Shadow Health Tine Jones Health History Subjective Data PDF

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Health History Results | Turned In Advanced Health Assessment - Summer 2021, NUR 703 Return to Assignment (/assignments/486483/)

Your Results

Overview

Lab Pass (/assignment_attempts/9873101/lab_pass.pdf)

Subjective Data Collection: 95 of 100 (95.0%)

Transcript Subjective Data Collection

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Objective Data Collection Education & Empathy Documentation Information Processing Program Competency Progress

Category

Scored Items

Health History Tips and Tricks

Patient Data Not Scored

Self-Reflection

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Student Survey

A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.

Chief Complaint

Established chief complaint

Reports pain Reports foot wound

History of Present Illness

Asked to rate current pain level on a scale

Asked for details about the pain

Reports current pain is 7/10

Reports pain is throbbing Reports pain is sharp when she attempts to stand Reports pain has increased in the past 2 days Reports feeling pain radiating into ankle Reports pain prevents bearing weight on foot

Asked location of wound

Reports right foot is injured Reports wound is on the planta

Support

foot

Asked details of the injury

Reports she scraped foot on a cement step Reports initial injury occurred 1 week ago Reports mild ankle injury Reports being barefoot at the time of injury

Asked about the assessment of the injury at the ER

Reports going to the ER after sustaining the injury Reports going to the ER because she suspected an ankle sprain Reports receiving an X-ray at the ER Reports X-ray showed no broken bones Reports receiving a prescription for pain pills

Asked about drainage from the foot wound

Reports that the wound bled a little after sustaining the injury Reports seeing pus draining from wound Reports noticing pus 2 days ago

Followed up on drainage

Reports pus as white or yellow Denies odor from the wound

Asked about home treatment of foot wound

Reports wound care regimen of bandaging Reports cleaning wound twice a day Reports cleaning wound with hydrogen peroxide Reports applying bacitracin, neomycin and polymyxin B (Neosporin)

Asked about other foot wound symptoms

Reports swelling around foot wound Reports swelling worsened in the past 2 days Reports redness around the wound Reports that the wound feels warm

Explored impact of patient's foot injury on activities of daily living

Reports pain affects ability to walk Reports pain affects ability to stand at work for long periods of time Reports pain prevented her from being able to walk to class

Past Medical History

Asked about preexisting medical conditions

Reports diabetes Reports asthma

Followed up on diabetes diagnosis

Reports specific age of diagnosis was 24 Reports that her diabetes is Type 2

Asked about diabetes management through lifestyle changes

Asked about current diabetes medication use

Reports staying away from sweets Reports drinking diet soda instead of regular

Reports that she does not currently take medication for diabetes

Asked about past diabetes medication use

Reports that she used to take diabetes medication Reports previous medication was prescription metformin Reports last use of medication was 3 years ago

Asked about blood glucose monitoring

Reports infrequent blood glucose monitoring Reports last glucose check was a week ago at the ER Reports confusion about what the numbers mean

Asked about thirst

Reports increased thirst Reports increased water intake

Asked about frequency of urination

Reports more frequent urination Reports urinating every hour or two during the day Reports urinating 2 to 3 times during the night

Asked about change in appetite

Reports increased appetite Reports change in appetite began a month ago

Asked about weight change

Reports recent loss of 10 lbs Reports weight loss occurred over the past month

Followed up on reason for weight change

Asked about history of asthma exacerbations

Reports weight loss was unintentional

Reports last asthma attack was in high school Reports last exacerbation was three days ago

Asked about asthma symptoms

Reports chest tightness during exacerbation Reports difficulty breathing during exacerbation Reports wheezing during exacerbation

Asked about prior hospitalizations

Reports past hospitalizations Reports last hospitalization was for asthma Reports last hospitalization was age 16 Reports about 5 total hospitalizations for asthma as a child and teen Reports past nebulizer use

Asked about asthma diagnosis

Asked about asthma management

Reports specific age of diagnosis is 2.5 years old

Reports using an inhaler Reports inhaler is albuterol (Proventil) Reports last use of inhaler was 3 days ago Reports using inhaler no more than 2 times per week

Asked about number of puffs when using

Reports recommended dose is 1-3 puffs as

asthma inhaler

needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms

Asked about asthma triggers

Reports asthma triggered by cats Reports asthma triggered by dust Reports asthma triggered by running up stairs Denies seasonal triggers

Asked about general allergies

Reports allergy to cats

Followed up on cat allergy symptoms

Reports sneezing, itchy eyes, and wheezing

Asked about latex allergy

Denies latex allergy

Asked about medication allergies

Reports penicillin allergy

Asked about penicillin reaction

Asked about food allergies

Asked if the patient has allergies to dust, mold, or pollen

Reports that penicillin resulted in hives in childhood

Denies food allergies

Reports reaction to dust Reports dust causes sneezing, itchy eyes, and wheezing Denies seasonal allergies

Asked about general immunizations received

Asked about childhood immunizations

Asked if the patient has received a flu vaccine

Asked if the patient received a tetanus immunization

Asked about hypertension

Reports being up to date on shots

Reports receiving all necessary childhood immunizations

Denies receiving annual flu vaccine

Reports last tetanus vaccination was in the past year

Denies past diagnosis of hypertension Reports that last BP reading was 140 over 80 or 90 Denies checking BP regularly

Home Medications

Asked about use of pain medication

Reports taking prescription pain medication Reports medication is tramadol

Followed up on pain medication frequency

Reports taking pain medication for 2 days Reports taking tramadol 3 times a day

Reports last dose was this morning

Followed up on pain medication dose

Reports dosage is 50 mg Reports taking 2 pills each time

Followed up on efficacy of pain medication

Reports that pain pills provide partial relief Reports pain returns in full every few hours

Asked about other prescription medications

Asked about use of OTC medication

Reports a prescription inhaler

Reports occasionally taking Advil (ibuprofen) for cramps Reports occasionally taking Tylenol (acetaminophen) for headaches Denies vitamin supplements Denies herbal supplements

Social Determinants of Health

Asked about access to healthcare

Denies finances are a barrier to healthcare Denies transportation is a barrier to healthcare

Followed up on diabetes noncompliance

Reports that she got sick of the demands of medication compliance Reports disliking metformin side effects Reports disliking checking blood glucose Denies that cost of metformin was reason for discontinuing medication Denies that glucometer-related costs are reason for not checking blood glucose

Asked about patient's level of education

Reports currently working toward undergraduate degree Reports her major is accounting

Asked about patient's living situation

Reports living with mother and sister Reports family members will be able to help with activities

Social History

Asked about stressors

Asked about food intake

Reports she is currently under high stress

Reports last meal was dinner time the previous night Reports last meal consisted of baked chicken and mashed potatoes Reports breakfast is usually a muffin or pumpkin bread Reports lunch is usually a sandwich Reports dinner is usually a home-cooked meat dish and side of vegetables Reports snacks are pretzels or French fries

Asked about salt intake

Asked about caffeine intake

Denies adding salt to food

Denies drinking coffee Reports habitual diet soda drinking Reports drinking up to 4 diet sodas per day

Asked about illicit drug use

Followed up on drug use

Reports history of recreational marijuana smoking

Reports last use was at age 20 or 21 Reports she stopped because of health reasons and waning interest

Asked about alcohol intake

Reports last alcoholic drink was 3 weeks ago Reports no more than 2 or 3 alcoholic drinks in one sitting Reports no more than 1 or 2 nights a week drinking alcohol

Asked about tobacco use

Denies smoking tobacco Denies vaping

Asked about secondhand smoke

Denies exposure to secondhand smoke

Family Medical History

Asked about mother's health

Reports mother diagnosed with high blood pressure Reports mother diagnosed with high cholesterol

Asked about father's health

Reports father was diagnosed with Type 2 diabetes Reports father was diagnosed with high blood pressure Reports father was diagnosed with high cholesterol

Followed up on father's death

Reports father died at age 58 Reports cause of death was a car accident

Followed up on coping with father's death

Reports past grief Reports feeling at peace now

Asked about paternal grandfather's health

Reports paternal grandfather diagnosed with Type 2 diabetes Reports paternal grandfather diagnosed with high blood pressure Reports paternal grandfather diagnosed with high cholesterol Reports paternal grandfather died of colon cancer

Asked about paternal grandmother's health

Reports paternal grandmother diagnosed with high blood pressure

Reports paternal grandmother diagnosed with high cholesterol

Asked about maternal grandfather's health

Reports maternal grandfather diagnosed with high blood pressure Reports maternal grandfather diagnosed with high cholesterol

Asked about maternal grandmother's health

Reports maternal grandmother diagnosed with high blood pressure Reports maternal grandmother diagnosed with high cholesterol

Asked about brother's health

Denies brother having diagnosed health problems

Asked about sister's health

Reports sister diagnosed with asthma

Asked about family history of obesity

Reports that family members are overweight

Asked about family history of thyroid issues

Denies family history of thyroid issues

Asked about family history of substance abuse

Reports 1 uncle has alcoholism

Asked about family history of headaches

Denies family history of headaches

Review of Systems

Asked about constitutional health

Reports occasional tiredness or fatigue Reports typical sleep pattern Reports fever Reports chills Denies night sweats

Asked about review of systems for mental health

Asked about review of systems for head

Denies depression Denies suicidal ideation or attempts

Reports occasional headaches Denies current headache Denies head injury

Asked about review of systems for ears

Denies change in hearing Denies ringing or tinnitus Denies ear pain Denies ear discharge

Asked about review of systems for eyes and vision

Reports periods of blurry vision Denies corrective lenses Denies double vision Reports infrequent itchy eyes Denies eye redness Denies discharge, crusting or wateriness

Denies eye pain Denies dry eyes Reports last eye exam was in childhood

Asked about review of systems for nose

Reports infrequent nose problems Reports infrequent runny nose Denies frequent sinus problems Denies change in sense of smell Denies nosebleeds

Asked about review of systems for mouth and jaw

Denies dental problems Reports last dental visit was several years ago Denies change in sense of taste Denies dry mouth Denies mouth pain Denies mouth sores Denies gum problems Denies tongue problems Denies jaw problems

Asked about review of systems for neck, throat, and glands

Denies difficulty swallowing Denies sore throat Denies lymph node problems Denies frequent sore throat Denies swollen glands Denies voice changes Denies general neck problems

Asked about breast health

Reports doing occasional breast exams Denies general breast problems Denies breast lumps Denies breast pain Denies nipple changes Denies nipple discharge Denies ever having a mammogram

Asked about review of systems for respiratory

Denies current breathing problems Denies current wheezing Denies current chest tightness Denies pain while breathing Denies frequent coughing

Asked about review of systems for cardiovascular

Denies chest pain or discomfort Denies palpitations Denies irregular heartbeat Denies easy bruising Denies edema Denies circulation problems Denies vascular diseases

Asked review of systems for gastrointestinal

Denies nausea Denies vomiting Denies stomach pain Denies change in bowel movements Denies heartburn, GERD, or indigestion Denies constipation Denies diarrhea or loose stool

Denies flatulence or bloating Denies bloody or tarry stool

Asked review of systems for genitourinary

Denies painful or difficult urination Reports waking up to urinate during the night Reports large amount of urine Denies blood in urine Denies flank pain Denies incontinence Denies history of urinary tract or bladder infection Reports normal vaginal discharge

Asked review of systems for reproductive

Reports last menstrual period was 3 weeks ago Reports that periods are irregular Reports menstruating every 6 weeks to 2 months Reports typical period lasts 9 days

Followed up on menstrual flow

Reports heavy periods Reports heavy flow for 4 to 5 days Reports changing tampon every 2 to 3 hours Reports using super absorbency tampons Denies anemia

Followed up on menstrual symptoms

Reports heavy cramping Reports cramps for the first 2 days of period

Asked about treatment of menstrual symptoms

Reports using a heating pad at home to treat cramps Reports taking ibuprofen for first 3 days of period Reports ibuprofen effectively reduces pain from cramps

Asked about sexual activity

Denies recent sexual activity Reports past sexual activity Reports that she prefers to sleep with men Reports first sexual activity was at age 18 Reports last sexual activity was 2 years ago Reports total number of partners is 3

Asked about contraception

Reports no current use of any oral or hormonal birth control Reports past use of oral contraception Reports last taking oral contraception a couple of years ago Reports she didn't see the point in taking contraception while single

Asked about condom use

Reports past condom use Reports past sexual encounters without condoms Reports oral contraceptive use while sexually active

Asked about STI testing

Reports last STI testing was 4 years ago

Denies STI symptoms Reports uncertainty about past partners and STI testing

Asked about history of pap smears

Reports last pap smear was 4 years ago Reports no abnormal pap smears

Asked about history of pregnancy

Denies current pregnancy Denies past pregnancies

Asked review of systems for musculoskeletal

Denies muscle pain Denies joint pain Denies muscle weakness Denies joint swelling Denies back pain Denies history of fractures or breaks

Asked review of systems for neurological

Denies recent loss of consciousness or fainting Denies dizziness or vertigo Denies lightheadedness Denies vision disturbances Denies tingling Denies loss of coordination Denies loss of sensation Denies history of seizures Denies problems with balance or disequilibrium Denies memory loss

Asked review of systems for skin, hair, and nails

Denies skin rashes Reports rarely using sunscreen Reports acne Reports excessive facial or body hair Reports changes to neck skin Reports moles Reports no body sores (aside from foot wound) Denies dandruff Denies nail abnormalities Reports occasional dry skin

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