Documentation / Electronic Health Record
Document: Provider Notes
Documentation about Tina Jones’s Breathing Problems
Table of Contents
Records / Digital Health Files
Record: Doctor’s Notes
Student’s Writing Model’s Writing
Personal
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Medical History: Ms. Jones is a nice 28-year-old African American lady who came to the clinic because she had trouble breathing and wheezing after nearly having an asthma attack two days ago. She says she was at her cousin’s place and was around cats, which made her asthma act up. During the incident, she felt her wheezing was a 6/10 in severity, and her shortness of breath was about a 7-8/10, lasting for five minutes.
She didn’t have any chest pain or allergic reactions. She used her albuterol inhaler at that time, which helped a bit but didn’t completely solve the problem. Since then, she’s had about 10 episodes of wheezing and feels short of breath about every four hours. She last felt short of breath this morning before coming to the clinic. She notices that lying flat and moving around make her symptoms worse, and she has a dry cough. She wakes up feeling short of breath twice a night.
She’s worried because her asthma seems to be getting worse, and her albuterol inhaler doesn’t work as well as before. She was diagnosed with asthma when she was 2.5 years old. She hasn’t had any recent lung function tests, doesn’t use a peak flow meter, doesn’t keep track of her attacks, and doesn’t have a nebulizer or vaporizer at home. She’s been hospitalized five times for asthma, with the last time being when she was 16. She’s never needed a breathing tube for her asthma. She doesn’t see a lung specialist or allergy doctor currently. Social Background: She doesn’t know of any substances or things in her environment at work or home that might bother her. She changes her bed sheets every week and doesn’t have dust or mold in her home. She uses a special pillowcase for allergies, and her mattress is a year old. She doesn’t smoke, drink alcohol, or use drugs now. She smoked marijuana for about five or six years, with the last time being when she was 21. She doesn’t exercise.
Physical Exam: General: Ms. Jones is a friendly, overweight 28-year-old African American lady who doesn’t seem to be in any immediate trouble. She’s awake, knows where she is, and is sitting up straight on the exam table. She keeps eye contact during the interview and examination. Respiratory: Her chest moves evenly with breathing. There’s normal vibration when touching her chest, and it feels the same on both sides. When tapping her chest, it sounds hollow, not dull. There are wheezing sounds when she breathes out in the lower back parts of both sides of her chest. No crackling noises are heard. A lung function test done in the office showed that she can breathe out 3.91 liters of air in one go, and her lung function is 80.56% of what it should be. Her blood oxygen level is 97%.
Evaluation
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Worsening of asthma
Course of Action
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Advise Ms. Jones to keep track of her symptoms and write down when she has trouble breathing or wheezing, along with anything that might be causing it, and bring the notes to her next appointment. • Check her blood oxygen level at the clinic. • Order lung function tests to be done after her asthma gets better so we can compare with later tests. • Suggest she wash her bedding and think about using covers to keep dust mites away and reduce her nighttime allergy symptoms. • Do a test in the office called NMT once. • Tell her to drink more water and other fluids. • Teach Ms. Jones when she should go to the emergency room, like if she has chest pain or trouble breathing even when resting, if her asthma gets worse, or if she feels like her rescue inhaler isn’t helping. • Ask her to come back to the clinic in 2-4 weeks for another checkup.
Shadow Health Tina Jones Respiratory Objective and subjective data
Shadow Health Tina Jones Respiratory Documentation
| Student Documentation | Model Documentation |
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Subjectivexxx |
HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7-8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive cough. She awakens with night-time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less effective than previous. Currently she states that her breathing is normal. Diagnosed with asthma at age 2.5 years. She has no recent use of spirometry, does not use a peak flow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been hospitalized five times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current pulmonologist or allergist. Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last use was at age 21 years. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain • Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16. |
Objectivexxxx |
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on exam table. She maintains eye contact throughout interview and examination. • Respiratory: Chest expansion is symmetrical with respirations. Normal fremitus, symmetric bilaterally. Chest resonant to percussion; no dullness. Bilateral expiratory wheezes in posterior lower lobes. Bilateral muffled words with notable expiratory wheezes in posterior lower lobes. No crackles. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%. |
Assessmentxxx |
Asthma exacerbation |
Planxxxx |
Encourage Ms. Jones to continue to monitor symptoms and log her episodes of asthma symptoms and wheezing with associated factors and bring log to next visit. • Obtain office oxygen saturation. • Order PFTs to be completed after exacerbation to have baseline available for future comparison. • Encourage to wash bedding and consider dust mite covers to decrease allergic nighttime symptoms. • NMT in office x 1. • Educate to increase intake of water and other fluids. • Educate Ms. Jones on when to seek emergent care including episodes of chest pain or shortness of breath unrelieved by rest, worsening asthma symptoms or wheezing, or the sense that rescue inhaler is not helping. • Revisit clinic in 2-4 weeks for follow up and evaluation. |
