Tina Comprehensive Assessment Shadow Health Subjective e Data Collection Latest 2021/2022

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Subjective Data Collection: 50 of 50 (100.0%) Curr ent Heal th Stat us Psyc hoso cial Hist ory Soci al Dete rmin ants of Heal th Ment al Heal th Revi ew of Syst ems Indica... tes an item that you found. Indicates an item that is available to be found. Categ ory Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Confirmed reason for visit Reports needing a pre-employment physical Reports no current acute health problems Asked about last visit to a healthcare provider Last visit to a healthcare provider was 4 months ago Reason for last visit was annual gynecological exam Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler Asked about current prescription medications Reports taking diabetes medication Reports using a daily inhaler Reports taking prescription birth control pills Followed up about diabetes medication Medication is metformin Started taking metformin 5 months ago Reports that eating probiotic yogurt helps with side effects and they have abated over time Followed up on metformin frequency and dose Reports taking metformin twice daily Metformin dose is 850 mg Asked about asthma medication Reports using Flovent inhaler twice daily Has a Proventil rescue inhaler Last use of Proventil inhaler was three months ago Has used Proventil inhaler twice in the last year Followed up about birth control prescription Started taking birth control 4 months ago Reason for birth control was to manage PCOS symptoms Birth control type is Yaz (drospirenone and ethinyl estradiol) Takes birth control pill daily Takes birth control pill at the same time every day Reports no skipped days Asked about current non-prescription medications Reports rare Advil use for cramps Reports no OTC herbal products Reports no OTC vitamins Reports no OTC supplements Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. This study source was downloaded by 100000831988016 from CourseHero.com on 03-14-2022 05:52:09 GMT -05:00 https://www.coursehero.com/file/54061240/Tina-Comprehensive-Assessment-Shadow-Health-Subjective-Questionspdf/ 1/29/2020 Blackboard Learn https://class.waldenu.edu/webapps/blackboard/content/contentWrapper.jsp?course_id=_16633159_1&displayName=Shadow+Health+NURS6512&hr… 2/5 Asked about allergies Confirms allergies Reports no new allergies Followed up on seasonal allergies Reports no recent seasonal allergy symptoms Reports no current medication for allergies Asked about diabetes Reports managing diabetes with diet and exercise in addition to medication Asked about blood glucose monitoring Reports checking blood sugar once a day Checks sugar in the morning Blood sugar number is usually around 90 Reports having adequate supplies Asked about asthma symptoms Reports no current asthma symptoms Reports no recent asthma exacerbations Reports last asthma exacerbation was three months ago Asked about headache symptoms Reports no recent headache Asked about vision Reports optometrist visit Optometrist visit 3 months ago Reports prescription eyeglasses Reports that glasses improve overall vision Reports reduction in blurry vision Asked about palpitations Reports no current palpitations Reports no recent palpitations Asked about hypertension treatment Reports that blood pressure responded to diet and exercise changes Asked about GERD Reports no recent GERD symptoms Reports no current GERD symptoms Reports no current medication for GERD Asked about back pain Reports no current back pain Reports no recent back pain Asked date of last menstrual period Last menstrual period was 2 weeks ago Asked about menstrual patterns Reports a period every 4 weeks Reports that period lasts 5 days Reports some cramping Reports a medium flow Asked about weight changes Reports recent weight loss Reports weight loss of about 10 pounds Reports that weight loss was result of change in diet and increased exercise Asked about diet Typical breakfast is fruit smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt Typical lunch is dinner leftovers or tuna or chicken sandwich on wheat bread Typical dinner is vegetables with a protein and brown rice or quinoa Typical snack is carrot sticks or an apple Asked about caffeine intake Reports limiting caffeine since heart and sleep This study source was downloaded by 100000831988016 from CourseHero.com on 03-14-2022 05:52:09 GMT -05:00 problems https://www.coursehero.com/file/54061240/Tina-Comprehensive-Assessment-Shadow-Health-Subjective-Questionspdf/ 1/29/2020 Blackboard Learn https://class.waldenu.edu/webapps/blackboard/content/contentWrapper.jsp?course_id=_16633159_1&displayName=Shadow+Health+NURS6512&hr… 3/5 Reports no coffee drinking Reports only caffeine is diet Coke Reports drinking 2 diet Cokes per day Asked about alcohol intake Drinks 2-3 nights per month Has 2 or 3 drinks when out with friends Orders single drinks Usually orders rum and diet Coke Asked about exercise Reports mild to moderate exercise Reports walking four or five times a week Reports that a typical walk is thirty or forty minutes Reports weekly swimming at YMCA Reports no asthma exacerbation during exercise Asked about relationship status and current sexual activity Reports no new sexual partners Reports new month-old relationship Plans to use condoms if sexually active in the future Asked about education Reports graduated with accounting degree Asked about work Reports being hired at Smith, Stevens, Stewart, Silver & Company Reports job title is Accounting Clerk Reports will start work in 2 weeks Asked about living situation Reports currently living at home with mom and sister Reports moving into her own apartment near work in 1 month Asked about support system Reports strong friendships Reports strong familial relationships Reports church remains a strong support system Asked about stress Reports feeling less stress after graduation and passing CPA exam Reports improved ability to cope with stress Asked about indicators of depression Reports no depression Reports feeling positive about upcoming life changes Asked about anxiety Reports anxiety improved with relief of stressors and passing of time Reports coping well with upcoming life changes Asked about sleep Reports no current difficulties falling asleep Reports sleeping 8 or 9 hours a night Asked general indicators of health Reports no recent or frequent illness Reports no fatigue Reports no fever Reports no chills Reports no night sweats Asked about review of systems for head Reports no current or recent head problems Reports no head injury [Show More]

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