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Shadow Health Tina Jones Subjective Data Collection_Completed 2021

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Health History Results | Completed Health Assessment -, NUR3067C Return to Assignment (/assignments/140509/) Subjective Data Collection: 92 of 104 (88.5%) Chief Complaint History of Present Illne... ss Your Results Lab Pass (/assignment_attempts/2759705/lab_pass.p Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Health History Tips and Tricks Lifespan Self-Reflection Indicates an item that you found. Indicates an item that is available to be found. Category 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 yiel better patient data. The following details are facts of patient's case. Established chief complaint Reports pain Reports open foot wound Asked for details about the pain Describes the pain as throbbing Describes the pain as sharp when she attempts to stand Initial injury occurred 1 week ago Pain has increased in the past 2 days Reports feeling pain radiating into ankle Pain prevents bearing weight on foot Asked to rate pain on a scale Rates present pain at a 7 out of 10 Clarified location of wound Confirmed that right foot is injured Confirmed that wound is on the plantar surface of her foot Determined details of the injury Scraped foot on a cement step Reports mild ankle injury Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.5/25/2020 Health History | Completed | Shadow Health Medical History: Medication Was not drinking at the time of the injury Was not wearing shoes at the time of injury Asked about the assessment of the injury at the ER Went to the ER after sustaining the injury Decided to go because she suspected an ankle sprain Received an x-ray X-ray showed no broken bones Received 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 Began noticing pus 2 days ago Followed up about character of drainage from the foot wound Describes pus as white or yellow in color Reports no odor from the wound Asked about home treatment of foot wound Describes wound care regimen of cleaning and bandaging Cleaned wound twice a day Cleaned wound with hydrogen peroxide Changed bandage twice a day Applied neosporin Asked about other foot wound symptoms Reports swelling around foot wound Noticed swelling getting worse 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 Pain affects ability to walk Pain affects job performance Pain prevented her from attending class Asked about recent fever Reports a fever last night Asked about use of pain medication Has been taking prescription pain medication Medication is Tramadol Asked about pain medication frequency Has been taking pain medication for 2 days Takes dose 3 times a day Last dose was this morning Asked about pain medication dose Dosage is 50 milligrams Takes 2 pills each time Asked about the efficacy of pain medication Reports that pain pills provide partial relief Pain returns in full every few hours Asked about othe [Show More]

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