Question

Module 08 Lab Assignment – Documentation a Respiratory Examination

You will perform a history of a respiratory problem that either your instructor has provided you or one that you have experienced and perform a respiratory assessment. You will document your subjective and objective findings, identify actual or potential risks, and submit this in a Word document to the drop box provided.

Answer 1

Documentation for asthma

History of present illness- History of wheezing, cough and breathing difficulty for past 1 months. (These symptoms are subjective)

Past History- had a similar episode 1 year back

family history of asthma in mother. No History of TB, DM and hypertension

The patient was apparently well 1 month back when he developed wheezing accompanied by cough and breathing difficulty. The cough was dry in nature. The breathing difficulty was enhanced during night

Physical examination

Respiratory system examination

Bilateral wheezing on auscultation. Crepts and ronchi are also heard.

Bilaterally symmetrical chest

Laboratory examination

Spirometry- This simple breathing test measures how much air you blow out and how fast. It’s often used to know the amount of airway obstruction you have. The spirometry showed obstructive lung disease with fev1 decreased.

Peak flow tests measure how well your lungs push out air. The peak flow volume was decreased.

These are objective tests

Risks for asthma

The most common risk factors for developing asthma is having a parent with asthma in which case the risk is increased 3 to 5 times, having a severe respiratory infection as a child, having an allergic condition, occupational exposure to certain chemicals, smoking, air pollution and obesity