Module 1 - Health History
Develop strong communication skills
ï Interview the patient to elicit subjective health information about her health and health history
ï Ask relevant follow-up questions to evaluate patient
...
Module 1 - Health History
Develop strong communication skills
ï Interview the patient to elicit subjective health information about her health and health history
ï Ask relevant follow-up questions to evaluate patient condition
ï Demonstrate empathy for patient perspectives, feelings, and sociocultural background
ï Identify opportunities to educate the patient
Document accurately and appropriately
ï Document subjective data using professional terminology
ï Organize appropriate documentation in the EHR
Demonstrate clinical reasoning skills
ï Organize all components of an interview
ï Assess risk for disease, infection, injury, and complications
After completing the assessment, you will refl ect on personal strengths, limitations, beliefs, prejudices, and values.
Learning Objectives
High Priority
ï Acute pain of the foot
ï Local infection of skin and
subcutaneous tissue of the foot
ï Uncontrolled type 2 diabetes
mellitus
Low Priority:
ï Acanthosis nigricans
ï Asthma
ï Dysmenorrhea
ï Hirsutism
ï Hypertension
ï Menorrhagia
ï Obesity
ï Oligomenorrhea
ï Polycystic ovarian syndrome
Underlying ICD- 10 Diagnoses
ï Information Processing Activity
ï Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective
data categories include interview questions and patient data. Objective data categories include examination
and patient data.
Module Features
I got this scrape on my foot a while ago, and I thought
it would heal up on its own, but now it’s looking
“
pretty nasty. And the pain is killing me!
Downloaded by Denis Munene (
[email protected])
lOMoARcPSD|16310140
ADVANCED HEALTH ASSESSMENT
Health History - TINA JONES™
© Shadow Health® 062015 || ShadowHealth.com
**For instructor use only**
Page 1 of 3
Instructor Use Only
One week after sustaining the cut, Tina Jones develops an infection in the cut on the bottom of her foot; she seeks
treatment when the infection starts to swell and produce pus.
Day 1 (Onset): Tina was at home, going down the back steps, and she tripped. She turned her ankle and scraped the
bottom of her foot. The wound bled, but she stopped the bleeding quickly and cleaned the wound. She worried that
she had sprained her ankle, and her mom drove her to the ER. (“a week ago”)
The ER did an x ray (no broken bones), gave her a prescription for Tramadol, and sent her home. In the following days,
her ankle seemed fi ne not as serious as she thought.
Day 2 - 4: She cleaned the wound dutifully, twice a day, with soap and water or hydrogen peroxide, let it dry, put
Neosporin on it, and bandaged it. The wound wasn’t getting worse, but it wasn’t healing, either. She expresses that
she “took really good care of it.” Tina was able to go to work and attend school.
Day 4: Tina went to her cousin’s house, where she encountered cats and experienced wheezing. She tried two puff s on
her albuterol inhaler, and she had to do a third puff . (“three days ago”)
Day 5 - 6: Tina noticed pus in the wound, and swelling, redness and a warm feeling in her foot. Her pain increased to
the point she was unable to walk. She began to take the Tramadol to try to manage the pain, but it didn’t resolve the
pain completely. She missed class and work. (“two days ago”)
On the night of Day 6: Tina started to run a fever. They took her temperature at home, and it was 102. (“last night”)
Morning of Day 7: Tina fi nally recognizes that her foot infection is not going to get better, and her mom takes her to
the nurse practitioner to get the foot looked at.
History of Present Illness
Medications
1. Acetaminophen 500- 1000 mg PO prn (headaches)
2. Ibuprofen 600 mg PO TID prn (menstrual cramps)
3. Tramadol 50 mg PO BID prn (foot pain)
4. Albuterol 90 mcg/spray MDI 2 puff s Q4H prn (last
use: “a few months ago”)
Vitals
ï Weight (kg) - 88
ï BMI - 30.5
ï Heart Rate (HR) - 82
ï Respiratory Rate (RR) - 16
ï Pulse Oximetry - 99%
ï Blood Pressure (BP) - 139/87
ï Blood Glucose - 117
ï Temperature (F) - 98.9
ï Penicillin: rash
ï Denies food and latex allergies
ï Allergic to cats and dust. When she is exposed to
allergens she states that she has runny nose, itchy and
swollen eyes, and increased asthma symptoms.
Allergies
Printable “Answer Key” available within the Shadow Health DCE.
Subjective and Objective Model Documentation
ï Symptoms - Foot pain and discharge
ï Diagnosis - Infected foot wound
Chief Complaint
Downloaded by Denis Munene (
[email protected])
lOMoARcPSD|16310140
ADVANCED HEALTH ASSESSMENT
Health History - TINA JONE
