Shadow Health Tina Jones Respiratory Documentation

Documentation / Electronic Health Record


Document: Provider Notes

Student Documentation Model Documentation



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.



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%.



Asthma exacerbation



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.