Health History documentation Shadow Health PDF

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Shadow health cardiovascular assignment documentation with description of model documentation...

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10/4/21, 3:29 PM

Health History | Completed | Shadow Health

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Health History Results | Turned In Advanced Health Assessment for the APN - Fall 2021, 625 Return to Assignment (/assignments/519371/)

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Overview

Lab Pass (/assignment_attempts/10656960/lab_pass.

Documentation / Electronic Health Record

Transcript Subjective Data Collection

Document: Provider Notes

Objective Data Collection

Document: Provider Notes Education & Empathy Documentation

Student Documentation

Information Processing

Identifying Data & Reliability

Program Competency Progress

Ms. Jones is a pleasant 28-year-old obese African American woman who presents to the clinic today to establish primary care and for a recent right foot injury. She is the primary source of the history and offers information freely. Speech is clear and understandable. She is alert, oriented, and maintains eye contact throughout the interview.

Health History Tips and Tricks Self-Reflection

Model Documentation

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a rec right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Sp is clear and coherent. She maintains eye contact throughou interview.

Student Survey

General Survey Ms. Jones is alert and oriented. She is sitting upright on the exam table. She is in no apparent distress. She is well nourished, dressed appropriately and appears to have good hygiene.

Chief Complaint Scrape on right foot with intense pain and symptoms of infection

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Ms. Jones is alert and oriented, seated upright on the exam table, and is in no apparent distress. She is well-nourished, developed, and dressed appropriately with good hygiene.

“I got this scrape on my foot a while ago, and I thought it wo heal up on its own, but now it's looking pretty nasty. And th is killing me!”

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Health History | Completed | Shadow Health

Student Documentation

History Of Present Illness Ms. Jones scraped her foot a week ago outside barefoot, she cleansed the wound, used neosporin and banaged it. She went to the ER than night and recieved tramadol prescription which she has been using for pain control. The pain worsened two days ago and she began to notice white pus discharge, reddness, swelling, and warmth. She states that she is unable to bear weight on the injured foot. She has been cleaning the wound and changing the bandage twice a day.

Model Documentation

Ms. Jones reports that a week ago she tripped while walking concrete stairs outside, twisting her right ankle and scraping ball of her foot. She sought care in a local emergency depar where she had x-rays that were negative; she was treated w tramadol for pain. She has been cleansing the site twice a d She has been applying antibiotic ointment and a bandage. S reports that ankle swelling and pain have resolved but that t bottom of the foot is increasingly painful. The pain is describ “throbbing” and “sharp” with weight bearing. She states her “ached” but is resolved. Pain is rated 7 out of 10 after a rece dose of tramadol. Pain is rated 9 with weight bearing. She re that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the woun shoes feel tight. She has been wearing slip-ons. She reports of 102 last night. She denies recent illness. Reports a 10-po unintentional weight loss over the month and increased app Denies change in diet or level of activity.

Medications She states that she is taking 50 mg tramadol for pain control prescribed by the ER. She was taking Advil for pain control. She occassionally uses an albuterol 90 mg inhaler, 2-3 puffs for asthma, 2-3 times per week. She used to take metformin for diabetes but no longer takes it.

Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprof mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO TID (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago)

Allergies Penicillin-hives/rash Cats-Sneezing, itchy, watery eyes Dust- Asthma symptoms No food allergies

Medical History Asthma, diagnosed at 2 years old, had frequent asthma attacks as a child requiring hospitalization, last hospitalized for asthma at 16 Type 2 diabetes diagnosed at age 24

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Penicillin: rash • Denies food and latex allergies • Allergic to and dust. When she is exposed to allergens she states that has runny nose, itchy and swollen eyes, and increased asth symptoms.

Asthma diagnosed at age 2 1/2. She uses her albuterol inha when she is around cats and dust. She uses her inhaler 2 to times per week. She was exposed to cats three days ago an to use her inhaler once with positive relief of symptoms. She last hospitalized for asthma “in high school”. Never intubate Type 2 diabetes, diagnosed at age 24. She previously took metformin, but she stopped three years ago, stating that the made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn't monitor her blood sugar. L blood glucose was elevated last week in the emergency roo surgeries. OB/GYN: Menarche, age 11. First sexual encount age 18, sex with men, identifies as heterosexual. Never preg Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 No current partner. Used oral contraceptives in the past. Wh sexually active, reports she did not use condoms. Never tes HIV/AIDS. No history of STIs or STI symptoms. Last tested f STIs four years ago. Hematologic: Denies bleeding, bruising blood transfusions and history of blood clots. Skin: Reports since puberty and bumps on the back of her arms when her is dry. Complains of darkened skin on her neck and increase and body hair. She reports a few moles but no other hair or changes.

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Health History | Completed | Shadow Health

Student Documentation

Health Maintenance States that she eats fruit 2x/week & vegetables every night with dinner States that she does not exercise Up to date on all immunizations

Family History Paternal grandfather-colon cancer, high blood pressure, diabetes Parental grandmother- hypertension, high cholesterol Maternal grandfather- died of heart attack at 80, hypertension, high cholesterol Maternal grandmother- died of stroke at 73, high cholesterol, hypertension Father- died in car accident at 58, type 2 diabetes, high cholesterol, hypertesion Mother- high cholesterol, hypertension Brother- obesity Sister- Asthma no history of substance abuse in the family

Social History Alcohol use 1-2 days per week, few drinks at a time with friends Last used marijuana when she was 20-21 No other illicit drug use No cigarrette use or second-hand smoke exposure No history of substance abuse No regular exercise Reports eating fruits 2x/week and vegetables every dinner Access to health insurance from work, no vision insurance, last dental exam as child Works as supervisor at Copy & Ship and in school for bachelors in accounting, has had to miss school and work due to foot injury

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Model Documentation

Last Pap smear 4 years ago. Last eye exam in childhood. La dental exam “a few years ago.” PPD (negative) ~2 years ago exercise. 24-hour Diet Recall: States that she skipped break yesterday, and would typically have a baked good for break sandwich for lunch, and a meatloaf or chicken for dinner. He snacks consist of pretzels or French fries. Immunizations: Te booster was received within the past year, influenza is not c and human papillomavirus has not been received. She repo that she believes she is up to date on childhood vaccines an received the meningococcal vaccine in college. Safety: Has smoke detectors in the home, wears seatbelt in car, and doe ride a bike. Does not use sunscreen. Guns, having belonged her dad, are in the home, locked in parent’s room.

• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history o hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, histo type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, k disease, sickle cell anemia, thyroid problems

Never married, no children. Lived independently since age 2 currently lives with mother and sister in a single family home support family after death of father one year ago. Employed hours per week as a supervisor at Mid-American Copy and She enjoys her work and was recently promoted to shift supervisor. She is a part-time student, in her last semester t a bachelor’s degree in accounting. She hopes to advance to accounting position within her company. She has a car, cell phone, and computer. She receives basic health insurance f work, but is deterred from healthcare due to out-of-pocket c She enjoys spending time with friends, attending Bible stud volunteering in her church, and dancing. Tina is active in he church and describes a strong family and social support sys She reports stressors relating to the death of her father and balancing work and school demands, and finances. She sta that family and church help her cope with stress. No tobacc Occasional cannabis use from age 15 to age 21. Reports no of cocaine, methamphetamines, and heroin. Uses alcohol w “out with friends, 2-3 times per month,” reports drinking no than 3 drinks per episode. She drinks 4 caffeinated drinks p (diet soda). No foreign travel. No pets. Not currently in an int relationship, ended a three-year serious monogamous relatio two years ago. She plans on getting married and having chi someday.

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10/4/21, 3:29 PM

Health History | Completed | Shadow Health

Student Documentation

Model Documentation

Review of Systems General: recent unintentional weight loss, fever last night of 102, chills last night, no fatigue reported Mental health: denies mental health problems HEENT: occasional headaches after studying for 2+ hours, takes advil and sleeps to improve headaches, denies ear problems, reports blurry vision after reading for long periods of time, last vision exam as child, does not wear glasses/contacts, denies nose problems, denies mouth or throat problems Breast: breast tenderness before period, last breast exam few years ago Respiratory: history of asthma and inhaler use, asthma symptoms triggered by cats and dust allergy Cardiovascular: denies heart problems GI: denies nausea, vomitting, diarrhea or any GI problems GU: increased urination frequency, every couple hours when awake, no pain or discoloration associated with urination, increased thirst Reproductive: Not currently sexually active, sexually active with males, history of 3 partners, no history of STI's, last pap smear 4 years ago, never been pregnant, previously used birth control pill, uses condoms Musculoskeletal: denies musculoskeletal problems Neurological: denies any neurological problems Skin/Hair/Nails: denies any skin, hair, nail problems

(No Model Documentation Provided)

Objective Ms. Jones is a pleasant 28-year-old obese African American woman who presented to the clinic today with a foot wound. She is alert and oriented. She maintains eye contact throughout the interview and exam. Foot: The wound is 2 cm x 1.5 cm and 2.5 mm deep. The wound is located on the right foot on the ball of the foot. It is erythematous, inflammed, swollen and warm to the touch. There is white pus discharge from the wound.

Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound ed right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema, no tracking.

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