RESPIROTARY LAB DATA
• Overview
• Transcript
• Subjective Data Collection
• Objective Data Collection
• Documentation
• Video Tutorial
Transcript
Started: Oct 22, 2022 | Total Time: 77 min
All Lines (200)Interview Questions (119)Statements (4)Exam Actions (77)
Hello!
Question
10/22/22
10:44 PM
EDT
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just
as a preceptor would in real life. Pay close attention to this information as it will help
guide your exam. At the end of this prebrief, you will answer a short question about the
upcoming assignment. During the simulation, you may return to these instructions at any
time by scrolling to the top of your transcript.
What is the situation?
Question
10/22/22
10:44 PM
EDT
It’s noon on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in
this simulation is that of a healthcare provider who will perform a full respiratory exam on
Ms. Jones given her history of asthma.
What are my objectives in this assessment? Question
10/22/22
10:44 PM
EDT
In your interview with Ms. Jones, you will ask about her respiratory system and identify
any risk factors so that you can determine any current and potential issues. If you discover
any disease states, ask about symptoms and the patient’s experiences of them. Your
questioning should cover a broad array of the symptoms’ characteristics. You will
also inquire into the health history of Ms. Jones’ family with regards to the respiratory
system so you can determine her genetic predisposition to any diseases. Regardless of
whether you have assessed Tina previously, ask all questions that are medically relevant to
her respiratory system. In addition to collecting subjective data, you will perform a
physical exam on Ms. Jones’ respiratory system to gather objective data about the system’s
health and physiology. While you should communicate with patients using accessible,
everyday language, it is standard practice to use professional medical terminology
everywhere else, such as in documenting physical findings and nursing notes. You may
complete the exam activities in any order and move between them as needed.
What else will this exam involve?
Question
10/22/22
10:46 PM
EDT
You will complete nursing tasks to protect the patients safety, privacy, and health. You
can document your findings, including vital signs, in the Electronic Health Record. This
record provides necessary information for healthcare professionals who will continue patient
care. Activities other than Subjective and Objective Data Collection, such as Documentation
and Education and Empathy, provide valuable practice for their real-world counterparts.
However, they are not automatically graded by the simulation.
How will I be evaluated?
Question
10/22/22
10:47 PM
EDT
In this assignment, you will be evaluated on your Subjective and Objective Data
Collection. The evaluation of your interview is dependent on how you word your questions
therapeutically and precisely and explore all relevant topics with comprehensive breadth
and depth. The evaluation of your physical exam is based on how successfully you report on
your physical findings by selecting among clinical terms in the Electronic Health
Record. This assignment takes on average between 40 and 50 minutes. You can pause and
resume the assignment at any time; your work is always saved automatically.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Based on
your current knowledge, explain the pathophysiology of asthma.
The pathophysiology of asthma would be inflammation of respiratory tubes and tightening of
respiratory smooth muscle.
Statement
10/23/22 6:36
PM EDT
Time to begin.
Good day Mrs. Jones. I am Nurse Bob and will be taking care of you today.
Greet
10/23/22 6:37
PM EDT
Hey.
You closed the curtain for privacy.
Exam Action
10/23/22 6:37
PM EDT
You washed your hands.
Exam Action
10/23/22 6:37
PM EDT
You checked the patient’s armband.
Exam Action
10/23/22 6:38
PM EDT
You checked the bed and rails position.
Exam Action
10/23/22 6:38
PM EDT
You checked the call light.
Exam Action
10/23/22 6:38
PM EDT
You checked for non-skid footwear.
Exam Action
10/23/22 6:38
PM EDT
You checked the patient’s table.
Exam Action
10/23/22 6:38
PM EDT
Checked vitals
Exam Action
10/23/22 6:38
PM EDT
What is your current of pain on a scale from 1 to 10?
Question
10/23/22 6:40
PM EDT
Right now it’s about a 6 out of 10, I’d say. The pain pill helped.
How old are you Mrs. Jones?
Question
10/23/22 6:42
PM EDT
I’m 28.
How tall are you?
Question
10/23/22 6:42
PM EDT
I’m around 5′ 7″.
Mrs. Jones, please blow into the spirometer.
Question
10/23/22 6:44
PM EDT
Tested lung capacity with spirometer
Exam Action
10/23/22 6:44
PM EDT
Thank you Ma’am.
Empathize
10/23/22 6:45
PM EDT
Thanks.
I am going to ask you a few questions.
Question
10/23/22 6:46
PM EDT
Ok. What about?
What brings you in today?
Question
10/23/22 6:46
PM EDT
I came in last night because of my foot. It just wasn’t healing, and it’s been hurting.
I am sorry about your foot.
Empathize
10/23/22 6:46
PM EDT
Thanks.
How is your breathing?
Question
10/23/22 6:47
PM EDT
My breathing is okay right now.
Are you having any increased breathing problems or shortness of breath? (Clarified to Have
you had breathing problems lately?.)
Question
10/23/22 6:47
PM EDT
I was at my cousin’s house three days ago, and my asthma acted up while I was there.
(Clarified to if I have been short of breath recently.)
Do you use an inhaler?
Question
10/23/22 6:48
PM EDT
Yeah, I use it when my asthma acts up.
Does the inhaler help your asthma?
Question
10/23/22 6:48
PM EDT
Yeah, it helps. I’m normally good with two puffs. Every now and then, I’ll take a third.
What type of inhaler do you use?
Question
10/23/22 6:49
PM EDT
It’s just a regular Proventil inhaler.
What caused your asthma to act up? (Clarified to What started your recent asthma problems?.)
Question
10/23/22 6:49
PM EDT
I haven’t had a full asthma attack in a while, but my breathing got bad three days ago at my
cousin’s house. She has three cats, and I’m allergic. (Clarified to what triggered my recent
asthma problems.)
Are you allergic to anything else?
Question
10/23/22 6:50
PM EDT
Well, besides cats, I’m allergic to penicillin.
What happens when you have a reaction? (Clarified to What happens when you are around a
cat?.)
Question
10/23/22 6:50
PM EDT
Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act
up. (Clarified to what the symptoms of my cat allergy are.)
What happens when you take penicillin?
Question
10/23/22 6:50
PM EDT
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.
Do you get shortness of breath?
Question
10/23/22 6:51
PM EDT
I have breathing problems sometimes, yeah, but I haven’t had a full attack in years.
Have you had any further problems with your asthma since the flare up? (Clarified to Have
you had asthma since childhood?.)
Question
10/23/22 6:51
PM EDT
Yeah, though it’s not as bad as it used to be when I was a kid. (Clarified to if I have had
asthma since childhood.)
Is the asthma serious?
Question
10/23/22 6:52
PM EDT
I haven’t had a full attack in years, but I have trouble breathing sometimes.
Do you experience chest pain with your asthma? (Clarified to Are the shortness of breath
episodes associated with chest pain?.)
Question
10/23/22 6:53
PM EDT
No, my chest feels tight when I have breathing problems, but it doesn’t hurt. (Clarified to if
my shortness of breath episodes are associated with chest pain.)
Do you experience wheezing with your asthma?
Question
10/23/22 6:53
PM EDT
During a full attack, I would wheeze a lot, like I couldn’t breathe at all, but that hasn’t
happened in years. Now I wheeze a little when I have breathing problems, but it’s not nearly
that bad.
Do you experience chest tightness with your asthma? (Clarified to Does your chest feel tight
during asthma exacerbations?.)
Question
10/23/22 6:54
PM EDT
Well. . . when my asthma gets bad my chest feels pretty tight, like I can’t take in air. (Clarified
to If asthma exacerbations make my chest tight.)
Are you experiencing any coughing?
Question
10/23/22 6:54
PM EDT
I don’t have a cough, no.
Is your asthma worse at night?
Question
10/23/22 6:55
PM EDT
I don’t think my asthma’s worse at any particular time of day.
Does lying down help? (Clarified to Does lying down make your asthma worse?.)
Question
10/23/22 6:55
PM EDT
I don’t think lying down changes my breathing. (Clarified to if lying down makes my asthma
worse.)
Does movement make your asthma worse? (Clarified to Does exercise make your asthma
worse?.)
Question
10/23/22 6:55
PM EDT
Yeah, if I have a little burst of activity like running up the stairs or hurrying to my class, I
sometimes need my inhaler. (Clarified to if exercise makes my asthma worse.)
How long does your asthma attack last?
Question
10/23/22 6:56
PM EDT
I guess it sometimes takes a couple minutes for me to realize I need the inhaler, and then a
minute or two after I use it before I feel better. . . so five minutes at most, maybe? I haven’t
had a full asthma attack in years, though.
Is your asthma interfering with your daily activities?
Question
10/23/22 6:57
PM EDT
At this point, it doesn’t really affect me that much. It’s annoying when I have breathing
problems and that I have to remember to bring my inhaler places, but it’s not really a big deal.
Are you having any issues breathing?
Question
10/23/22 6:57
PM EDT
My breathing’s fine right now, but I do have asthma.
Are you having any issues swallowing?
Question
10/23/22 6:58
PM EDT
Nope.
What are your current medications?
Question
10/23/22 6:58
PM EDT
I’ve been getting insulin shots, something in my IV for the infection, and the pain pills. I think
it should all be on my chart.
Any new medications?
Question
10/23/22 6:58
PM EDT
I’ve gotten pain pills, and insulin for my diabetes, and then there’s stuff in my IV for my
infection. I think it’s all in my chart.
Have you been experiencing any side effects?
Question
10/23/22 6:59
PM EDT
I don’t think I’m having any problems with the medications.
Do you use your inhaler to treat your asthma?
Question
10/23/22 6:59
PM EDT
Yeah.
Do you use anything else to treat your asthma?
Question
10/23/22 6:59
PM EDT
I really just use the inhaler. Otherwise, I just try to avoid stuff that makes my breathing worse.
That’s all. [AUDIO COMING SOON]
What type of inhaler do you use?
Question
10/23/22 7:00
PM EDT
It’s just a regular Proventil inhaler.
When was the last time you used your inhaler?
Question
10/23/22 7:00
PM EDT
I had to use my inhaler three days ago when I was at my cousin’s house.
How often to you use the inhaler after an asthma attack? (Clarified to Do you use your inhaler
immediately when you have an asthma attack?.)
Question
10/23/22 7:00
PM EDT
I haven’t had a full asthma attack in years, but I always use my inhaler when my asthma acts
up, and it helps me breathe better. (Clarified to if I use my inhaler during asthma attacks.)
Are you still using the inhaler?
Question
10/23/22 7:01
PM EDT
Yeah, I use it when my asthma acts up.
How many puffs do you take on your inhaler?
Question
10/23/22 7:01
PM EDT
I usually use two puffs from my albuterol inhaler, but sometimes I need three. I think it’s 90
mcg per puff. [AUDIO COMING SOON]
Any how many times per day do you use your inhaler? (Clarified to How many times a day
are you using your inhaler?.)
Question
10/23/22 7:01
PM EDT
I don’t use my inhaler every day. I use it probably twice a week when I have trouble breathing,
but that’s it. (Clarified to how many times a day I use my inhaler.)
What is your prescribed usage for the inhaler? (Clarified to Do you have a prescription for an
inhaler?.)
Question
10/23/22 7:02
PM EDT
Yeah, I use a Proventil inhaler probably twice a week. (Clarified to if I have an inhaler
prescription.)
How many puffs are you supposed to do?
Question
10/23/22 7:02
PM EDT
I usually use two puffs from my albuterol inhaler, but sometimes I need three. I think it’s 90
mcg per puff. [AUDIO COMING SOON]
Do you have any new allergies? (Clarified to Have you had new health problems recently?.)
Question
10/23/22 7:02
PM EDT
The only thing that’s new is this infection on my foot! (Clarified to if I have had recent new
health problems.)
Do you have any environmental allergies?
Question
10/23/22 7:03
PM EDT
No, unless cats count.
Does dust effect you?
Question
10/23/22 7:03
PM EDT
If I’m around a lot of dust, I can get sneezy, or I can start wheezing. Sometimes I get itchy
eyes.
Does walking up stairs effect you? (Clarified to Does climbing stairs trigger your asthma?.)
Question
10/23/22 7:04
PM EDT
A lot of my classes are on the third floor of the Maria Bamford Business Building, and when
I’m late I have to hurry up the stairs sometimes, then I get out of breath, and usually I need to
use my inhaler. (Clarified to if climbing stairs triggers my asthma.)
Do you have any seasonal allergies?
Question
10/23/22 7:04
PM EDT
No, not really.
Des changes in weather affect your allergies?
Question
10/23/22 7:05
PM EDT
Not that I’ve noticed.
Any asthma triggers at work?
Question
10/23/22 7:05
PM EDT
Well. . . sometimes when there’s dust at work it can make my asthma act up, but that doesn’t
happen very often.
Do you have an asthma doctor?
Question
10/23/22 7:05
PM EDT
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.
It is important to go to the asthma doctor for a check up in case your condition has changed
and you need to be reevaluated.
Educate
10/23/22 7:06
PM EDT
Thanks for telling me.
When were you diagnosed with asthma?
Question
10/23/22 7:07
PM EDT
My doctor told me when I was pretty little… I think I was about two and a half? I used to have
a lot of trouble with asthma attacks back then.
You were diagnosed with asthma as a child?
Question
10/23/22 7:07
PM EDT
Yeah, though it’s not as bad as it used to be when I was a kid.
HAve you ever been hospitalized for your asthma?
Question
10/23/22 7:08
PM EDT
I went a bunch of times when I was little, for asthma attacks.
When was you last hospitalization for your asthma?
Question
10/23/22 7:08
PM EDT
I used to go to the hospital a lot for asthma attacks, but not since I was sixteen.
How many times have you been hospitalized for asthma?
Question
10/23/22 7:09
PM EDT
The last time was years ago, but I think I’ve been to the hospital maybe five times total. . . all
for asthma.
Have you ever needed help breathing from your asthma? (No matching questions found.)
Question
10/23/22 7:09
PM EDT
Have you ever been intubated because of your asthma?
Question
10/23/22 7:09
PM EDT
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 any over the counter medication to treat your asthma?
Question
10/23/22 7:10
PM EDT
I just use my inhaler.
Do you track your asthma episodes?
Question
10/23/22 7:12
PM EDT
Well. . . I’ve had asthma for a long time, but I only have breathing problems some of the time.
Have you ever used a peak flow meter? (Clarified to Do you use a peak flow meter?.)
Question
10/23/22 7:12
PM EDT
For my asthma? I just use my inhaler. (Clarified to if I use a peak flow meter.)
HAve you ever used a nebulizer?
Question
10/23/22 7:12
PM EDT
Yeah, they put me on a nebulizer at the hospital a couple times when I went in for asthma.
Do you have dust in your home>
Question
10/23/22 7:13
PM EDT
No, we keep the house pretty clean.
What type of bedding do you use? (No matching questions found.)
Question
10/23/22 7:13
PM EDT
Do you use hypoallergenic sheets? (Clarified to Do you use a hypoallergenic mattress cover?.)
Question
10/23/22 7:13
PM EDT
I have one of those crinkly kinds of mattress covers for people with allergies. My mom had
them for my sister, and she put one on my bed when I moved in. (Clarified to if I use a
hypoallergenic mattress cover.)
Do you have any pets?
Question
10/23/22 7:14
PM EDT
No. . . I’m too busy to take care of a dog, and I can’t have cats because of my allergies.
Do you smoke?
Question
10/23/22 7:14
PM EDT
No. I think it’s gross.
Are you around second hand smoke?
Question
10/23/22 7:14
PM EDT
Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home
smokes.
How long are you exposed to the second hand smoke?
Question
10/23/22 7:14
PM EDT
Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home
smokes.
Do you exercise>
Question
10/23/22 7:15
PM EDT
I don’t have the energy to go to a gym or anything after work…I’m pretty exhausted by the end
of the day. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise
most days at least.
Does the asthma affect your exercise?
Question
10/23/22 7:15
PM EDT
Honestly, I’m not really that into exercise anyway.
Do you have any family history of asthma?
Question
10/23/22 7:16
PM EDT
My baby sister has asthma like me, but she’s pretty healthy. She almost never has trouble with
it.
What does your sister use to treat her asthma?
Question
10/23/22 7:16
PM EDT
Yeah, I think she has one, but I don’t remember her ever needing it.
Do you have a history of eczema?
Question
10/23/22 7:17
PM EDT
No.
Do you have a history of sinus problems? (Clarified to Do you get sinus infections?.)
Question
10/23/22 7:17
PM EDT
My nose is fine. (Clarified to if I get sinus infections.)
Any heartburn or indigestion? (No matching questions found.)
Question
10/23/22 7:18
PM EDT
Any history of heartburn or indigestion?
Question
10/23/22 7:18
PM EDT
No, not at all.
Any history of cardiopulmonary disorder or emphysema? (No matching questions found.)
Question
10/23/22 7:19
PM EDT
Any history of cardiopulmonary disorder? (No matching questions found.)
Question
10/23/22 7:19
PM EDT
Any history of emphysema?
Question
10/23/22 7:19
PM EDT
No, just the asthma.
Any history of heart problems?
Question
10/23/22 7:19
PM EDT
I’ve never had heart problems, thank God. I’ve been lucky.
Have you ever smoked cigarettes?
Question
10/23/22 7:20
PM EDT
No. I think it’s gross.
Have you ever smoked marijuana?
Question
10/23/22 7:20
PM EDT
Well, I used to smoke pot. . . but I don’t do that anymore.
When was the last time you smoked marijuana?
Question
10/23/22 7:20
PM EDT
I haven’t smoked pot since I was twenty or twenty-one.
Does anyone around you smoke marijuana?
Question
10/23/22 7:21
PM EDT
Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home
smokes.
Do any of your friend smoke marijuana?
Question
10/23/22 7:21
PM EDT
Yeah, a couple of my friends smoke when we go out. I don’t like being around smokers,
though.
HAve any of your family members been sick recently?
Question
10/23/22 7:22
PM EDT
No, I don’t think so.
Has anyone at home been sick recently? (No matching questions found.)
Question
10/23/22 7:23
PM EDT
Do any of your family members have allergies?
Question
10/23/22 7:23
PM EDT
My sister has hay fever, I think, and it sometimes makes her asthma get pretty bad.
What happens to your sister when she gets hay fever? (No matching questions found.)
Question
10/23/22 7:24
PM EDT
Does anyone in your family have eczema? (No matching questions found.)
Question
10/23/22 7:24
PM EDT
Does anyone in your family have any skin conditions?
Question
10/23/22 7:24
PM EDT
No, I don’t think so.
Does anyone in your family have nose problems? (Clarified to Does anyone in your family
have throat problems?.)
Question
10/23/22 7:25
PM EDT
No, I don’t think so. (Clarified to if anyone in my family has throat problems.)
Does anyone in your family have sinus problems?
Educate
10/23/22 7:25
PM EDT
Thanks for telling me.
Does anyone in your family have sinus problems? (No matching questions found.)
Question
10/23/22 7:25
PM EDT
Does anyone in your family have breathing problems?
Question
10/23/22 7:26
PM EDT
My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think.
Does anyone in your family have emphysema?
Question
10/23/22 7:26
PM EDT
My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think.
Does anyone in your family have heart problems?
Question
10/23/22 7:26
PM EDT
Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack.
How old was your grandfather when he died of a heart attack?
Question
10/23/22 7:27
PM EDT
Let me think. He died when I was really little… I think he was in his mid-sixties. He died of
colon cancer.
When you cough, is there any mucus?
Question
10/23/22 7:28
PM EDT
No, I don’t.
Is your throat sore or feel swollen?
Question
10/23/22 7:28
PM EDT
No, it’s fine.
Any family history of skin issues? (Clarified to Do you have a family history of skin
disease?.)
Question
10/23/22 7:29
PM EDT
Nope. (Clarified to if I have a family history of skin disease.)
Do you have family history of heart disease?
Question
10/23/22 7:29
PM EDT
Um, none that I know of. Wait, my Poppa–that’s Mom’s dad–died of a heart attack.
Has anyone at home been sick recently? (No matching questions found.)
Question
10/23/22 7:30
PM EDT
Has anyone at home been sick?
Question
10/23/22 7:30
PM EDT
No, I don’t think so.
What are your allergy symptoms?
Question
10/23/22 7:31
PM EDT
My allergies mostly just act up around cats. I start sneezing, my eyes get itchy. . . and my
asthma starts to go crazy.
Do you vape?
Question
10/23/22 7:31
PM EDT
I would never vape.
How long did you use marijuana?
Question
10/23/22 7:32
PM EDT
About five or six years, I guess?
How long ago did you stop using marijuana?
Question
10/23/22 7:32
PM EDT
I haven’t smoked pot since I was twenty or twenty-one.
Does anyone in your family smoke?
Question
10/23/22 7:32
PM EDT
No, nobody at home smokes.
Does your family have a history of lung cancer?
Question
10/23/22 7:33
PM EDT
Nobody in my family has had lung cancer and, Lord willing, no one ever will. [AUDIO
COMING SOON]
Thank you for your time.
Question
10/23/22 7:33
PM EDT
Alright, thanks.
Do you have any questions for me?
Question
10/23/22 7:33
PM EDT
I can’t think of any questions right now.
I am now going to do a physical examination on you. (Clarified to May I start your physical
exam now?.)
Question
10/23/22 7:34
PM EDT
Sure. (Clarified to if nurse can start my physical exam.)
Inspected anterior chest wall
Exam Action
10/23/22 7:34
PM EDT
Inspected right side chest wall
Exam Action
10/23/22 7:34
PM EDT
Inspected anterior chest wall
Exam Action
10/23/22 7:34
PM EDT
Inspected left side chest wall
Exam Action
10/23/22 7:34
PM EDT
Inspected anterior chest wall
Exam Action
10/23/22 7:34
PM EDT
Palpated chest expansion: Both sides rise symmetrically
Exam Action
10/23/22 7:38
PM EDT
Palpated fremitus in anterior upper chest wall: Present and equal bilaterally
Exam Action
10/23/22 7:39
PM EDT
Ninety-nine.
Palpated fremitus in anterior lower chest wall: Present and equal bilaterally
Exam Action
10/23/22 7:39
PM EDT
Ninety-nine.
Palpated fremitus in posterior upper chest wall: Present and equal bilaterally
Exam Action
10/23/22 7:39
PM EDT
Ninety-nine.
Palpated fremitus in posterior middle chest wall: Present and equal bilaterally
Exam Action
10/23/22 7:39
PM EDT
Ninety-nine.
Palpated fremitus in posterior lower chest wall: Present and equal bilaterally
Exam Action
10/23/22 7:39
PM EDT
Ninety-nine.
Palpated fremitus in posterior upper chest wall: Present and equal bilaterally
Exam Action
10/23/22 7:40
PM EDT
Ninety-nine.
Palpated fremitus in posterior middle chest wall: Present and equal bilaterally
Exam Action
10/23/22 7:40
PM EDT
Ninety-nine.
Palpated fremitus in posterior lower chest wall: Present and equal bilaterally
Exam Action
10/23/22 7:40
PM EDT
Ninety-nine.
Percussed anterior right upper lobe
Exam Action
10/23/22 7:41
PM EDT
Percussed anterior right upper lobe
Exam Action
10/23/22 7:41
PM EDT
Percussed anterior left upper lobe
Exam Action
10/23/22 7:41
ORDER A PLAGIARISM-FREE PAPER HERE
PM EDT
Percussed anterior right middle lobe
Exam Action
10/23/22 7:41
PM EDT
Percussed anterior left mid-chest (upper lobe)
Exam Action
10/23/22 7:41
PM EDT
Percussed anterior right lower lobe
Exam Action
10/23/22 7:41
PM EDT
Percussed anterior left lower lobe
Exam Action
10/23/22 7:41
PM EDT
Percussed posterior left upper lobe
Exam Action
10/23/22 7:41
PM EDT
Percussed posterior right upper lobe
Exam Action
10/23/22 7:41
PM EDT
Percussed posterior right mid-back (lower lobe)
Exam Action
10/23/22 7:41
PM EDT
Percussed posterior left mid-back (lower lobe)
Exam Action
10/23/22 7:41
PM EDT
Percussed posterior left lower lobe
Exam Action
10/23/22 7:41
PM EDT
Percussed posterior right lower lobe
Exam Action
10/23/22 7:41
PM EDT
Percussed posterior right lower lobe on side
Exam Action
10/23/22 7:42
PM EDT
Percussed posterior left lower lobe on side
Exam Action
10/23/22 7:42
PM EDT
Percussed posterior left lower lobe near spine
Exam Action
10/23/22 7:42
PM EDT
Percussed posterior right lower lobe near spine
Exam Action
10/23/22 7:42
PM EDT
Percussed anterior right middle lobe
Exam Action
10/23/22 7:42
PM EDT
Percussed anterior right lower lobe
Exam Action
10/23/22 7:42
PM EDT
Auscultated breath sounds in anterior right upper lobe
Exam Action
10/23/22 7:43
PM EDT
Auscultated breath sounds in anterior left upper lobe
Exam Action
10/23/22 7:43
PM EDT
Auscultated breath sounds in anterior right middle lobe
Exam Action
10/23/22 7:43
PM EDT
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Exam Action
10/23/22 7:43
PM EDT
Auscultated breath sounds in anterior right lower lobe
Exam Action
10/23/22 7:43
PM EDT
Auscultated breath sounds in anterior left lower lobe
Exam Action
10/23/22 7:44
PM EDT
Auscultated breath sounds in posterior left upper lobe
Exam Action
10/23/22 7:44
PM EDT
Auscultated breath sounds in posterior right upper lobe
Exam Action
10/23/22 7:44
PM EDT
Auscultated breath sounds in posterior right mid-back (lower lobe)
Exam Action
10/23/22 7:44
PM EDT
Auscultated breath sounds in posterior left mid-back (lower lobe)
Exam Action
10/23/22 7:44
PM EDT
Auscultated breath sounds in posterior left lower lobe
Exam Action
10/23/22 7:44
PM EDT
Auscultated breath sounds in posterior right lower lobe
Exam Action
10/23/22 7:44
PM EDT
Auscultated breath sounds in posterior right lower lobe on side
Exam Action
10/23/22 7:44
PM EDT
Auscultated breath sounds in posterior left lower lobe on side
Exam Action
10/23/22 7:45
PM EDT
Auscultated breath sounds in posterior left lower lobe near spine
Exam Action
10/23/22 7:45
PM EDT
Auscultated breath sounds in posterior right lower lobe near spine
Exam Action
10/23/22 7:45
PM EDT
Auscultated breath sounds in posterior left mid-back (lower lobe)
Exam Action
10/23/22 7:45
PM EDT
Auscultated breath sounds in posterior right mid-back (lower lobe)
Exam Action
10/23/22 7:46
PM EDT
Auscultated breath sounds in posterior right upper lobe
Exam Action
10/23/22 7:46
PM EDT
Auscultated voice sounds in anterior right upper lobe
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in anterior left upper lobe
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in anterior left mid-chest (upper lobe)
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in anterior right middle lobe
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in anterior right lower lobe
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior left lower lobe
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in posterior left upper lobe
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in posterior right upper lobe
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in posterior right mid-back (lower lobe)
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in posterior left mid-back (lower lobe)
Exam Action
10/23/22 7:48
PM EDT
Auscultated voice sounds in posterior left lower lobe
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in posterior right lower lobe
Exam Action
10/23/22 7:48
PM EDT
Auscultated voice sounds in posterior right lower lobe on side
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in posterior right lower lobe near spine
Exam Action
10/23/22 7:48
PM EDT
Auscultated voice sounds in posterior left lower lobe near spine
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe on side
Exam Action
10/23/22 7:48
PM EDT
Ninety-nine.
Ninety-nine.
Can you confirm your name?
Question
10/23/22 7:50
PM EDT
Tina Jones.
Thank you for your time today. Do you have any further questions?
Question
10/23/22 7:50
PM EDT
I can’t think of any questions right now.
Subjective Data Collection: 27 of 27 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
• Found:
Indicates an item that you found.
• Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint •
Finding:
Asked about asthma
•
Finding:
Reports having asthma
(Found)
Pro Tip: Asking whether Tina has had asthma will elicit information regarding any previous respiratory diagnosis.
Example Question:
Do you have asthma?
•
Finding:
Reports asthma exacerbations
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or
condition they are presenting with.
Example Question:
Do you have asthma attacks?
Relevant Medical History •
Finding:
Asked about severity of asthma
•
Finding:
Reports asthma is intermittent
(Found)
Pro Tip: Establishing the severity classification of Tina’s asthma is important for understanding the impact on her life and the
functioning of her respiratory system, as well as assessing the appropriateness of her medication.
Example Question:
What is the severity of your asthma?
•
Finding:
Asked about asthma frequency and duration
•
Finding:
Reports asthma exacerbations occur up to 2 times a week
(Found)
Pro Tip: Establishing a timeline for how often Tina’s asthma attacks occur will help in treatment and in understanding the severity of
her asthma.
Example Question:
How many times a week do you have an asthma attack?
•
Finding:
Reports asthma exacerbations last around five minutes
(Found)
Pro Tip: Establishing a timeline for how long Tina’s asthma attacks last will help in treatment and in understanding the severity of
her asthma.
Example Question:
How long do your asthma attacks last?
•
Finding:
Asked about most recent asthma exacerbation
•
Finding:
Reports last exacerbation was three days ago
(Found)
Pro Tip: Establishing a timeline for Tina’s asthma attacks will help in treatment and in understanding the severity of her asthma.
Example Question:
When is the last time you had an asthma attack?
•
Finding:
Reports last exacerbation around cats at cousin’s house
(Found)
Pro Tip: Questions about what factors might have caused an illness can point to a patient’s environmental stressors, habits, and
general wellbeing. Asking Tina what caused her asthma attacks might indicate her health literacy and understanding of what factors
impact her breathing.
Example Question:
What caused your last asthma attack?
•
Finding:
Asked about asthma triggers
•
Finding:
Reports cat allergy as asthma trigger
(Found)
Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such
trigger.
Example Question:
Do cats trigger your asthma?
•
Finding:
Reports dust as asthma trigger
(Found)
Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such
trigger.
Example Question:
Does dust trigger your asthma?
•
Finding:
Denies asthma problems at work
(Found)
Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work
might indicate a relevant factor in her recent exacerbation.
Example Question:
Does anything at work make your asthma worse?
•
Finding:
Denies asthma problems at home
(Found)
Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at home
might indicate a relevant factor in her recent exacerbation.
Example Question:
Have you had problems with your asthma at home?
•
Finding:
Asked about asthma management
•
Finding:
Reports inhaler
(Found)
Pro Tip: Tina’s response to a question about asthma management will reveal the severity of her symptoms, her health literacy, and
the way she’s complied with previous treatment plans.
Example Question:
How do you manage your asthma?
•
Finding:
Asked about asthma medication
•
Finding:
Reports albuterol inhaler (Proventil)
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication
she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.
Example Question:
What is the name of the inhaler you are currently using?
•
Finding:
Reports last inhaler use was three days ago
(Found)
Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used
her inhaler will indicate when her symptoms most recently required medical treatment.
Example Question:
When did you last use your inhaler?
•
Finding:
Reports using inhaler no more than 2 times per week
(Available)
Pro Tip: After an asthma exacerbation, patients often will become more reliant on medical tools like inhalers. Asking Tina how many
times a week she uses her inhaler will point to the severity of her recent exacerbation.
Example Question:
How many times a week are you using your inhaler?
•
Finding:
Asked about number of puffs when using asthma inhaler
•
Finding:
Reports recommended dose is 1-3 puffs as needed
(Found)
Pro Tip: Tina’s response to a question about asthma medicine dosing will reveal the severity of her symptoms, her health literacy,
and the way she’s complied with her treatment plans.
Example Question:
What is the recommended dose of your asthma medication?
•
Finding:
Reports typically taking 2 puffs
(Found)
Pro Tip: Tina’s response to a question about asthma medicine dosing will reveal the severity of her symptoms, her health literacy,
and the way she’s complied with her treatment plans.
Example Question:
How many puffs do you normally take?
•
Finding:
Reports sometimes needing 3 puffs to control symptoms
(Found)
Pro Tip: Tina’s response to a question about asthma medicine dosing will reveal the severity of her symptoms, her health literacy,
and the way she’s complied with her treatment plans.
Example Question:
What is the most puffs you ever take?
•
Finding:
Asked about exacerbation symptoms
•
Finding:
Reports chest tightness during exacerbation
(Found)
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s had chest
tightness since exacerbation can indicate the severity of her symptoms since exacerbation.
Example Question:
Have you had chest tightness?
•
Finding:
Reports wheezing during exacerbation
(Found)
Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this
information. Asking Tina if she’s been wheezing illustrates how her asthma is presenting.
Example Question:
Have you been wheezing?
•
Finding:
Reports shortness of breath during exacerbation
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences shortness of breath during an attack will
indicate how her individual symptoms manifest.
Example Question:
Do you have shortness of breath during an asthma attack?
•
Finding:
Denies coughing during exacerbation
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences coughing during an attack will indicate
how her individual symptoms manifest.
Example Question:
Do you cough during an asthma attack?
•
Finding:
Denies chest pain during exacerbation
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences chest pain during an attack will indicate
how her individual symptoms manifest.
Example Question:
Do you have chest pains when you have asthma attacks?
•
Finding:
Denies painful breathing
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences painful breathing during an attack will
indicate how her individual symptoms manifest.
Example Question:
Is it painful for you to breathe?
•
Finding:
Asked about current breathing
•
Finding:
Denies current breathing problems
(Found)
Pro Tip: Asking about how Tina is currently breathing can provide a comparative baseline for assessing Tina’s current condition and
previous breathing concerns or conditions.
Example Question:
Are you having breathing problems now?
Review of Systems •
Finding:
Asked about cough history
•
Finding:
Reports only coughing when she has a cold
(Available)
Pro Tip: When a cough occurs can be indicative of its cause. Asking Tina when she coughs will allow you to determine the reason
behind it and what treatment plans are appropriate.
Example Question:
When are you coughing?
•
Finding:
Denies coughing up blood
(Available)
Pro Tip: Coughing up blood can be indicative of a major health concern. Asking Tina if she has been coughing up blood solicits an
important health history.
Example Question:
Have you been coughing up blood?
•
Finding:
Asked about sputum
•
Finding:
Denies sputum
(Found)
Pro Tip: Asthma symptoms may vary from one attack to the next. Determining which other symptoms Tina has experienced since
exacerbation will more specifically illustrate the ways in which Tina’s asthma manifests.
Example Question:
Are you coughing up phlegm or sputum?
Risk Factors •
Finding:
Asked about respiratory illness history besides asthma
•
Finding:
Denies history of bronchitis
(Available)
Pro Tip: Asking whether Tina has had bronchitis will elicit information regarding any previous respiratory diagnosis.
Example Question:
Have you had bronchitis?
•
Finding:
Denies history of pneumonia
(Available)
Pro Tip: Asking whether Tina has had pneumonia will elicit information regarding any previous respiratory diagnosis.
Example Question:
Have you had pneumonia?
•
Finding:
Denies history of emphysema
(Found)
Pro Tip: Asking whether Tina has had emphysema will elicit information regarding any previous respiratory diagnosis.
Example Question:
Have you had emphysema?
•
Finding:
Followed up on asthma diagnosis
•
Finding:
Reports specific age of diagnosis is 2.5 years old
(Found)
Pro Tip: By determining the onset of asthma you can get a sense for Tina’s asthma history, instance, and frequency of
exacerbation.
Example Question:
When were you diagnosed with asthma?
•
Finding:
Asked about seeing an asthma specialist
•
Finding:
Reports not seeing asthma doctor in two years
(Found)
Pro Tip: Seeing a specialist, like an asthma doctor, can help patients to manage symptoms. Asking when Tina last saw an asthma
doctor will allow you to assess her current treatment plan and healthcare access.
Example Question:
When did you last see a doctor for asthma?
•
Finding:
Asked about past hospitalizations
•
Finding:
Reports past hospitalizations for asthma
(Found)
Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina if she’s been hospitalized, you are
soliciting information about the history and severity of her condition.
Example Question:
Have you been hospitalized for asthma in the past?
•
Finding:
Reports five past hospitalizations for asthma
(Found)
Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina how many times she was hospitalized,
you are soliciting information about the history and severity of her condition.
Example Question:
How many times have you been hospitalized for asthma?
•
Finding:
Reports most recent hospitalization at age 16
(Found)
Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina when she was last hospitalized, you are
soliciting information about the history and severity of her condition.
Example Question:
When was your most recent hospitalization for asthma?
•
Finding:
Reports hospital treatment was usually steroids and a nebulizer
(Available)
Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina how she was treated when she was
hospitalized, you are soliciting information about the history and severity of her condition.
Example Question:
How were you treated at the hospital for asthma?
•
Finding:
Asked about general allergies
•
Finding:
Reports allergy to cats
(Found)
Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such
trigger.
Example Question:
Are you allergic to cats?
•
Finding:
Followed up on allergy symptoms
•
Finding:
Reports sneezing, itchy eyes, and wheezing
(Found)
Pro Tip: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening.
Example Question:
What are your allergy symptoms?
•
Finding:
Asked about allergy treatment
•
Finding:
Reports avoiding cats when possible
(Available)
Pro Tip: Tina’s response to a question about avoiding allergy triggers will reveal the severity of her symptoms, her health literacy,
and the way she’s complied with previous treatment plans.
Example Question:
Do you stay away from cats?
•
Finding:
Reports using inhaler
(Found)
Pro Tip: Tina’s response to a question about recent allergy management will reveal the severity of her symptoms, her health
literacy, and the way she’s complied with previous treatment plans.
Example Question:
How do you treat your cat allergy?
•
Finding:
Reports showering
(Available)
Pro Tip: Tina’s response to a question about recent allergy management will reveal the severity of her symptoms, her health
literacy, and the way she’s complied with previous treatment plans.
Example Question:
How do you treat your cat allergy?
•
Finding:
Asked about tobacco use
•
Finding:
Denies currently smoking tobacco
(Found)
Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she currently smokes can help you to
discern whether smoking was a factor in Tina’s recent asthma exacerbation.
Example Question:
Do you use tobacco products?
•
Finding:
Denies history of smoking tobacco
(Found)
Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she has a history of smoking can help
you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.
Example Question:
Have you ever used tobacco?
•
Finding:
Denies vaping
(Found)
Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she vapes can help you to discern
whether smoking was a factor in Tina’s recent asthma exacerbation.
Example Question:
Do you vape?
•
Finding:
Asked about marijuana use
•
Finding:
Reports past recreational marijuana smoking
(Found)
Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked marijuana can help
you to discern whether smoking was an exacerbating factor for Tina’s asthma.
Example Question:
Have you ever smoked marijuana?
•
Finding:
Followed up on marijuana
•
Finding:
Reports smoking marijuana for 5 or 6 years
(Found)
Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina how long she smoked marijuana can
help you to discern whether smoking exacerbated Tina’s asthma.
Example Question:
How long did you smoke marijuana?
•
Finding:
Reports stopped smoking marijuana 6 or 7 years ago
(Found)
Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina when she quit smoking marijuana can
help you to discern whether smoking exacerbated Tina’s asthma.
Example Question:
When did you stop smoking marijuana?
•
Finding:
Reports stopping because of health reasons and waning interest
(Available)
Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina why she quit smoking marijuana can
help you to discern whether smoking exacerbated Tina’s asthma.
Example Question:
Why did you stop smoking marijuana?
•
Finding:
Asked about secondhand smoke
•
Finding:
Denies secondhand smoke exposure
(Found)
Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking how often Tina is around people who smoke might
indicate a proximate environmental trigger.
Example Question:
Are you exposed to secondhand smoke?
Relevant Family History •
Finding:
Asked about family history of asthma
•
Finding:
Reports sister has asthma
(Found)
Pro Tip: Soliciting a family history helps you to determine which, if any, conditions are inherited. In asking Tina whether anyone in
her family has asthma, you’re ascertaining whether Tina’s condition is inherited.
Example Question:
Does anyone else in your family have asthma?
•
Finding:
Asked about family history of other respiratory illness
•
Finding:
Denies family history of respiratory illness
(Found)
Pro Tip: People with a family history of respiratory illness are often at a higher risk for asthma. If Tina has a family history of
respiratory illness, this could suggest inherited sensitivity.
Example Question:
Does respiratory illness run in your family?
•
Finding:
Asked about family tobacco use
•
Finding:
Denies family history of tobacco use
(Found)
Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking whether anyone in Tina’s household smokes might
indicate a proximate environmental trigger.
Example Question:
Does anyone in your family use tobacco products?
•
Finding:
Asked about family history of lung cancer
•
Finding:
Denies family history of lung cancer
Objective Data Collection: 6 of 6 (100%)
Inspected chest
1 of 1 point
Symmetry (1/2 point)
• [X] Symmetric
• Asymmetric
Appearance (1/2 point)
• [X] No visible abnormal findings
• Rash or lesion
• AP diameter abnormal
• Intercostal retraction while breathing
• Excessive use of accessory muscles while breathing
• Pectus excavatum
• Evidence of trauma (scar, laceration, or bruising)
Palpated chest expansion
1 of 1 point
Symmetry (1/1 point)
• [X] Equal bilaterally
• Unequal bilaterally
Palpated tactile fremitus
1 of 1 point
Symmetry (1/2 point)
• [X] Equal bilaterally
• Unequal bilaterally
Vibration (1/2 point)
• [X] Expected fremitus
• Decreased fremitus
• Absent fremitus
Percussed chest wall
1 of 1 point
Observations (1/2 point)
• [X] All areas resonant
• Some areas of dullness
Location (1/2 point)
• [X] No areas of dullness
• Dullness, anterior right upper lobe
• Dullness, anterior right middle lobe
• Dullness, anterior right lower lobe
• Dullness, anterior left upper lobe
• Dullness, anterior left lower lobe
• Dullness, posterior right upper lobe
• Dullness, posterior right lower lobe
• Dullness, posterior left upper lobe
• Dullness, posterior left lower lobe
Auscultated breath sounds
1 of 1 point
Breath Sounds (1/3 point)
• [X] Present in all areas
• Diminished in some areas
• Absent in some areas
Adventitious Sounds (1/3 point)
• No adventitious sounds
• [X] Wheezing
• Fine crackles
• Stridor
• Rhonchi
• Rales
Location (1/3 point)
• All areas clear
• Adventitious sounds in anterior right upper lobe
• Adventitious sounds in anterior right middle lobe
• Adventitious sounds in anterior right lower lobe
• Adventitious sounds in anterior left upper lobe
• Adventitious sounds in anterior left lower lobe
• Adventitious sounds in posterior right upper lobe
• [X] Adventitious sounds in posterior right lower lobe
• Adventitious sounds in posterior left upper lobe
• [X] Adventitious sounds in posterior left lower lobe
Auscultated for bronchophony
1 of 1 point
Bronchophony (1/1 point)
• Positive
• [X] Negative
• Vitals
Vitals 22:00 00:00 02:00 04:00 06:00 08:00 10:00
Temp (<38° C) 38.7 C /
101.7 F
39.1 C /
102.4 F
38.6 C /
101.5 F
37.9 C /
100.2 F
37.1 C /
98.8 F
36.7 C /
98.1 F
37 C /
98.6 F 36.7 C / 98.1 F
BP (<120/80) 138/90 138/88 136/88 138/90 134/88 138/90 136/88
HR (60-100) 90 72 68 69 70 68 70
RR (12-20) 18 16 16 18 18 16 18
O2 Sat (>94%) 98% 98% 98% 98% 98% 98% 98%
Pain Scale 10 7 asleep asleep 9 6 8 6
Pain
Reassessment
7
@23:00 asleep 5
@07:00
4
@11:00 6
Vitals 22:00 00:00 02:00 04:00 06:00 08:00 10:00
after
Intervention
Height 67
inches
Weight 90 kg
FVC 1.78 L
FEV1 1.549 L