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.

NB: We have all the questions and documented answers as listed and attached below. All you need to do is ORDER NOW for an equivalent of 4 pages for this assignment and all other iHuman/Shadow Health Assignments.

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.

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.

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?

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.

WE GUARANTEE A DCE SCORE OF ABOVE 95% AND HANDLE THE SOAP NOTE

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
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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
If your instructor provides individual feedback on this assignment, it will appear here.

shadow health respiratory transcript

APPROACH

SAMPLE Shadow Health Respiratory Assessment

N 518 Module 2: THE GENERAL SURVEY AND HEENT

Module 2: Discussion Question

Start by reading and following these instructions:

You are responsible for minimally at least 3 posts for each question in your discussion boards; your initial post and reply to two of your classmates. Your initial post(s) should be your response to the questions posed in the discussion question. You should research your answer and cite at least one scholarly source when appropriate, and always use quality writing.The discussion board is never a place to use text language or emoticons. You will also be asked to respond to your classmates. This is designed to enhance the academic discussion around the topic. It is all right to disagree with something posted by another, however your responses should always be thoughtful and respectful and reflect your opinions professionally.

Discussion Question:

In your professional opinion, what is the difference between chronic and acute pain? How is the assessment for each type of pain different? What must you keep in mind when assessing acute pain? What must you keep in mind when assessing chronic pain? Reflect upon a time when you assessed a patient in pain. What did you do well? What points could you have improved upon? How did the pain impact the patient? What specific treatments could have lessened the impact of the pain on the patient?

Your initial posting should be 200 to 300 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 100 words in length. To properly “thread” your discussion posting, please click on REPLY.

When you are ready for the discussion, do the following:

Click on the discussion link above.
Start your answer by clicking “Start a New Thread” button with the title of your answer and the body of text following the guidance above.
To properly post your answer, please click on the “Post” button.
After posting your contribution, you must read what others have posted, reply to at least two of those posts, and respond (when appropriate) to those you have responded to you.

To reply to a classmate’s post:

Click on the title of another student’s post.
Click “Reply to Thread” and type your response to the student.
Click the “Post” button to post your reply.

N 581 Module 2: Assignment

Remember to submit your work following the file naming convention FirstInitial.LastName_M01.docx. For example, J.Smith_M01.docx. Remember that it is not necessary to manually type in the file extension; it will automatically append.

Start by reading and following these instructions:

1. Quickly skim the questions or assignment below and the assignment rubric to help you focus.

2. Read the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.

3. Consider the discussion and the any insights you gained from it.

4. Create your Assignment submission and be sure to cite your sources, use APA style as required, check your spelling.

Assignment:

Exercises:

Complete the Shadow Health HEENT assessment.

Professional Development

Write a reflection essay of your experience with the Shadow Health virtual assessment. At least two scholarly sources in addition to your textbook should be utilized. Please be sure to address each of the following prompts:
- What went well in your assessment?
- What did not go so well? What will you change for your next assessment?
- What findings did you uncover?
- What questions yielded the most information? Why do you think these were effective?
- What diagnostic tests would you order based on your findings?
- What differential diagnoses are you currently considering?
- What patient teaching were you able to complete? What additional patient teaching is needed?
- Would you prescribe any medications at this point? Why or why not? If so, what?
- How did your assessment demonstrate sound critical thinking and clinical decision making? What could you change to make it better?

Shadow Health Physical Assessment Rubric

Criteria

Ratings

Pts

Subjective Data, Organization, Communication, and Summary (DCE Score or transcript)

25.0 pts

Above Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.

21.0 pts

Average- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.

10.0 pts

Below Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.

0.0 pts

Unsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing.

25.0 pts

Objective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation

20.0 pts

Above Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.

16.0 pts

Average- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).

8.0 pts

Below Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).

0.0 pts

Unsatisfactory- No physical assessment documentation or no treatment plan.

20.0 pts

Self-Reflection

5.0 pts

Above Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.

3.0 pts

Average- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.

2.0 pts

Below Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight

0.0 pts

Unsatisfactory- No reflection posts for the assignment.

5.0 pts

Total Points: 50.0

Shadow Health Respiratory Assessment Transcript