NR 509 Comprehensive_Health_History_Assignment_Completed_Shadow_Health_Transcript - Chamberlain College of Nursing
NR 509 Comprehensive_Health_History_Assignment_Completed_Shadow_Health_Transcript
Comprehensive Health
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NR 509 Comprehensive_Health_History_Assignment_Completed_Shadow_Health_Transcript - Chamberlain College of Nursing
NR 509 Comprehensive_Health_History_Assignment_Completed_Shadow_Health_Transcript
Comprehensive Health History Assignment Results | Turned In
Advanced Health Assessment - Chamberlain - June 2019, NR509-June-2019
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Your Results Lab Pass Lab Pass
Started: Jul 10, 2019 | Patient Exam Time: 124 min
Transcript
Exam Action
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Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Information Processing
Health History Tips and Tricks
Self-Reflection
Interview Questions (245) Interview Questions (245) Statements (34) Statements (34) Exam Actions (12) Exam Actions (12)
Height: 170 cm
Weight: 90 kg
BMI: 31
Random blood glucose: 238
Temperature: 101.1 F
Blood pressure: 142/82
Respiratory rate: 19
O2 sat: 99%
All Lines (291) All Lines (291)7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health
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Exam Action
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Exam Action
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Greet
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Empathize
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Heart rate: 86
hello. My name is Tneshia Richards. I will be your provider today.
Hey.
What is your name
Tina Jones.
what is your date of birth Mrs. Jones
February 17th.
what year were you born in
I was born in . . . [Ms. Jones reports correct birth year.]
what brings you in today?
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!
I'm sorry to hear that you are having pain.
I appreciate you saying that.
which foot did you scrape7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health
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My right foot.
when did the scrape occur
Well, I got the scrape a week ago, but the scrape and the pain got
a lot worse in the last few days.
which part of the foot is the scrape on (Clarified to Where is the cut
on your foot?.)
It's on the ball of my foot. (Clarified to where the scrape is on my
foot.)
what is your pain level
I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet.
describe how the pain feels
It's throbbing and like, sharp if I try to put weight on it.
what makes the pain worse
I'd say the pain is at its worst when I have to put any weight on my
foot. . . otherwise, it's when the pain pills wear off.
what makes the pain better
The pain pills help for a few hours.
does resting the foot help with the pain
Putting my foot up helps a little I guess, but the only thing that
makes a real difference is the pain pills.
where did you get pain pills from7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health
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The ER doctor prescribed them for me when I was in there a week
ago.
are you allergic to any medications
Yeah, I'm allergic to penicillin.
what happens when you take penicillin
I don't remember that well because the last time I had penicillin I
was pretty little. . . I think I got a rash, like, hives. The doctor told
me not to take it again after that.
are you allergic to any food
Nope, no food allergies that I know of.
what other allergies do you have
Well, besides cats, I'm allergic to penicillin.
What kind of reaction do you have to cap (Clarified to What
happens when you are around a cat?.)
Whenever I'm around cats, I start sneezing, my eyes get itchy. . .
and my asthma starts to act up. (Clarified to what the symptoms of
my cat allergy are.)
When were you diagnosed with asthma
My doctor told me when I was pretty little... I think I was about two
and a half? I used to have a lot of trouble with asthma attacks back
then.
How do you manage your asthma now
I try to avoid things that give me breathing problems, but when my
asthma starts to act up, I just use my inhaler.7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health
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07/10/19 6:56 PM
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07/10/19 6:58 PM
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Educate
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What kind of inhaler do you use
It's just a regular Proventil inhaler.
How often do you use it (Clarified to How often do you use your
inhaler?.)
Not often. Maybe two or three times a week. (Clarified to how often
I use my inhaler.)
Do you know what the dosage is of the provincial (Clarified to What
dosage of albuterol do you take?.)
I usually use two puffs from my albuterol inhaler -- it's 90
micgrograms a spray -- but lately sometimes I need three puffs.
[AUDIO COMING SOON] (Clarified to what dose of albuterol I
take.)
How long have you been taking an inhaler
I've had an inhaler since I was two and a half, when I was
diagnosed.
Do you know how to take your inhaler (No matching questions
found.)
Using your inhaler properly is important.
Sure, I think I understand what you mean.
You should use your inhaler when you have shortness of breath.
Alright, thanks for letting me know.
Rinse your mouth after each use.
OK, I understand.
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Lunch is the meal I usually pick up near campus because of my
schedule. I go to Subway mostly and get a turkey sandwich or
something.
Do you snack
Yeah, I usually have some snacks during the day.
What kind of snacks do you eat
I try to eat snacks that are kind of healthy like pretzels-sometimes
I'll treat myself and get french fries, but I try not to do that too often.
How much salt do you eat in a day
Honestly, I don't pay much attention to how much salt I eat. My
mom is always reaching for the salt shaker, but I don't usually add
salt to my food.
Do you drink coffee
Never. I don't like it. Too bitter for my taste.
How much caffeine do you drink
I don't know how much caffeine is in them exactly, but I drink about
four Diet Cokes a day.
When was the last time you used marijuana
I haven't smoked pot since I was twenty or twenty-one.
Why did you stop (Clarified to Why did you stop smoking
marijuana?.)
It just wasn't that fun anymore, plus it started to bother my asthma.
(Clarified to why I stopped smoking pot.)7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health
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How many alcoholic beverages do you usually have in one sitting
Just a few. I'm not a big drinker.
How many would you say is a few (Clarified to What do you mean
by "a few drinks"?.)
Like, two or three drinks. If I have more than two or three drinks, I
feel like hell the next day, so I stop at three. (Clarified to what I
mean by a few drinks.)
How many alcoholic drinks have you had in the past month
Oh, I don't know. Let's see... I might go out every few weeks, so
twice a month... and I maybe have 2 or 3 drinks at a time, so
maybe 6 drinks a month. Even if I go out more than usual, no more
than ten.
Does anyone in your household smoke
No, nobody at home smokes.
Have you ever had a mental health diagnosis (Clarified to Have you
had a mental illness?.)
No, definitely not. (Clarified to if I have had a mental illness.)
Do you wear contact lenses
I don't wear contacts or glasses, no.
When was your last eye exam
I got my vision tested as a kid at the doctor, but I haven't gotten an
eye exam since then.
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Um, I think the last time was a few years ago. I went twice a year
as a kid, though.
Do you have any cavities or pain
I had a cavity or two as a kid that the dentist filled. I've never had
any problems with my teeth beyond that.
Are you having any difficulty breathing right now
No, my breathing is fine right now.
Do you have any difficulty swallowing
Nope.
Do you have any chest pain
No, my chest feels tight when I have breathing problems, but it
doesn't hurt.
Do you have anemia
I don't really know... I mean, I don't think I have a problem with iron,
but I've never been tested.
Do you bruise easily
I don't think so, no... I don't hurt myself very often.
Have you ever had a urinary tract infection
Nope.
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07/10/19 8:35 PM
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I haven't had a mammogram. I've just had the exam where the
doctor felt around for lumps.
Do you do self breast exams monthly
Uh, I guess I tried a couple of times, but I didn't really know what I
was looking for.
When doing self-breast exams you're looking for any lumps that
were not present before
That makes sense.
Do you have any drainage from your nipples
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