NURSING/Shadow_Health_Health_History_Tina_Jones___Advance_Assessment__Subjective_Data_Collection.pdf.pdf

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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 w... ill yie better patient data. The following details are facts of patient's case. Established chief complaint Reports pain Reports foot wound Asked to rate current pain level on a scale Reports current pain is 7/10 Asked for details about the pain Reports pain is throbbing Reports pain is sharp when she attempts to stand Reports pain has increased in the past 2 days Reports feeling pain radiating into ankle Reports pain prevents bearing weight on foot Asked location of wound Reports right foot is injured Reports wound is on the plantar surface of her foot Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Support 10/1/2020 Health History | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/7742024 2/10 Past Medical History Asked details of the injury Reports she scraped foot on a cement step Reports initial injury occurred 1 week ago Reports mild ankle injury Reports being barefoot at the time of injury Asked about the assessment of the injury at the ER Reports going to the ER after sustaining the injury Reports going to the ER because she suspected an ankle sprain Reports receiving an X-ray at the ER Reports X-ray showed no broken bones Reports receiving 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 Reports noticing pus 2 days ago Followed up on drainage Reports pus as white or yellow Denies odor from the wound Asked about home treatment of foot wound Reports wound care regimen of bandaging Reports cleaning wound twice a day Reports cleaning wound with hydrogen peroxide Reports applying bacitracin, neomycin and polymyxin B (Neosporin) Asked about other foot wound symptoms Reports swelling around foot wound Reports swelling worsened 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 Reports pain affects ability to walk Reports pain affects ability to stand at work for long periods of time Reports pain prevented her from being able to walk to class Asked about preexisting medical conditions Reports diabetes Reports asthma Followed up on diabetes diagnosis Reports specific age of diagnosis was 24 Reports that her diabetes is Type 2 Asked about diabetes management through lifestyle changes Reports staying away from sweets Reports drinking diet soda instead of regular Asked about current diabetes medication use Reports that she does not currently take medication for diabetes Asked about past diabetes medication use Reports that she used to take diabetes medication 10/1/2020 Health History | Completed | Shadow Health https://app.shadowhealth.com/assignment_attempts/7742024 3/10 Reports previous medication was prescription metformin Reports last use of medication was 3 years ago Asked about blood glucose monitoring Reports infrequent blood glucose monitoring Reports last glucose check was a week ago at the ER Reports confusion about what the numbers mean Asked about thirst Reports increased thirst Reports increased water intake Asked about frequency of urination Reports more frequent urination Reports urinating every hour or two during the day Reports urinating 2 to 3 times during the night Asked about change in appetite Reports increased appetite Reports change in appetite began a month ago Asked about weight change Reports recent loss of 10 lbs Reports weight loss occurred over the past month Followed up on reason for weight change Reports weight loss was unintentional Asked about history of asthma exacerbations Reports last asthma attack was in high school Reports last exacerbation was three days ago Asked about asthma symptoms Reports chest tightness during exacerbation Reports difficulty breathing during exacerbation Reports wheezing during exacerbation Asked about prior hospitalizations Reports past hospitalizations Reports last hospitalization was for asthma Reports last hospitalization was age 16 Reports about 5 total hospitalizations for asthma as a child and teen Reports past nebulizer use Asked about asthma diagnosis Reports specific age of diagnosis is 2.5 years old Asked about asthma management Reports using an inhaler Reports inhaler is albuterol (Proventil) Reports last use of inhaler was 3 days ago Reports using inhaler no more than 2 times per week Asked about number of puffs when using asthma inhaler Reports recommended dose is 1-3 puffs as needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms [Show More]

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