit.
Medication: Continue her short-acting Proventil
inhaler along with a new prescription for a
combination inhaled coritcosteroid and long-acting
• Obtain office oxygen saturation
• NMT in office x 1
• Initiate step-up medication therapy with inhaled
• Continue albuterol inhaler
• Encourage Ms. Jones to continue to monitor
symptoms and log her episodes of asthma
Student Documentation Model Documentation
beta agonist, such as Advair or Symbicort, and
directions to start taking over the counter Loratadine
10mg QD.
Education: Swish and rinse mouth after every use of
the combination corticosteriod/long-acting beta
agonist in order to prevent thrush from the inhaled
steroid. Also educate the patient on the importance
of monitoring, tracking and maintaining her blood
sugars with previously prescribed medications,
which is especially important since we are ordering
her steroids at this visit which can cause an increase
in her already increased blood sugars. Educate
patient on worsening signs & symptoms, such as
increased difficulty in breathing/shortness of breath
that does not subside with rest or Proventil inhaler
fails to alleviate any symptoms (,
Diagnosis 2: Primary spontaneous pneumothorax
Diagnostics:CXR &/or CT scan, ABGs
Medication:Dependent on size of pneumothorax
treatment could be as little as bed rest with O2
supplementation with a small (<15%) pneumo versus
a larger pneumo (>15%) where treatment would
consist of aspiration via thoracentesis catheter or
chest tube drainage and possibly surgical
intervention of greater than 30% (,
Education: Educate the patient on the
pathophysiology of primary spontaneous
pneumothorax and also secondary spontaneous
pneumothorax due to patients HX of asthma along
with possibility of reoccurrence. Also educate patient
on activities that she may want to avoid that could
potentiate another episode such as air travel and
scuba diving. Education would also be given on
emergent reasons to seek medical attention such as:
chest pain that radiates to the back and shoulder,
severe shortness of breath, tachycardia, perioral
Diagnosis 3: Acute bronchitis
Medication: OTC Ibuprofen 200-600mg q 4-6hrs or
acetaminophen 650mg q 4-6hrs not to exceed
4000mg/day to help alleviate discomfort and if
patient had been febrile, OTC mucolytic if patient
had been reporting expectorating mucus.
Education: Hand washing is the single most
important piece of education that can be given to
patients in helping to avoid illnesses. It would be
beneficial to re-iterate this to the patient along with
avoiding smoking and second-hand smoke.
Follow-up: Schedule a phone visit in a few days
along with an in office visit in 2 weeks for reevaluation of patients symptoms.
Referral: Pulmonologist for PFT
symptoms and wheezing with associated factors and
bring log to next visit
• Encourage to wash bedding and consider dust mite
covers to decrease allergic nighttime symptoms
• Educate to increase intake of water and other fluids
• Create Asthma Action Plan
• Refer to allergy specialist for evaluation and testing
Follow-up Planning
• Order PFTs to be completed after exacerbation to
have baseline available for future comparison
• Instruct Ms. Jones on when to seek emergent care
including episodes of chest pain or shortness of
breath unrelieved by rest, worsening asthma
symptoms or wheezing, or the sense that rescue
inhaler is not helping
• Revisit clinic in 2-4 weeks for follow up and

SAMPLE Shadow Health Respiratory Assessment

Shadow Health Respiratory Assessment