Tina Jones Respiratory Shadowhealth - Shadow Health Assessments (2024)

Hi. My name is xxx . I will be interviewing you today and later examine you.

Greet
10/03/20 4:23 AM EDT

Hey.

What is your name?

Question
10/03/20 4:34 AM EDT

Tina Jones.

What is your date of birth?

Question
10/03/20 4:45 AM EDT

February 17th.

How a old are you?

Question
10/03/20 4:55 AM EDT

I’m 28.

What brings you to the clinic today?

Question
10/03/20 5:56 AM EDT

I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does.

Am sorry to hear that.

Empathize
10/03/201 5:57 AM EDT

I appreciate you saying that.

What medical problems do you have?

Question
11/05/21 9:13 PM EDT

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.

What do you use for your asthma?

Question
11/05/21 9:14 PM EDT

It’s just a regular Proventil inhaler.

How often do you use your inhaler?

Question
11/05/21 9:15 PM EDT

I’ve been using it probably every. . . four hours or so, I’d say.

When did your symptoms start?

Question
11/05/21 9:15 PM EDT

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.

Am sorry to hear that

Empathize
11/05/21 9:16 PM EDT

Thanks for understanding.

How long have you had breathing problems?

Question
11/05/21 9:17 PM EDT

My breathing’s been acting up off and on for the past two days.

How frequent are your shortness of breath episodes?

Question
11/05/21 9:18 PM EDT

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?

How long does one episode last?

Question
11/05/21 9:19 PM EDT

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.

How many times have you had breathing problems in the past 2 days?

Question
11/05/21 9:20 PM EDT

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.

Is your asthma keeping you up at night?

Question
11/05/21 9:21 PM EDT

My asthma doesn’t usually wake me up, but it has the past couple nights.

How bad was your asthma attack?

Question
11/05/21 9:22 PM EDT

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.

Is there anything you can’t do because of your asthma?

Question
11/05/21 9:22 PM EDT

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.

Do you wheeze during an asthma exacerbation?

Question
11/05/21 9:23 PM EDT

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.

Any chest tightness? (Clarified to Have you had chest tightness?.)

Question
11/05/21 9:23 PM EDT

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.)

Are you having any chest tightness?

Question
11/05/21 9:24 PM EDT

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.

Any cough?

Question
11/05/21 9:24 PM EDT

I’ve been coughing a lot, yeah.

How long have you had the cough?

Question
11/05/21 9:25 PM EDT

Since my asthma acted up two days ago.

How would you describe the cough?

Question
11/05/21 9:26 PM EDT

Um. . . I guess I’d describe it as a small, dry cough.

How would you describe the cough?

Question
11/05/21 9:27 PM EDT

Um. . . I guess I’d describe it as a small, dry cough.

What makes your cough better?

Question
11/05/21 9:28 PM EDT

Drinking some water helps a little, as long as the water isn’t too cold.

Have you tried to treat your cough?

Question
11/05/21 9:28 PM EDT

I haven’t taken medicine for it or anything.

Is your asthma worse at night?

Question
11/05/21 9:29 PM EDT

It has been the past couple nights, yeah.

Does lying on your back make your asthma worse?

Question
11/05/21 9:30 PM EDT

Just recently lying on my back has definitely made my breathing worse.

To help your breathing, you may want to elevate your head with two pillows

Educate
11/05/21 9:31 PM EDT

Alright, thanks for letting me know.

Any allergies?

Question
11/05/21 9:32 PM EDT

Yeah, I’m allergic to cats.

Any medication allergies?

Question
11/05/21 9:32 PM EDT

Yeah, I’m allergic to penicillin.

Any family history breathing problems?

Question
11/05/21 9:32 PM EDT

My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think.

Inspected anterior chest wall

Exam Action
11/05/21 9:35 PM EDT

Inspected right side chest wall

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11/05/21 9:36 PM EDT

Inspected posterior chest wall

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11/05/21 9:36 PM EDT

Inspected left side chest wall

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11/05/21 9:36 PM EDT

Inspected anterior chest wall

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11/05/21 9:36 PM EDT

Palpated chest expansion: Both sides rise symmetrically

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11/05/21 9:37 PM EDT

Percussed anterior right upper lobe

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11/05/21 9:43 PM EDT

Percussed anterior left upper lobe

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11/05/21 9:43 PM EDT

Percussed anterior right middle lobe

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11/05/21 9:43 PM EDT

Percussed anterior left mid-chest (upper lobe)

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11/05/21 9:43 PM EDT

Percussed anterior right lower lobe

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11/05/21 9:43 PM EDT

Percussed anterior left lower lobe

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11/05/21 9:44 PM EDT

Percussed posterior left upper lobe

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11/05/21 9:45 PM EDT

Percussed posterior right upper lobe

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11/05/21 9:46 PM EDT

Percussed posterior left mid-back (lower lobe)

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11/05/21 9:46 PM EDT

Percussed posterior right mid-back (lower lobe)

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11/05/21 9:46 PM EDT

Percussed posterior left lower lobe

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11/05/21 9:46 PM EDT

Percussed posterior right lower lobe

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11/05/21 9:46 PM EDT

Percussed posterior right lower lobe

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11/05/21 9:46 PM EDT

Percussed posterior left lower lobe on side

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11/05/21 9:46 PM EDT

Percussed posterior left lower lobe near spine

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11/05/21 9:46 PM EDT

Percussed posterior right lower lobe near spine

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11/05/21 9:46 PM EDT

Percussed posterior right lower lobe on side

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11/05/21 9:47 PM EDT

Auscultated breath sounds in anterior right upper lobe

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11/05/21 9:48 PM EDT

Auscultated breath sounds in anterior left upper lobe

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11/05/21 9:49 PM EDT

Auscultated breath sounds in anterior right middle lobe

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11/05/21 9:49 PM EDT

Auscultated breath sounds in anterior left mid-chest (upper lobe)

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11/05/21 9:49 PM EDT

Auscultated breath sounds in anterior right lower lobe

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11/05/21 9:49 PM EDT

Auscultated breath sounds in anterior left lower lobe

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11/05/21 9:49 PM EDT

Auscultated breath sounds in posterior left upper lobe

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11/05/21 9:49 PM EDT

Auscultated breath sounds in posterior right upper lobe

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11/05/21 9:49 PM EDT

Auscultated breath sounds in posterior left mid-back (lower lobe)

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11/05/21 9:49 PM EDT

Auscultated breath sounds in posterior right mid-back (lower lobe)

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11/05/21 9:49 PM EDT

Auscultated breath sounds in posterior left lower lobe

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11/05/21 9:49 PM EDT

Auscultated breath sounds in posterior right lower lobe

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11/05/21 9:49 PM EDT

Auscultated breath sounds in posterior left lower lobe on side

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11/05/21 9:49 PM EDT

Auscultated breath sounds in posterior left lower lobe near spine

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11/05/21 9:50 PM EDT

Auscultated breath sounds in posterior right lower lobe near spine

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11/05/21 9:50 PM EDT

Auscultated breath sounds in posterior right lower lobe on side

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11/05/21 9:50 PM EDT

Auscultated voice sounds in anterior right upper lobe

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11/05/21 9:53 PM EDT

Ninety-nine.

Auscultated voice sounds in anterior left upper lobe

Exam Action
11/05/21 9:53 PM EDT

Auscultated voice sounds in anterior right middle lobe

Exam Action
11/05/21 9:53 PM EDT

Ninety-nine.

Auscultated voice sounds in anterior left mid-chest (upper lobe)

Exam Action
11/05/21 9:53 PM EDT

Ninety-nine.

Ninety-nine.

Auscultated voice sounds in anterior right lower lobe

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Ninety-nine.

Auscultated voice sounds in anterior left lower lobe

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Ninety-nine.

Auscultated voice sounds in posterior left upper lobe

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Auscultated voice sounds in posterior right upper lobe

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Auscultated voice sounds in posterior left mid-back (lower lobe)

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Ninety-nine.

Auscultated voice sounds in posterior right mid-back (lower lobe)

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Auscultated voice sounds in posterior left lower lobe

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Ninety-nine.

Auscultated voice sounds in posterior right lower lobe

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Auscultated voice sounds in posterior left lower lobe on side

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Ninety-nine.

Auscultated voice sounds in posterior left lower lobe near spine

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Auscultated voice sounds in posterior right lower lobe near spine

Exam Action
11/05/21 9:54 PM EDT

Ninety-nine.

Auscultated voice sounds in posterior right lower lobe on side

Exam Action
11/05/21 9:55 PM EDT

Ninety-nine.

Ninety-nine.

Check pulse oximetry using right hand

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11/05/21 9:57 PM EDT

Checked pulse oximetry using left hand

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11/05/21 9:57 PM EDT

Checked spirometer

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11/05/21 9:58 PM EDT

Checked patient’s inhaler

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11/05/21 9:58 PM EDT

Always make sure your inhaler is up to date.

Educate
11/05/21 11:38 PM EDT

Sure, I think I understand what you mean.

What medications do you take?

Question
11/05/21 11:39 PM EDT

My inhaler is the only prescription I always have, but I usually don’t need it everyday, except for recently. . .

When did you last use your inhaler?

Question
11/05/21 11:40 PM EDT

I had to use it early this morning.

How many puffs of your inhaler are you prescribed?

Question
11/05/21 11:43 PM EDT

I’m supposed to just do two puffs of the albuterol inhaler. It’s 90 micrograms a spray. [AUDIO COMING SOON]

Make sure to follow the Proventil instructions as prescribed.

Educate
11/05/21 11:45 PM EDT

Thanks for telling me.

Are you taking any other medications?

Question
11/05/21 11:46 PM EDT

No, all I really use is my inhaler.

Do you take any over-the-counter medications?

Question
11/05/21 11:52 PM EDT

I take Tylenol for a headache sometimes, or Advil for cramps, but not often.

How much Tylenol do you take? (Clarified to How much Tylenol do you take?.)

Question
11/05/21 11:55 PM EDT

I just take one or two of the 500 mg acetaminophen. I usually get the headaches at night from reading — squinting I guess — and so I take one or two and go to bed. [AUDIO COMING SOON] (Clarified to how much Tylenol I take.)

How much advil do you take for cramps?

Question
11/05/21 11:57 PM EDT

I take three 200 mg pills at a time. And I’d bet I take it up to three times a day. [AUDIO COMING SOON]

Any new allergies?

Question
11/05/21 11:57 PM EDT

No, not that I know of.

What started your recent asthma problems?

Question
11/05/21 11:58 PM EDT

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.

Does being around dust trigger your asthma?

Question
11/06/21 12:00 AM EDT

Yeah, being around a lot of dust, especially hanging out in a really dusty house, can make my asthma act up.

Am sorry to hear that

Empathize
11/06/21 12:03 AM EDT

I appreciate you saying that.

Does climbing stairs trigger asthma?

Question
11/06/21 12:05 AM EDT

Only when I’m in a rush and have to hurry up them.

Any seasonal allergies?

Question
11/06/21 12:10 AM EDT

A little while ago, I had some seasonal allergies, but it didn’t really bother my asthma, and it’s better now.

Does anything at work make your asthma worse?

Question
11/06/21 12:11 AM EDT

Well. . . sometimes when there’s dust at work it can make my asthma act up, but that doesn’t happen very often.

Do you see an asthma specialist?

Question
11/06/21 12:16 AM EDT

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.

It is important to follow up regularly with your asthma specialist.

Educate
11/06/21 12:18 AM EDT

OK, I understand.

How long have you had asthma?

Question
11/06/21 12:18 AM EDT

I’ve had asthma a long time. . . since I was really little.

How old were you when you were diagnosed with asthma?

Question
11/06/21 12:19 AM EDT

My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.

Have you ever been hospitalized for asthma?