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Hello Im xxx.
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Greet |
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Hey.
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I will be xxx
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Educate |
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Alright, thanks for letting me know.
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How are you feeling? do you have any pain?
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It doesn’t hurt. . . it’s just hard to breathe, but there’s no pain.
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I understand that can be scary.
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Empathize |
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Thanks for saying that.
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What is your date of birth?
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February 17th.
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How old are you?
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I’m 28.
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What brings you to the clinic 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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Am sorry to hear that.
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Educate |
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Sure, I think I understand what you mean.
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What medical problems do you have?
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Well. . . I’ve had asthma since I was really little, though for a while there it wasn’t really much of a problem. And I have sugar diabetes, too.
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What do you use for your asthma?
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It’s just a regular Proventil inhaler.
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How often do you use the inhaler?
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I’ve been using it probably every. . . four hours or so, I’d say.
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When did your symptoms start?
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I don’t know if I’d call it an asthma attack, but my asthma started acting up two days ago at my cousin’s 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.
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Am sorry to hear that.
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Empathize |
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Thanks for understanding.
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How long have you had the breathing problems?
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My breathing’s been acting up off and on for the past two days.
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How frequent are the shortness of breath episodes? (Clarified to How long do these shortness of breath episodes last?.)
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Sometimes it can take a few minutes for me to realize I need my inhaler, then once I use it the wheezing usually gets better. . . I’d say it takes about a minute to work at most after that. So five minutes total, at the longest? (Clarified to how long the shortness of breath episodes last.)
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How long does one episode last?
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I haven’t had a full attack in years, but usually once I use my inhaler it only takes a minute or two for my breathing to go back to normal. . . that’s not what’s been happening recently, though.
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How many times have you had breathing problems in the past 2 days?
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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.
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Is yous asthma keeping you up at night? (No matching questions found.)
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Is your asthma keeping you up at night?
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My asthma doesn’t usually wake me up, but it has the past couple nights.
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How bad was your asthma attack?
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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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Is there anything you can’t do because of your asthma?
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There usually isn’t anything I can’t do because of my asthma. . . 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.
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Do you wheeze during an asthma exacerbation?
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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.
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Any chest tightness? (Clarified to Have you had chest tightness?.)
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Yeah, when my asthma gets bad my chest feels pretty tight, like I can’t take in air. It’s felt that way a lot the past two days. (Clarified to if I have had chest tightness.)
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Are you having any chest tightness?
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It just feels like I can’t really take in air when I breathe, sort of like breathing makes my chest tighter. . . it doesn’t hurt or anything, though.
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Any coughs?
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I’ve been coughing a lot, yeah.
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How long have you had the cough?
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Since my asthma acted up two days ago.
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How would you describe the cough?
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Um. . . I guess I’d describe it as a small, dry cough.
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What makes your cough better?
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Drinking some water helps a little, as long as the water isn’t too cold.
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Have you tried to treat your cough?
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I haven’t taken medicine for it or anything.
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Is your asthma worse at night?
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It has been the past couple nights, yeah.
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Does lying on your back make the asthma worse? (No matching questions found.)
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Does lying on your back make your asthma worse?
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Inspected anterior chest wall
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Exam Action |
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Inspected right side chest wall
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Inspected posterior chest wall
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Inspected left 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 upper chest wall: Equal bilaterally, expected vibration
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Ninety-nine.
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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 posterior upper chest wall: Equal bilaterally, expected vibration
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Ninety-nine.
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Palpated fremitus in posterior middle chest wall: Equal bilaterally, expected vibration
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Ninety-nine.
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Palpated fremitus in posterior lower chest wall: Equal bilaterally, expected vibration
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Ninety-nine.
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Percussed anterior right upper lobe
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Percussed anterior left upper lobe
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Percussed anterior right middle lobe
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Percussed anterior left mid-chest (upper 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 left upper lobe
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Percussed posterior right 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 left lower lobe
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Percussed posterior right 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 near spine
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Percussed posterior right lower lobe on side
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Auscultated breath sounds in anterior right upper lobe
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Auscultated breath sounds in anterior left upper lobe
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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 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 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 left mid-back (lower lobe)
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Auscultated breath sounds in posterior right mid-back (lower lobe)
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Auscultated breath sounds in posterior left lower lobe
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Auscultated breath sounds in posterior right lower lobe
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Auscultated breath sounds in posterior left lower lobe on side
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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 voice sounds in anterior right upper lobe
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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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Auscultated voice sounds in anterior right middle lobe
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Exam Action |
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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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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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Auscultated voice sounds in anterior left lower lobe
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Exam Action |
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Ninety-nine.
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Auscultated voice sounds in posterior left upper lobe
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Exam Action |
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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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Auscultated voice sounds in posterior left mid-back (lower lobe)
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Exam Action |
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Auscultated voice sounds in posterior right mid-back (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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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 on side
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Exam Action |
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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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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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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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Check pulse oximetry using right hand
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Checked pulse oximetry using left hand
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Blow into the spirometer.
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Checked spirometer
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Checked spirometer
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Checked spirometer
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Checked patient’s inhaler
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Exam Action |
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