Coastal Carolina University - NURSING 111Shadow Health Tina Jones Health History. Health Assessment Laboratory - Fall 2019, NUR 305L: Fall 2019.

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Health History Results | Turned In Return to Assignment Your Results L La ab b P Pa as ss s Indicates an item that you found. Indicates an item that is available to be found. Category Scored I... tems 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. Chief Complaint Established chief complaint pain foot wound History of Presenting Illness Asked to rate current pain level on a scale current pain is 7/10 Asked for details about the pain pain is throbbing pain is sharp when she attempts to stand pain has increased in the past 2 days feeling pain radiating into ankle Overview Subjective Data Collection: 52 of 88 (59.1%) Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Self-Reflection Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. pain prevents bearing weight on foot Asked location of wound right foot is injured wound is on the plantar surface of her foot Asked details of the injury she scraped foot on bottom rung of a step stool injury occurred 1 week ago other injuries besides foot wound being barefoot at the time of injury seeing a healthcare provider for the injury until now Asked about drainage from the foot wound that the wound bled a little after sustaining the injury seeing pus draining from wound noticing pus 2 days ago Followed up on drainage pus as white or yellow odor from the wound Asked about home treatment of foot wound wound care regimen of bandaging cleaning wound twice a day applying bacitracin, neomycin and polymyxin B (Neosporin) Followed up on effectiveness of ointment bacitracin, neomycin and polymyxin B (Neosporin) was ineffective Asked about other foot wound symptoms swelling around foot wound swelling worsened in the past 2 days redness around the wound that the wound feels warm Explored impact of patient's foot injury on activities of daily living pain affects ability to walk pain affects ability to stand at work for long periods of time pain prevented her from being able to walk to class Past Medical HistoryAsked about preexisting medical conditions diabetes asthma Followed up on diabetes diagnosis specific age of diagnosis was 24 that her diabetes is Type 2 Asked about diabetes management through lifestyle changes staying away from sweets drinking diet coke instead of regular Asked about current diabetes medication use that she does not currently take medication for diabetes Asked about past diabetes medication use that she used to take diabetes medication previous medication was prescription metformin last use of medication was 3 years ago Followed up on stopping diabetes regimen disliking diabetes medication side effects that she didn't like checking sugar and taking daily pills Asked about blood glucose monitoring infrequent blood glucose monitoring she last checked blood sugar a month ago confusion about what the numbers mean Asked about thirst increased thirst increased water intake Asked about frequency of urination more frequent urination urinating every hour or two during the day urinating 2 to 3 times during the night Asked about diet eating a bowl of cereal for breakfast yesterday eating mac and cheese for lunch yesterday eating chicken and roll for dinner yesterdayAsked about change in appetite increased appetite change in appetite began a month ago Asked about weight change recent loss of 10 lbs weight loss occurred over the past month Followed up on reason for weight change weight loss was unintentional Asked about history of asthma exacerbations last asthma attack was in high school last exacerbation was three days ago Asked about asthma symptoms chest tightness during exacerbation difficulty breathing during exacerbation wheezing during exacerbation Asked about prior hospitalizations past hospitalizations last hospitalization was for asthma last hospitalization was age 16 about 5 total hospitalizations for asthma as a child and teen past nebulizer use Asked about asthma diagnosis specific age of diagnosis is 2.5 years old Asked about asthma management using an inhaler inhaler is albuterol (Proventil) last use of inhaler was 3 days ago using inhaler no more than 2 times per week Asked about number of puffs when using asthma inhaler recommended dose is 1-3 puffs as needed typically taking 2 puffs sometimes needing 3 puffs to control symptomsAsked about asthma triggers asthma triggered by cats asthma triggered by dust seasonal triggers Asked about general allergies allergy to cats Followed up on cat allergy symptoms sneezing, itchy eyes, and wheezing Asked about latex allergy latex allergy Asked about medication allergies penicillin allergy Asked about penicillin reaction that penicillin resulted in hives last penicillin reaction was in childhood Asked about food allergies food allergies Asked if the patient has allergies to dust, mold, or pollen reaction to dust dust causes sneezing, itchy eyes, and wheezing seasonal allergies Asked about general immunizations received being up to date on shots Asked about childhood immunizations receiving measles-mumpsrubella shot receiving polio shot receiving varicella shot receiving Hepatitis A and B shot receiving meningococcal shot receiving HPV vaccine series Asked if the patient has received a flu vaccine receiving annual flu vaccine Asked if the patient received a tetanus immunization last tetanus vaccination was in the past year Asked about use of pain medication taking ibuprofen (Advil) at home ER administered pain medication Followed up on home pain medication taking ibuprofen (Advil) for 2 days taking doses at morning, noon and night taking 2 pills each time ibuprofen is regular strength Asked about the effectiveness of pain medication at home ibuprofen helped a little pain returned in full every few hours Asked about prescription medications only prescription is an inhaler Asked about use of OTC medication occasionally taking ibuprofen for cramps occasionally taking acetaminophen (Tylenol) for headaches taking supplements taking herbals Social History Asked about patient's level of education currently working toward undergraduate degree her major is accounting Asked about stressors she is currently under high stress Asked about patient's living situation living with mother and sister living in a house house is one-story family members will be able to help with activities Asked about patient belief system her religious affiliation is Baptist Asked if patient has experienced abuse experiencing abuse Asked about illicit drug use history of recreational marijuana smokingFollowed up on drug use last use was at age 20 or 21 she stopped because of health reasons and waning interest Asked about alcoholic intake last alcoholic drink was 3 weeks ago no more than 2 or 3 alcoholic drinks in one sitting no more than 1 or 2 nights a week drinking alcohol Asked about tobacco use smoking tobacco Vaping Asked about secondhand smoke exposure to secondhand smoke Family Medical History Asked about mother's health mother diagnosed with high blood pressure mother diagnosed with high cholesterol Asked about father's health father was diagnosed with Type 2 diabetes father was diagnosed with high blood pressure father was diagnosed with high cholesterol Followed up on father's death cause of death was a car accident father died at age 58 Followed up on coping with father's death past grief feeling at peace now Asked about paternal grandfather's health paternal grandfather diagnosed with Type 2 diabetes paternal grandfather diagnosed with high blood pressure paternal grandfather diagnosed with high cholesterol paternal grandfather died of colon cancerAsked about paternal grandmother's health paternal grandmother diagnosed with high blood pressure Asked about maternal grandfather's health maternal grandfather diagnosed with high blood pressure maternal grandfather diagnosed with high cholesterol Asked about maternal grandmother's health maternal grandmother diagnosed with high blood pressure maternal grandmother diagnosed with high cholesterol Asked about brother's health brother having diagnosed health problems Asked about sister's health sister diagnosed with asthma Asked about family history of obesity that family members are overweight Asked about family history of thyroid issues family history of thyroid issues Asked about family history of substance abuse 1 uncle has alcoholism Asked about family history of headaches family history of headaches Review of Systems Asked about constitutional health occasional tiredness or fatigue typical sleep pattern fever chills night sweats Asked about review of systems for mental health depression suicidal ideation or attempts Asked about review of systems for head occasional headaches current headache head injury Asked about review of systems for ears change in hearing ringing or tinnitus ear pain ear discharge Asked about review of systems for eyes and vision periods of blurry vision corrective lenses infrequent itchy eyes infrequent eye redness infrequent discharge, crusting or wateriness eye pain dry eyes Asked about review of systems for nose current nose problems infrequent runny nose infrequent sinus problems nosebleeds change in sense of smell Asked about review of systems for mouth and jaw dental problems last dental visit was several years ago change in sense of taste dry mouth mouth pain mouth sores gum problems tongue problems jaw problems Asked about review of systems for neck, throat and glands difficulty swallowing sore throat lymph node problems frequent sore throat swollen glands voice changes Asked about breast health doing occasional breast exams swelling breast rashes lumps nipple discharge ever having a mammogram history of breast cancerAsked about review of systems for respiratory current breathing problems current wheezing current chest tightness pain while breathing frequent coughing Asked about review of systems for cardiovascular chest pain or discomfort palpitations irregular heartbeat easy bruising edema circulation problems Asked review of systems for gastrointestinal nausea vomiting stomach pain change in bowel movements heartburn, GERD, or indigestion constipation diarrhea or loose stool excessive flatulence or bloating Asked review of systems for urinary painful or difficult urination waking up to urinate during the night large amount of urine blood in urine flank pain incontinence history of urinary tract or bladder infection Asked review of systems for reproductive last menstrual period was 3 weeks ago that periods are irregular past pregnancies vaginal itching or discomfort normal vaginal discharge history of STIs past condom use current birth control Asked review of systems for musculoskeletal muscle pain joint pain muscle weakness muscle swelling Asked review of systems for neurological dizziness or vertigo lightheadedness tingling loss of coordination loss of sensation no seizures problems with balance or disequilibrium Asked review of systems for skin, hair and nails acne excessive facial or body hair changes to neck skin moles dandruff hair loss nail abnormalities occasional dry skin skin rashes Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2012 - 2019 [Show More]

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