Respiratory Physical Assessment Shadow Health Assignment (LATEST 2020)

Respiratory | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/9138323 1/1 Respiratory Results | Turned In Nursing 562/562L Advanced Health Assessment - Spring 2021, N562 Return to Assignm ...

Respiratory | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/9138323 1/1 Respiratory Results | Turned In Nursing 562/562L Advanced Health Assessment - Spring 2021, N562 Return to Assignment (/assignments/433792/) Experience Overview Your Results Reopen (/assignment_attempts/9138323/reopen) Lab Pass (/assignment_attempts/9138323/lab_pass.pd Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Patient: Tina Jones Digital Clinical Experience Score 100% This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent. Student Performance Index 31 out of 31 Proficiency Level: Proficient Students rated as “proficient” demonstrate an entry-level expertis advanced practice competencies and clinical reasoning skills comparable programs, the top 25% of students perform at the l of a proficient practitioner. Beginning Developing Proficient Subjective Data Collection 21 out of 21 Objective Data Collection 6 out of 6 Education and Empathy 4 out of 4 Time 75 minutes total spent in assignment Interaction with patient 75 minutes Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health 2012 - 2021 (800) 860-3241 | Help Desk (https://support.shadowhealth.com/) | Terms of Service (/static/terms_of_service) | Privacy Policy (/static/privacy_policy) | Patents (https://www.shadowhealth.com/patents) ® Support 2/17/2021 Respiratory | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/9138323 1/4 Respiratory Results | Turned In Nursing 562/562L Advanced Health Assessment - Spring 2021, N562 Return to Assignment (/assignments/433792/) Subjective Data Collection: 21 of 21 (100.0%) Chief Complaint History of Presenting Illness Your Results Reopen (/assignment_attempts/9138323/reopen) Lab Pass (/assignment_attempts/9138323/lab_pass.pd Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Indicates an item that you found. 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 t patient's case. Established chief complaint Reports increased breathing problems and shortness of breath Reports decreased effectiveness of inhaler Asked about onset of symptoms Reports symptoms began two days ago Asked about frequency and duration of SOB episodes Reports exacerbations lasting several minutes Reports exacerbated breathing about every 4 hours since original episode Reports waking up twice a night with asthma the past 2 nights Asked about severity of symptoms Describes asthma severity as "not full attack," but worse than usual Reports asthma has been interfering with activities of daily life Asked about character of symptoms Reports recent wheezing Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Support 2/17/2021 Respiratory | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/9138323 2/4 Medical History Reports chest tightness Denies chest pain Asked about cough Reports cough Cough has persisted since original asthma exacerbation 2 days ago Describes cough as "dry" Describes cough as "small" and not severe Reports cough slightly relieved by drinking water Has not treated cough with medication or home remedies Asked about aggravating factors Reports symptoms worse at night Reports symptoms increase when lying flat on back Reports symptoms aggravated by movement Confirmed use of medications Confirms medications (no new medications reported) Followed up about inhaler use Uses an inhaler to treat asthma symptoms Inhaler is Proventil Reports most recent inhaler use was this morning Reports using inhaler every 4 hours or so since exacerbation Prescribed usage is 2 puffs Reports needing more than 2 puffs to resolve asthma symptoms Confirmed allergies Confirms allergies (no new allergies reported) Followed up on exposure to allergy and asthma triggers Reports cat allergy triggered recent episodes Reports dust as a known trigger Reports activity such as walking up stairs as a known trigger Denies seasonal pattern Denies changes in weather as a trigger Reports minimal exposure to asthma triggers at work Asked detailed questions about asthma history No current asthma doctor Diagnosed with asthma in childhood Age of diagnosis was 2 1/2 years old Asked about hospitalizations for asthma Reports prior hospitalizations for asthma Reports last hospitalization was age 16 Estimates 5 total hospitalizations for asthma Reports she has never been intubated Followed up about non-medication forms of asthma management Denies record keeping of asthma exacerbation or shortness of breath episodes Denies using peak flow meter Denies nebulizer use 2/17/2021 Respiratory | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/9138323 3/4 Social Determinants of Health Social History Review of Systems Family History Asked about environmental control Reports living situation is tidy and free of dust Reports hypoallergenic bedding hygiene Reports avoiding animals and has no pets at home Reports avoiding exposure to secondhand smoke Asked about exercise and activity level Reports general low activity level Reports diminished activity due to asthma Asked about possible contributing factors in health history Denies history of eczema Denies history of sinus problems Denies history of GERD, heartburn, or indigestion Denies history of COPD or emphysema Asked about smoking, inhalants, or tobacco Denies history of tobacco use, including cigarettes Reports past history of marijuana use Last use of marijuana was age 20 or 21 Denies inhaling substances Asked about general symptoms Denies recent respiratory or other illness Denies fever Denies nausea or vomiting Denies chills Reports low energy level Denies night sweats Asked review of systems for respiratory Denies phlegm or sputum Denies sore throat, swelling, or difficulty swallowing Denies nasal drainage Asked about relevant family history Reports no recent illnesses with family members at home Reports younger sister as only family with asthma Reports younger sister as only family member with allergies Reports no family history of eczema Reports no family history of chronic nasal or sinus problems Reports no family history of COPD or emphysema