Chief complaint: Dyspnea

Question 0

Related medical problems:

Answer 0

Asthma

COPD

Question 1

With HPI, focus on:

Answer 1

1) context (C)
2) associated symptoms (A)
3) palliation (P)
4) onset/duration (T)

Like what we need to CAPTure !

Question 2

Common medications used at home:

Answer 2

Albuterol
Provair
Nebulizer
Prednisone

These are all inhalers!

Question 3

Common associated symptoms:

Answer 3

Chest pain, cough, fever

If a pt. has chest pain, it is important to specify whether it’s related to SOB or not

Question 4

PE:

What are the contradictory abnormal exam findings related to each normal exam?

1) CTAB (clear to auscultation BL ((clear lung sounds)))
2) No respiratory distress (aka patient breathing normally)
3) Good Air Exchange

Answer 4

1)
A) faint (inspiratory/expiratory) wheezes
B) diffuse wheezes heard throughout bases BL
C) Rhonchi “
D) Crackles “
E) Rales “

2) Tachypneic (aka when a pt is breathing harder or RR is 20 and above)
3) diminished breath sounds

Question 5

Dr. Barriac likes to state whether ___ ____ were used

Answer 5

Accessory muscles

Question 6

Be sure to:

Answer 6

Record pulse ox accurately. Remember that 94% below is abnormal on RA

Question 7

Chest X-ray : doctors will usually order a chest x ray to visualize the lungs

Common findings:

Answer 7

1) no infiltrate (substances that sneak in or # of infiltrating cells
2) No Pneumothorax (PTX)
3) No effusions (a buildup of fluid between the tissues that line the lungs and chest)

Question 8

MDM: common treatments used for dyspnea:

Answer 8

1) Neb treatment
2) SoluMedrol
3) Albuterol
4) Non-rebreather mask
5) Prednisone

Question 9

Common ddx:

Answer 9

1) asthma exacerbation
2) COPD
3) dyspnea
4) hypoxia