Unit 2 DB

Within the Discussion Board area, write 500700 words that respond to the following questions with your thoughts, ideas, and comments. This will be the foundation for future discussions by your classmates. Be substantive and clear, and use examples to reinforce your ideas.In this weeks Discussion Board assignment, your Faculty will assign you one of the following exams to complete:

• Respiratory: Tina Jones

using this info retrieve from Shadow Health interview and physical assessment of:

Tina Jones 28 year old African American Female

Chief complaint: patient presents with chief complaint of recent asthma episodes that is not fully resolved.

Subjective Findings

SOB 2 days ago while at cousins house with cats

symptoms: SOB, coughing (small, dry cough – no phlegm), and chest tightness

per pt, asthma flare worse “at night when lying down, or when moving around too much. Typically, it’s stuff like cats, dust that get to me”

allergic to cats and Penicillin

only other medical condition is diabetes – not on any medications – diagnosed at 24 years old – doesn’t check glucose levels at home – does not currently have primary care provider (PCP)

pt had asthma since she was 2.5 years old

lives with mom in the suburbs

denies smoking – no one smokes at home

drinks alcohol 1-2 weeks with friends who sometimes smoke cigarettes in her presence

only medication is albuterol – pt doesn’t know dose but reports taking it every 4 hours (10 times in the last few days)

Mom has high cholesterol and HTN

brother: obesity

sister: asthma

Vital signs/pertinent info/objective findings

wt: 89kg

BMI: 30.8

Glucose: 224

RR: 20

HR: 89

BP: 140/81

O2: 97%

Temp: 36.9 c

hyperpigmentation around the neck

facial acne

Assessment findings

inspect – chest and back: symmetrical no visible abnormal findings

chest expansion equal bilaterally

chest wall percussed: all areas resonant; no areas of dullness

Tactile fremitus – equally bilaterally, expected fremitus noted

breath sounds clear in all areas (lobes), no adventitious sounds

bronchophony – negative

pulse ox – Left index finger : 97% HR 89

Right index finger: 97% HR 89

spirometer volumes

FVC (forced vital capacity) – 3.91 L

FEV (forced expiratory volume) – 3.15 L

Treatment plan

Reinforce inhaler technique and spacer use

Discuss trigger avoidance: cats, pollen, dust, smoking

Establish care/Follow up with PCP for asthma and diabetes management

Encourage slow controlled breathing

signs and symptoms review that require immediate attention: SOB, wheezing, coughing, can’t speak in clear sentences, chest tightness/pain,

Upon completion of the Shadow Health case, you will be asked to synthesize the clinical findings from your completed assessment and provide a list of differential diagnosis, final diagnosis, and pathophysiology of the selected diagnosis by utilizing the enclosed . Your Faculty member will review the recording of your Shadow Health assessment of your assigned patient prior to Discussion Board grading.Your content should be 500700 words, with a minimum of 2 scholarly references no more than 5 years old. Feel free to use text book Physical Examination and Health Assessment – Jarvis 9th edition (ISBN: 9780323811705). Please review grading rubric to ensure all requirements are met.