Tina Jones Respiratory Shadow Health Transcript
Transcript
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Hi Ms Jones, I’m xx and I’m going to examine you today.
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Greet |
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Hey.
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Can you verify your name and date of birth?
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My name’s Tina Jones, and my birthday’s February 17th.
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What brings you in today?
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I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does.
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I’m sorry to hear you’re going through that.
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Empathize |
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Thanks for understanding.
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Can you please describe what’s going on with your inhaler? (No matching questions found.)
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Can you please describe what breathing problems you’re having? (Clarified to Can you describe your breathing problems?.)
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It feels like it’s been 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. (Clarified to to describe my breathing problems.)
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Do you know what are causing your asthma to flare up? (Clarified to What started your recent asthma problems?.)
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This all started at my cousin’s house. She has cats, and I’m allergic, so my asthma always goes crazy when I’m there. (Clarified to what triggered my recent asthma problems.)
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When was your most recent asthma exacerbation?
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The last time I had real trouble breathing was early this morning. But it’s been going on for the past two days.
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How many puffs of your inhaler do you use when your asthma symptoms flare up?
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Sometimes I have to take three puffs of the 90 mcg albuterol inhaler instead of two, and the past couple days, always three. [AUDIO COMING SOON]
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How often are you around cats?
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Not often. Just at my cousin’s house. . . and I’m only there a few times a year.
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What else triggers your asthma besides cats?
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For the last two days, it seems worse at night when I’m lying down, or when I’m moving around too much. Typically it’s stuff like cats or dust that gets to me.
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Do you have any other respiratory illnesses?
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No, just the asthma.
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How long have you had asthma?
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I’ve had asthma a long time. . . since I was really little.
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How do you manage your asthma?
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I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
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How is your breathing currently?
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My breathing feels okay right this second, but I’ve definitely been having problems recently with it.
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How severe is your asthma?
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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.
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What other symptoms have you had besides trouble breathing?
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Other than what I’ve told you? I don’t think so. It’s just needing my inhaler so much and the cough that’s been bothering me.
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Tell me more about your cough
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Um. . . I guess I’d describe it as a small, dry cough.
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When did this cough start?
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Two days ago, a little while after I first started having these asthma problems.
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Do you have any sputum with this cough?
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No, nothing’s coming up.
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How often do you cough?
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I’ve been coughing pretty much all the time.
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What are your allergies?
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I’m allergic to cats.
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Any other allergy besides cats? (Clarified to Are you allergic to anything besides cats?.)
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Yeah, I’m allergic to penicillin. (Clarified to if I am allergic to anything besides cats.)
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When did you have an allergic reaction to penicillin? (Clarified to Have you had an allergic reaction to penicillin?.)
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Yeah, but it was a long time ago, when I was little. . . the doctor told me not to take it again after that. (Clarified to if I have had a reaction to penicillin.)
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What happens when you take penicillin?
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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.
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How severe was your reaction to penicillin?
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It was a long time ago, so I don’t remember that well, but I don’t think it was that serious. I just got a rash–like, hives–I think. . . then the doctor said not to take penicillin again, so I didn’t.
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Do you have any environmental allergies?
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No, unless cats count.
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Can you describe what happens when you’re around cats?
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Whenever I’m around cats, I start sneezing, my eyes get itchy, my nose runs. . . and my asthma starts to act up.
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How do your treat your allergy to cats?
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I try not to be around cats at all, but when I have to be around them and my breathing gets bad, I use my inhaler. . . but I don’t totally feel better until I go home and take a shower.
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You mentioned your asthma flares up when you’re around dust. What happens when you’re around dust?
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If I’m around a lot of dust, I can get sneezy, or I can start wheezing.
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Do you smoke?
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No. I think it’s gross.
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Do you use any recreational drugs?
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No.
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Do you use marijuana?
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Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
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When was the last time you used marijuana?
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I haven’t smoked pot since I was twenty or twenty-one.
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Are you around secondhand smoke?
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Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes.
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How often are you around your friends that smoke? (Clarified to How often are you around people who smoke?.)
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Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes. (Clarified to how often I am around secondhand smoke.)
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Does anyone in your family have asthma?
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It’s just me and my baby sister that have asthma, but she really doesn’t have problems with it.
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Did your parents or grandparents have asthma?
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Yeah. Both Nana and Poppa died about five years ago.
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I’m so sorry to hear that
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Empathize |
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Thanks for saying that.
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What did your father die of?
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He died in a car accident.
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What happened in the car accident?
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He was driving to work and it was raining…and his car hydroplaned. And hit a tree. So it was really sudden.
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How did your grandfather die?
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Well, Grandpa Jones died of colon cancer, and Poppa died of a heart attack.
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Does your family have a history of lung cancer?
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The only cancer that I know of in our family is colon cancer–Grandpa Jones died of that.
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Does your family have a history of respiratory illness?
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My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think.
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Do you have a history of bronchitis, pneumonia or emphysema?
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Nope, never.
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Inspected anterior chest wall
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Exam Action |
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Inspected left side chest wall
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Inspected posterior chest wall
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Inspected right side chest wall
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Inspected anterior chest wall
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Palpated chest expansion: Both sides rise symmetrically
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Palpated fremitus in anterior lower chest wall: Equal bilaterally, expected vibration
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Ninety-nine.
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Palpated fremitus in anterior upper chest wall: Equal bilaterally, expected vibration
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Ninety-nine.
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Palpated chest expansion: Both sides rise symmetrically
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Percussed anterior left upper lobe
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Percussed anterior right upper lobe
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Percussed anterior left mid-chest (upper lobe)
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Percussed anterior right middle lobe
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Percussed anterior right lower lobe
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Percussed anterior left lower lobe
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Percussed posterior right upper lobe
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Percussed posterior left upper lobe
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Percussed posterior left mid-back (lower lobe)
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Percussed posterior right mid-back (lower lobe)
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Percussed posterior right lower lobe
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Percussed posterior left mid-back (lower lobe)
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Percussed posterior left lower lobe
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Percussed posterior left lower lobe on side
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Percussed posterior left lower lobe near spine
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Percussed posterior right lower lobe
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Percussed posterior right lower lobe near spine
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Percussed posterior right lower lobe on side
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Percussed posterior right lower lobe on side
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Auscultated breath sounds in anterior left upper lobe
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Auscultated breath sounds in anterior right upper lobe
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Auscultated breath sounds in anterior right middle lobe
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Auscultated breath sounds in anterior left upper lobe
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Exam Action |
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Auscultated breath sounds in anterior left mid-chest (upper lobe)
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Exam Action |
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Auscultated breath sounds in anterior left lower lobe
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Auscultated breath sounds in anterior right lower lobe
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Auscultated breath sounds in posterior left upper lobe
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Auscultated breath sounds in posterior right upper lobe
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Auscultated breath sounds in posterior right mid-back (lower lobe)
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Exam Action |
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Auscultated breath sounds in posterior left mid-back (lower lobe)
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Exam Action |
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Auscultated breath sounds in posterior left lower lobe
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Exam Action |
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Auscultated breath sounds in posterior right lower lobe
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Exam Action |
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Auscultated breath sounds in posterior left lower lobe on side
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Exam Action |
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Auscultated breath sounds in posterior left lower lobe near spine
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Auscultated breath sounds in posterior right lower lobe near spine
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Auscultated breath sounds in posterior right lower lobe on side
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Auscultated breath sounds in posterior right lower lobe
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Exam Action |
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Auscultated breath sounds in posterior left lower lobe
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Exam Action |
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Auscultated breath sounds in posterior right mid-back (lower lobe)
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Exam Action |
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Auscultated breath sounds in posterior left mid-back (lower lobe)
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Exam Action |
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Auscultated breath sounds in posterior left upper lobe
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Exam Action |
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Auscultated breath sounds in posterior left mid-back (lower lobe)
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Exam Action |
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Auscultated breath sounds in anterior left upper lobe
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Exam Action |
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Auscultated breath sounds in anterior right upper lobe
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Exam Action |
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Auscultated breath sounds in anterior right middle lobe
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Exam Action |
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Auscultated breath sounds in anterior left mid-chest (upper lobe)
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Exam Action |
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Auscultated breath sounds in anterior left lower lobe
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Exam Action |
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Auscultated breath sounds in anterior right lower lobe
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Exam Action |
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Auscultated breath sounds in anterior left lower lobe
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Auscultated breath sounds in anterior right lower lobe
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Auscultated voice sounds in anterior right upper lobe
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior right upper lobe
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior left upper lobe
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior left mid-chest (upper lobe)
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior right middle lobe
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior left lower lobe
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior right lower lobe
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior right upper lobe
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior right mid-back (lower lobe)
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior right lower lobe
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Exam Action |
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Ninety-nine.
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Auscultated voice sounds in posterior left lower lobe
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior right lower lobe on side
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior right lower lobe near spine
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior left lower lobe near spine
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in posterior left lower lobe on side
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Exam Action |
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior left lower lobe
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Auscultated voice sounds in anterior right lower lobe
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Ninety-nine.
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Ninety-nine.
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Ninety-nine.
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Check pulse oximetry using right hand
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Checked pulse oximetry using left hand
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Ms. Jones can you please blow into the spirometer?
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Checked spirometer
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Checked patient’s inhaler
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Do you see an asthma specialist?
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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.
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Have you had any hospitalizations?
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I went to the hospital a bunch of times when I was growing up, for asthma attacks. And I went for a foot injury a few months ago, but my foot is fine now.
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At the time of your asthma attack, how severe was it?
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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.
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What number on a scale of 0 to 10 would you rate the severity? (Clarified to How would you rate the severity of your asthma on a scale from one to ten?.)
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At its worst it’s been like a 7 or 8 out of 10, probably. (Clarified to how I would rate my asthma on a scale.)
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How you rate your shortness of breath from a scale of 0 to 10?
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