Building a Health History: A Patient-Centered Approach to Tina Jones.<\/p>\n
Effective communication forms the bedrock of accurate and detailed patient history, a cornerstone of quality healthcare. Advanced practice nurses must remain cognizant of the diverse factors influencing a patient’s health, including age, gender, ethnicity, and environmental setting, tailoring their communication techniques to each individual. This approach not only fosters rapport but also facilitates the gathering of crucial information for comprehensive health risk assessment.<\/p>\n
This paper delves into the case of Tina Jones, a 28-year-old African American female presenting for a pre-employment physical examination. We will explore specific communication techniques, a relevant risk assessment instrument, and targeted questions to effectively build her health history.<\/p>\n
Understanding Tina Jones: Tailoring Communication Techniques
\nTina presents as a young adult starting a new job, potentially indicating a period of both excitement and stress. Employing open-ended questions and active listening will be crucial to creating a safe space for her to share information openly. For instance, instead of directly asking about her stress levels, starting with “How are you feeling about starting your new job?” can elicit a more nuanced understanding of her emotional state.<\/p>\n
Given her history of asthma and type 2 diabetes, diagnosed at a young age, it is important to assess her understanding and management of these chronic conditions. Utilizing a conversational, rather than interrogative, tone when discussing her health history can encourage her active participation. Additionally, acknowledging her efforts in managing her conditions, such as her positive lifestyle modifications, can reinforce her agency in her healthcare.<\/p>\n
Assessing Health Risks: The Role of the American Diabetes Association (ADA) Risk Test
\nConsidering Tina’s medical history, the ADA Risk Test emerges as a particularly relevant risk assessment instrument (American Diabetes Association, 2023). This tool evaluates an individual’s risk for developing type 2 diabetes based on factors like age, weight, family history, and physical activity levels. Given Tina’s existing diagnosis, the test can be reframed to assess her risk for developing complications related to diabetes.<\/p>\n
Targeted Questions: Uncovering Potential Risks and Concerns
\nBuilding upon the ADA Risk Test, the following targeted questions can provide valuable insights into Tina’s health risks and guide further investigation:<\/p>\n
“You mentioned you’ve made positive lifestyle changes. Can you tell me more about your diet and exercise routine?” (This open-ended question explores her diabetes management and identifies areas for potential intervention).
\n“Do you have any family history of diabetes-related complications, such as heart disease or eye problems?” (This question assesses her awareness of potential long-term risks associated with diabetes).
\n“How would you describe your stress levels, and what strategies do you use to manage stress?” (This question explores the potential impact of stress on her diabetes and overall well-being).
\n“Have you noticed any changes in your vision or experienced any numbness or tingling in your hands or feet?” (This question screens for potential complications related to diabetes, such as retinopathy and neuropathy).
\n“Do you feel comfortable discussing your sexual health and any concerns you might have?” (This question creates a safe space to address potential risks associated with PCOS and initiate a conversation about contraception and sexually transmitted infections).
\nConclusion
\nBuilding a comprehensive health history requires a patient-centered approach that prioritizes effective communication and culturally sensitive care. By understanding Tina’s background, utilizing appropriate risk assessment tools like the ADA Risk Test, and asking targeted questions, healthcare providers can empower her to actively participate in her healthcare journey and mitigate potential health risks.<\/p>\n
References<\/p>\n
American Diabetes Association. (2023). Diabetes risk test. https:\/\/www.diabetes.org\/risk-test
\nBall, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel\u2019s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
\nDiamond-Fox, S. (2021). Undertaking consultations and clinical assessments at an advanced level. British Journal of Nursing, 30(4), 238\u2013243. https:\/\/doi.org\/10.12968\/bjon.2021.30.4.238
\nSullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.<\/p>\n
===================<\/p>\n
Building a Health History.<\/p>\n
Effective communication is essential in constructing an accurate and detailed patient history. A patient’s health or illness is influenced by various factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, understanding these factors and tailoring communication techniques accordingly is crucial. This paper explores the methods for building a health history, focusing on a case study involving Tina Jones, a 28-year-old African American woman.<\/p>\n
Communication Techniques
\nWhen interviewing patients like Tina Jones, employing open-ended questions and active listening is vital. These techniques encourage patients to share detailed information about their health. For instance, asking, “Can you tell me more about your asthma management?” allows the patient to provide comprehensive insights into their condition. Additionally, maintaining eye contact and using empathetic responses, such as “That sounds challenging,” can help build rapport and trust (Ball et al., 2023).<\/p>\n
Social Determinants of Health
\nSocial determinants significantly impact health outcomes. For Tina, factors such as her employment status, access to healthcare, and social support systems are crucial. Questions like “How does your job affect your health management?” can uncover potential stressors or barriers to care. Understanding these elements helps tailor interventions that address specific needs (Diamond-Fox, 2021).<\/p>\n
Risk Assessment Instruments
\nSelecting appropriate risk assessment tools is essential for identifying potential health risks. For Tina, the “Timed Up and Go” (TUG) test could be useful in assessing fall risk, given her history of diabetes and potential neuropathy (Chow et al., 2019). This tool is simple, quick, and provides valuable information about mobility and balance.<\/p>\n
Targeted Questions
\nTo build a comprehensive health history, the following questions are proposed:<\/p>\n
How do you manage your diabetes daily?
\nWhat triggers your asthma symptoms, and how do you handle them?
\nCan you describe any recent changes in your health or medications?
\nHow does your family history influence your health concerns?
\nWhat support systems do you rely on for managing your health?
\nThese questions aim to gather detailed information about Tina’s health management strategies, potential triggers, and support systems.<\/p>\n
Conclusion
\nBuilding a health history requires effective communication, understanding social determinants, and using appropriate risk assessment tools. By employing these strategies, healthcare providers can gather comprehensive information, enabling them to deliver personalized and effective care. For Tina Jones, this approach ensures that her unique health needs are addressed, promoting better health outcomes.<\/p>\n
References
\nBall, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel\u2019s guide to physical examination: An interprofessional approach (10th ed.). Elsevier Mosby.<\/p>\n
Chow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the \u201cTimed Up and Go\u201d (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED. The American Journal of Emergency Medicine, 37(3), 457\u2013460. https:\/\/doi.org\/10.1016\/j.ajem.2018.06.015<\/p>\n
Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238\u2013243. https:\/\/doi.org\/10.12968\/bjon.2021.30.4.238<\/p>\n
Adly, N. N., Abd-El-Gawad, W. M., & Abou-Hashem, R. M. (2019). Relationship between malnutrition and different fall risk assessment tools in a geriatric in-patient unit. Aging Clinical and Experimental Research, 32(7), 1279\u20131287. https:\/\/doi.org\/10.1007\/s40520-019-01309-0<\/p>\n
==========<\/p>\n
NURS 6512 Comprehensive Assessment Tina Jones Shadow Health Transcript Provided<\/p>\n
NURS 6512 Week 1: Discussion
\nBuilding A Health History \u2013 We Can Reliably Complete This And Related Assignments In This Course, Including All The Required Shadow Health Assessments. These Include Tina Jones Health History, Focused Cough Assessment On Danny Rivera, Focused Assessment \u2013 Chest Pain On Brian Foster, And The Comprehensive Health Assessment On Tina Jones.
\nEffective communication is vital to constructing an accurate and detailed patient history. A patient\u2019s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients\u2019 health risks.<\/p>\n
For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.<\/p>\n
Resources
\nBe sure to review the Learning Resources before completing this activity.
\nClick the weekly resources link to access the resources.<\/p>\n
WEEKLY RESOURCES<\/p>\n
To prepare:<\/p>\n
With the information presented in Chapter 2 of Ball et al. in mind, consider the following:<\/p>\n
By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the \u201cCourse Announcements\u201d section of the classroom for your new patient profile assignment.
\nHow would your communication and interview techniques for building a health history differ with each patient?
\nHow might you target your questions for building a health history based on the patient\u2019s social determinants of health?
\nWhat risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
\nIdentify any potential health-related risks based upon the patient\u2019s age, gender, ethnicity, or environmental setting that should be taken into consideration.
\nSelect one of the risk assessment instruments presented in Chapter 2 or Chapter 5 of the Seidel\u2019s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
\nDevelop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.
\nBY DAY 3 OF WEEK 1
\nPost a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.<\/p>\n
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues\u2019 postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!<\/p>\n
Read a selection of your colleagues\u2019 responses.<\/p>\n
BY DAY 6 OF WEEK 1<\/p>\n
Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:<\/p>\n
Share additional interview and communication techniques that could be effective with your colleague\u2019s selected patient.
\nSuggest additional health-related risks that might be considered.
\nValidate an idea with your own experience and additional research
\nLearning Resources
\nBall, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel\u2019s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
\no Chapter 2, \u201cThe History and Interviewing Proce
\nThis chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.<\/p>\n
o Chapter 5, \u201cRecording Information\u201d
\nThis chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.<\/p>\n
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
\no Chapter 2, \u201cThe Comprehensive History and Physical Exam\u201d (pp. 19\u201329)<\/p>\n
Adly, N. N., Abd-El-Gawad, W. M., & Abou-Hashem, R. M. (2019). Relationship between malnutrition and different fall risk assessment tools in a geriatric in-patient unit. Aging Clinical and Experimental Research, 32(7), 1279\u20131287. https:\/\/doi.org\/10.1007\/s40520-019-01309-0
\nChow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the \u201cTimed Up and Go\u201d (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED. The American Journal of Emergency Medicine, 37(3), 457\u2013460. https:\/\/doi.org\/10.1016\/j.ajem.2018.06.015
\nDiamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238\u2013243. https:\/\/doi.org\/10.12968\/bjon.2021.30.4.238
\nShadow Health Support and Orientation Resources
\nUse the following resources to guide you through your Shadow Health orientation as well as other support resources:<\/p>\n
Shadow Health. (2021). Welcome to your introduction to Shadow Health. https:\/\/link.shadowhealth.com\/Student-Orientation-Video
\nShadow Health. (n.d.). Shadow Health help deskLinks to an external site. Retrieved from https:\/\/support.shadowhealth.com\/hc\/en-us
\nShadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. Download Walden University quick start guide: NURS 6512 NP students.
\nDocument: Shadow Health Nursing Documentation Tutorial Download Shadow Health Nursing Documentation Tutorial(Word document)
\nRequired Media
\nWelcome and General Course Guidelines
\nDr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m).<\/p>\n
Module 1 Introduction
\nDr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the registration requirements for your use of Shadow Health for your Digital Clinical Experience (DCE) Assignments as well as the criteria for the DCE Assignments (3m).<\/p>\n
Building a Comprehensive Health History \u2013 Week 1 (19m)<\/p>\n
Optional Resources
\nLeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin\u2019s diagnostic examination (11th ed.). New York, NY: McGraw- Hill Medical.
\no Chapter 2, \u201cHistory Taking and the Medical Record\u201d (pp. 1)<\/p>\n
Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
\nComprehensive Assessment Tina Jones Shadow Health Transcript<\/p>\n
This comprehensive shadow health assessment of Tina Jones enables the student to master the art of patient data collection, with head to toe history taking and physical assessment.<\/p>\n
The process is highly involving, time-consuming and may require one to complete in different sessions, yet the goal is to be able to assess a patient in one sitting, taking as minimal time as possible. We can help you complete this and other shadow health assessments as and when needed, with excellent scores assured. Comprehensive Assessment Tina Jones Shadow Health Transcript<\/p>\n
Transcript
\nAll Lines (645) Interview Questions (210) Statements (41) Exam Actions (394)<\/p>\n
Hello, my name is Tammy. I will be conducting an interview and a physical exam. Greet
\n07\/22\/20 5:37 PM EDT
\nHey.
\nWhat is your name? Question
\n07\/22\/20 5:37 PM EDT
\nTina Jones.
\nWhat is your date of birth? Question
\n07\/22\/20 5:37 PM EDT
\nFebruary 17th.
\nHow old are you? Question
\n07\/22\/20 5:43 PM EDT
\nI\u2019m 28.
\nWhat brings you into the clinic today? Question
\n07\/22\/20 5:43 PM EDT
\nI came in because I\u2019m required to have a recent physical exam for the health insurance at my new job.
\nDo you have any current health problem? Question
\n07\/22\/20 5:44 PM EDT
\nI don\u2019t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I\u2019m taking good care of my health these days.
\nWhat is your new job? Question
\n07\/22\/20 5:44 PM EDT
\nI\u2019m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I\u2019ll be helping a more experienced accountant with her clients, and then eventually I\u2019ll get more responsibility, and build my own client list. I start in two weeks\u2013I\u2019m really excited! Comprehensive Assessment Tina Jones Shadow Health Transcript
\nThat is great. Empathize
\n07\/22\/20 5:45 PM EDT
\nThanks.
\nWhen was your last physical exam? Question
\n07\/22\/20 5:45 PM EDT
\nLet\u2019s see . . . I had two doctor\u2019s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.
\nWhat did your gynecologist say? Question
\n07\/22\/20 5:45 PM EDT
\nShe said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nHow often do you take birth control? Question
\n07\/22\/20 5:48 PM EDT
\nI take it every morning, with breakfast.
\nWhat is the name of the birth control pill you took? Question
\n07\/22\/20 5:49 PM EDT
\nThey\u2019re called Yaz.
\nHas your menstrual cycle improved since taking Yaz? Question
\n07\/22\/20 5:50 PM EDT
\nNow that I\u2019m on the pill I\u2019m getting my period every month.
\nThat is great. I am glad you are having your period every month. Empathize
\n07\/22\/20 5:50 PM EDT
\nThanks. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nHow long have you had asthma? Question
\n07\/22\/20 5:51 PM EDT
\nI\u2019ve had asthma a long time. . . since I was really little.
\nWhat age were you diagnosed with asthma? Question
\n07\/22\/20 5:51 PM EDT
\nMy doctor told me when I was pretty little\u2026 I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nI am sorry about the experience. Empathize
\n07\/22\/20 5:52 PM EDT
\nThanks. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nHow do you manage your asthma? Question
\n07\/22\/20 5:52 PM EDT
\nI try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
\nWhat are your triggers for asthma? Question
\n07\/22\/20 5:53 PM EDT
\nBeing around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven\u2019t had a full asthma attack in years, though. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nIt is important to stay away from triggers. Educate
\n07\/22\/20 5:54 PM EDT
\nThanks for telling me. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nWhat happens when you are around dust? Question
\n07\/22\/20 5:54 PM EDT
\nI used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn\u2019t happened since I got my daily inhaler. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nWhat inhaler do you use? Question
\n07\/22\/20 5:59 PM EDT
\nThe daily inhaler is Flovent, and the rescue inhaler is Proventil. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nHow often do you use Flovent? Question
\n07\/22\/20 6:00 PM EDT
\nTwice a day.
\nWhen did you most recently use the Flovent inhaler? Question
\n07\/22\/20 6:01 PM EDT
\nI use my Flovent inhaler two times a day. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nWhen did you last use your inhaler? Question
\n07\/22\/20 6:03 PM EDT
\nI used my Flovent inhaler this morning\u2013I have to take it twice a day. My albuterol. . . I\u2019ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nHow much Albuterol do you use? Question
\n07
\nI have a few friends I\u2019ve known since middle or high school, and we\u2019re all pretty close. Plus I have my friends from church.<\/p>\n
What is your relationship like with your family? Question
\n07\/22\/20 7:39 PM EDT
\nThings are pretty good between all of us\u2013we\u2019re a tight knit family. I think we\u2019re pretty special, the way we all get along.
\nThat is great. Empathize
\n07\/22\/20 7:39 PM EDT
\nThanks.
\nAre you involved in church? Question
\n07\/22\/20 7:39 PM EDT
\nYeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nAre you feeling stressed? Question
\n07\/22\/20 7:40 PM EDT
\nI\u2019m feeling really good lately. . . not stressed at all.
\nHow do you cope with stress? Question
\n07\/22\/20 7:40 PM EDT
\nI\u2019ve realized that I got overwhelmed with everything back when I had those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I\u2019ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I\u2019ve always done\u2013attending church, especially\u2013is all working well for me. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nThanks. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nAre you feeling depressed? Question
\n07\/22\/20 7:41 PM EDT
\nNo, I\u2019m actually feeling really good these days.
\nHow do you feel about your life? Question
\n07\/22\/20 7:41 PM EDT
\nI\u2019m starting my new job in two weeks, and I\u2019m excited about that. I\u2019m going to be an Accounting Clerk at this nice accounting firm. I\u2019m hoping I\u2019ll learn a lot in that position, and within a couple of years, I\u2019ll get promoted and be given new responsibilities. I always want to learn new things and improve my job. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nAre you feeling anxious? Question
\n07\/22\/20 7:41 PM EDT
\nI guess I had anxiety back when I was having those sleep problems. . . I\u2019ve been feeling much better lately, though. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nDo you have sleeping problems? Question
\n07\/22\/20 7:42 PM EDT
\nI\u2019m sleeping a lot better now, which is a relief.
\nGood to hear. Empathize
\n07\/22\/20 7:42 PM EDT
\nThanks.
\nHow many hours are you sleeping a night? Question
\n07\/22\/20 7:42 PM EDT
\nI\u2019m usually asleep by 11:30, and I wake up at 8, about 8 or 9 hours a night.
\nThat is great. Empathize
\n07\/22\/20 7:42 PM EDT
\nThanks.
\nHave you ever smoked tobacco? Question
\n07\/22\/20 7:43 PM EDT
\nNo. I think it\u2019s gross.
\nHave you ever used cocaine? Question
\n07\/22\/20 7:43 PM EDT
\nNo way, I have no interest in that. That stuff can mess you up.
\nHave you ever used heroin? Question
\n07\/22\/20 7:49 PM EDT
\nUh, no.
\nHave you ever used illegal drugs? Question
\n07\/23\/20 3:17 PM EDT
\nWell, I used to smoke pot. . . but I don\u2019t do that anymore.
\nWhat was the last time you smoked pot? Question
\n07\/23\/20 3:17 PM EDT
\nI haven\u2019t smoked pot since I was twenty or twenty-one.
\nDo you have any family history of mental illness? Question
\n07\/23\/20 3:18 PM EDT
\nNo. They\u2019re crazy, but nobody\u2019s diagnosed with anything.
\nHave you had suicidal thoughts? Question
\n07\/23\/20 3:19 PM EDT
\nNo, I\u2019ve never done that.
\nAny new family medical history report? Question
\n07\/23\/20 3:20 PM EDT
\nMy mom has some issues; I think some of my grandparents did, too.
\nHow old is your mom? Question
\n07\/23\/20 3:21 PM EDT
\nMom is 50.
\nWhat medical problems does your mum have? Question
\n07\/23\/20 3:21 PM EDT
\nMom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
\nWhat medical problems did your father have? Question
\n07\/23\/20 3:22 PM EDT
\nHe had high blood pressure and cholesterol, and diabetes too\u2026the same kind as me.
\nHow old is your brother? Question
\n07\/23\/20 3:24 PM EDT
\nHe\u2019s almost 27.
\nDoes he have any medical issues? (Clarified to Does your younger sister have health problems?.) Question
\n07\/23\/20 3:25 PM EDT
\nShe\u2019s pretty healthy. She has asthma too, but she rarely has attacks. (Clarified to if my younger sister has health problems.)
\nDoes your brother have health issues? (Clarified to Does your brother have medical problems?.) Question
\n07\/23\/20 3:25 PM EDT
\nNo, I don\u2019t think so. He\u2019s a little big, maybe. (Clarified to if my brother has health issues.)
\nHow old is your maternal grandmother? Question
\n07\/23\/20 3:26 PM EDT
\nNana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.
\nHow old is your maternal grandfather? Question
\n07\/23\/20 3:27 PM EDT
\nPoppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
\nAny medical history for your paternal grandmother? Question
\n07\/23\/20 3:30 PM EDT
\nShe takes some blood pressure pills and has high cholesterol, but Granny\u2019s doing great for 82.
\nDoes your dad\u2019s father have health issues? Question
\n07\/23\/20 3:30 PM EDT
\nGrandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure and\u2026I\u2019m pretty sure he had diabetes. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nHave you had any recent illnesses? Question
\n07\/23\/20 3:31 PM EDT
\nNo. . . the last time I was sick was when I was having those heartburn problems a while ago.
\nAny fever? Question
\n07\/23\/20 3:32 PM EDT
\nI haven\u2019t had a fever.
\nAny chills? Question
\n07\/23\/20 3:32 PM EDT
\nNope, no chills.
\nAny acne? Question
\n07\/23\/20 3:32 PM EDT
\nI took something for my acne. . . tetracycline, I think, back in high school. Since then I\u2019ve just washed my face, I haven\u2019t used anything special. But my zits have gotten better, and I think it\u2019s because I\u2019m on birth control now.
\nHas your body hair improved? Question
\n07\/23\/20 3:32 PM EDT
\nI think I have a little less body hair than I used to.
\nDo your eyes feel itchy? Question
\n07\/23\/20 3:33 PM EDT
\nThey haven\u2019t been itchy lately at all.
\nAre you having any redness in your eyes? Question
\n07\/23\/20 3:33 PM EDT
\nMy eyes haven\u2019t been red lately. . . not since I came in with those allergies a while ago.
\nAre your eyes dry? Question
\n07\/23\/20 3:34 PM EDT
\nMy eyes don\u2019t feel dry.
\nDo you have any pain in your eyes? Question
\n07\/23\/20 3:34 PM EDT
\nI haven\u2019t had any eye problems lately\u2013I went to the eye doctor a few months ago and got these glasses; she checked everything out and said it looked good.
\nAre you having any ear problems? Question
\n07\/23\/20 3:34 PM EDT
\nMy ears feel fine.
\nAny changes in your hearing? Question
\n07\/23\/20 3:36 PM EDT
\nMy hearing is good.
\nAny ear pain? Question
\n07\/23\/20 3:36 PM EDT
\nMy ears feel fine.
\nEar drainage? (Clarified to Do you have drainage from your ears?.) Question
\n07\/23\/20 3:36 PM EDT
\nNothing is coming out of my ears. (Clarified to if I have ear drainage.)
\nAny changes in your sense of smell? Question
\n07\/23\/20 3:46 PM EDT
\nNo.
\nAny nose bleeds? Question
\n07\/23\/20 3:47 PM EDT
\nNope, my nose isn\u2019t bleeding at all.
\nAny sinus pressures? Question
\n07\/23\/20 3:47 PM EDT
\nMy sinuses have been fine.
\nHas your sense of taste changed? Question
\n07\/23\/20 3:47 PM EDT
\nNo, I think my sense of taste is fine.
\nAre you having dry mouth? Question
\n07\/23\/20 3:48 PM EDT
\nMy mouth hasn\u2019t been dry.
\nANY pain in your mouth? Question
\n07\/23\/20 3:48 PM EDT
\nNo, my mouth feels fine.
\nANY sore throat? Question
\n07\/23\/20 3:49 PM EDT
\nNo, it\u2019s fine.
\nAny issue with your gums? Question
\n07\/23\/20 3:49 PM EDT
\nMy gums have been fine.
\nAny issue with your tongue? Question
\n07\/23\/20 3:49 PM EDT
\nMy tongue feels fine.
\nAny difficulties when swallowing? Question
\n07\/23\/20 3:50 PM EDT
\nI can swallow fine.
\nSORE throat? Question
\n07\/23\/20 3:50 PM EDT
\nNo, it\u2019s fine.
\nAny voice changes? Question
\n07\/23\/20 3:50 PM EDT
\nMy voice has been fine.
\nAny swollen lymph nodes? Question
\n07\/23\/20 3:52 PM EDT
\nMy lymph nodes seem fine.
\nAre you having any nausea? Question
\n07\/23\/20 3:52 PM EDT
\nNo, I haven\u2019t been nauseous at all.
\nAny vomiting? Question
\n07\/23\/20 3:53 PM EDT
\nNo.
\nANY pain in the abdomen? Question
\n07\/23\/20 3:53 PM EDT
\nI haven\u2019t really had any stomach problems since I came in with them a while ago.
\nAny constipation? Question
\n07\/23\/20 3:53 PM EDT
\nI don\u2019t have that problem. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nAny diarrhea? Question
\n07\/23\/20 3:54 PM EDT
\nI haven\u2019t had any problems with diarrhea.
\nExcessive flatulence? Question
\n07\/23\/20 3:54 PM EDT
\nI haven\u2019t been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked.
\nflatulence is one of the side effect of metformin Educate
\n07\/23\/20 3:55 PM EDT
\nThanks for telling me.
\nAny food intolerance Question
\n07\/23\/20 3:56 PM EDT
\nI can eat just about anything.
\nAny burning sensation when you urinate? Question
\n07\/23\/20 3:56 PM EDT
\nNo, it doesn\u2019t burn when I pee.
\nAny blood in your urine? Question
\n07\/23\/20 3:57 PM EDT
\nNo! That doesn\u2019t sound like it would be good.
\nAre you having any pain right now? Question
\n07\/23\/20 3:57 PM EDT
\nI don\u2019t have any pain anywhere.
\nAny vaginal discharge? Question
\n07\/23\/20 3:58 PM EDT
\nMy discharge is normal, I think. . . I have a little, and it\u2019s kind of clear, sometimes white-ish. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nAny vaginal itching? Question
\n07\/23\/20 3:58 PM EDT
\nNo, it feels normal.
\nDo you have any problem with your breasts? Question
\n07\/23\/20 3:59 PM EDT
\nNo, my breasts feel fine.
\nAny pain in the breasts? Question
\n07\/23\/20 3:59 PM EDT
\nNo, my breasts feel fine.
\nAre you having any dizziness\/ Question
\n07\/23\/20 3:59 PM EDT
\nI haven\u2019t been getting dizzy at all.
\nAny lightheadedness? Question
\n07\/23\/20 4:00 PM EDT
\nNo, I don\u2019t really get lightheaded.
\nAny tingling? Question
\n07\/23\/20 4:00 PM EDT
\nNope, no tingling. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nAny loss of balance? Question
\n07\/23\/20 4:00 PM EDT
\nMy balance is fine.
\nAny changes in sensation? Question
\n07\/23\/20 4:00 PM EDT
\nI haven\u2019t noticed any changes.
\nAny seizures? Question
\n07\/23\/20 4:01 PM EDT
\nNo, I\u2019ve still never had problems with seizures, fortunately.
\nDo you have memory problems? Question
\n07\/23\/20 4:01 PM EDT
\nI think my memory has been fine.
\nAny muscle pain? Question
\n07\/23\/20 4:01 PM EDT
\nMy muscles have felt great, especially since I started exercising more.
\nJoint pain? Question
\n07\/23\/20 4:02 PM EDT
\nMy joints always seem fine. Comprehensive Assessment Tina Jones Shadow Health Transcript
\nAny muscle weakness? Question
\n07\/23\/20 4:02 PM EDT
\nNo, I haven\u2019t felt weak at all.
\nAny swelling? Question
\n07\/23\/20 4:03 PM EDT
\nNothing is swollen.
\nPerformed pulse oximetry Exam Action
\n07\/24\/20 10:01 AM EDT
\nPerformed spirometry Exam Action
\n07\/24\/20 10:01 AM EDT
\nInspected scalp Exam Action
\n07\/24\/20 10:01 AM EDT
\nInspected scalp Exam Action
\n07\/24\/20 10:01 AM EDT
\nInspected hair on scalp Exam Action
\n07\/24\/20 10:01 AM EDT
\nInspected scalp Exam Action
\n07\/24\/20 10:01 AM EDT
\nInspected right eyebrow and orbital area Exam Action
\n07\/24\/20 10:02 AM EDT
\nInspected left eyebrow and orbital area Exam Action
\n07\/24\/20 10:02 AM EDT
\nInspected mouth: Oral mucosa moist. Exam Action
\n07\/24\/20 10:02 AM EDT
\nSubjective Data Collection: 50 of 50 (100.0%)<\/p>\n
Hover To Reveal\u2026<\/p>\n
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.<\/p>\n
Found:
\nIndicates an item that you found.<\/p>\n
Available:
\nIndicates an item that is available to be found.<\/p>\n
Category<\/p>\n
Scored Items<\/p>\n
Experts selected these topics as essential components of a strong, thorough interview with this patient.<\/p>\n
Patient Data
\nCurrent Health Status
\nFinding: A confirmed reason for the visit<\/p>\n
Finding: Reports needing a pre-employment physical<\/p>\n
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.<\/p>\n
Example Question: Can I confirm that you are here for a physical?<\/p>\n
Finding: Reports no current acute health problems<\/p>\n
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.<\/p>\n
Example Question: Do you have any current health problems?<\/p>\n
Finding: Asked about last visit to a healthcare provider<\/p>\n
Finding: Last visit to a healthcare provider was 4 months ago<\/p>\n
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.<\/p>\n
Example Question: When did you see a healthcare provider?<\/p>\n
Finding: Reason for last visit was annual gynecological exam<\/p>\n
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.<\/p>\n
Example Question: Why did you see a healthcare provider?<\/p>\n
Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler<\/p>\n
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.<\/p>\n
Example Question: When was your last physical exam?<\/p>\n
Finding: Asked about current prescription medications<\/p>\n
Finding: Reports taking diabetes medication<\/p>\n
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.<\/p>\n
Example Question: Have you been taking medication for your diabetes?<\/p>\n
Finding: Reports using a daily inhaler<\/p>\n
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.<\/p>\n
Example Question: Do you use a daily inhaler?<\/p>\n
Finding: Reports taking prescription birth control pills<\/p>\n
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.<\/p>\n
Example Question: Are you taking any form of birth control?<\/p>\n
Finding: Followed up about diabetes medication<\/p>\n
Finding: Medication is metformin<\/p>\n
Pro Tip: Follow up questions about Tina\u2019s medication history will help you to understand her treatment plan and recent health history.<\/p>\n
Example Question: What is the name of your diabetes medication?<\/p>\n
Finding: Started taking metformin 5 months ago<\/p>\n
Pro Tip: Follow up questions about Tina\u2019s medication history and timeline will help you to understand her treatment plan and recent health history.<\/p>\n
Example Question: How long have you been taking metformin?<\/p>\n
Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time<\/p>\n
Pro Tip: Follow up questions about Tina\u2019s medication history and timeline will help you to understand her treatment plan and recent health history.<\/p>\n
Example Question: Have you noticed any side effects from the metformin?<\/p>\n
Finding: Followed up on metformin frequency and dose<\/p>\n
Finding: Reports taking metformin twice daily<\/p>\n
Pro Tip: Follow up questions about Tina\u2019s medication history and timeline will help you to understand her treatment plan and recent health history.<\/p>\n
Example Question: How many times a day do you take metformin?<\/p>\n
Finding: Metformin dose is 850 mg<\/p>\n
Pro Tip: Follow up questions about Tina\u2019s medication history and timeline will help you to understand her treatment plan and recent health history. Comprehensive Assessment Tina Jones Shadow Health Transcript<\/p>\n
Example Question: What is the dose of your metformin?<\/p>\n
Finding: Asked about asthma medication<\/p>\n
Finding: Reports using Flovent inhaler twice daily<\/p>\n
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina\u2019s been using her inhaler more frequently since exacerbation can indicate how she\u2019s been treating her symptoms since exacerbation.<\/p>\n
Example Question: How often do you use your daily inhaler?<\/p>\n
Finding: Has a Proventil rescue inhaler<\/p>\n
Pro Tip: A patient\u2019s medication reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.<\/p>\n
Example Question: Do you have a rescue inhaler?<\/p>\n
Finding: Last use of Proventil inhaler was three months ago<\/p>\n
Pro Tip: Soliciting a shallow history of a patient\u2019s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.<\/p>\n
Example Question: When did you last use your rescue inhaler?<\/p>\n
Finding: Has used Proventil inhaler twice in the last year<\/p>\n
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina\u2019s been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation.<\/p>\n
Example Question: How often do you use your rescue inhaler?<\/p>\n
Finding: Followed up about birth control prescription<\/p>\n
Finding: I started taking birth control 4 months ago<\/p>\n
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.<\/p>\n
Example Question: How long ago did you start taking birth control?<\/p>\n
Finding: Reason for birth control was to manage PCOS symptoms<\/p>\n
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.<\/p>\n
Example Question: Why did you decide to start taking birth control?<\/p>\n
Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol)<\/p>\n
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina\u2019s birth control pill will solicit information about her health history and current treatment plan.<\/p>\n
Example Question: What type of birth control do you use?<\/p>\n
Finding: Takes birth control pill daily<\/p>\n
Pro Tip: Follow up questions about Tina\u2019s birth control prescription can help you to understand how effectively she complies with her treatment plan.<\/p>\n
Example Question: How often do you take your birth control pill?<\/p>\n
Finding: Takes birth control pill at the same time every day<\/p>\n
Pro Tip: Follow up questions about Tina\u2019s birth control prescription can help you to understand how effectively she complies with her treatment plan.<\/p>\n
Example Question: Do you take your pill at the same time every day?<\/p>\n
Finding: Reports no skipped days<\/p>\n
Pro Tip: Follow up questions about Tina\u2019s birth control prescription can help you to understand how effectively she complies with her treatment plan.<\/p>\n
Example Question: Have you missed any days of your birth control pill?<\/p>\n
Finding: Asked about current non-prescription medications<\/p>\n
Finding: Reports rare Advil use for cramps<\/p>\n
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan.<\/p>\n
Example Question: Do you take Advil?<\/p>\n
Finding: Reports no OTC herbal products<\/p>\n
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan.<\/p>\n
Example Question: Do you use any herbal products?<\/p>\n
Finding: Reports no OTC vitamins<\/p>\n
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan.<\/p>\n
Example Question: Do you take any vitamins?<\/p>\n
Finding: Reports no OTC supplements<\/p>\n
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan.<\/p>\n
Example Question: Do you take any supplements?<\/p>\n
Finding: Asked about allergies<\/p>\n
Finding: Confirms allergies<\/p>\n
Pro Tip: Discerning what is making Tina\u2019s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina\u2019s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina\u2019s health literacy.<\/p>\n
Example Question: Can you confirm your allergies?<\/p>\n
Finding: Reports no new allergies<\/p>\n
Pro Tip: Discerning whether anything is making Tina\u2019s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina\u2019s breathing.<\/p>\n
Example Question: Have you noticed any new allergies?<\/p>\n
Finding: Followed up on seasonal allergies<\/p>\n
Finding: Reports no recent seasonal allergy symptoms<\/p>\n
Pro Tip: Discerning whether anything is making Tina\u2019s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina\u2019s breathing.<\/p>\n
Example Question: Have you been having seasonal allergies?<\/p>\n
Finding: Reports no current medication for allergies<\/p>\n
Pro Tip: Tina\u2019s response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way she\u2019s complied with previous treatment plans.<\/p>\n
Example Question: Are you taking any medication for your allergies?<\/p>\n
Finding: Asked about diabetes<\/p>\n
Finding: Reports managing diabetes with diet and exercise in addition to medication<\/p>\n
Pro Tip: Tina\u2019s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she is complied with previous treatment plans.<\/p>\n
Example Question: How are you managing your diabetes?<\/p>\n
Finding: Asked about blood glucose monitoring<\/p>\n
Finding: Reports checking blood sugar once a day<\/p>\n
Pro Tip: Tina\u2019s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she\u2019s complied with previous treatment plans.<\/p>\n
Example Question: How often do you monitor your blood glucose?<\/p>\n
Finding: Checks sugar in the morning<\/p>\n
Pro Tip: Tina\u2019s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she is complied with previous treatment plans.<\/p>\n
Example Question: When do you check your blood glucose?<\/p>\n
Findng: Blood sugar number is usually around 90<\/p>\n
Pro Tip: Tina\u2019s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she\u2019 complied with previous treatment plans.<\/p>\n
Example Qestion: What is your average blood sugar number?<\/p>\n
Finding: Reports having adequate supplies<\/p>\n
Objective Data Collection: 70 of 73 (95.9%)<\/p>\n
Hover To Reveal\u2026<\/p>\n
Hover over the Patient Data items below to reveal important information, including Pro Tips.<\/p>\n
Found: Indicates an item that you found.<\/p>\n
Available: Indicates an item that is available to be found.<\/p>\n
Category<\/p>\n
Scored Items<\/p>\n
Experts selected these examinations as essential components of objective data collection for this patient.<\/p>\n
Patient Data<\/p>\n
Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient\u2019s case.<\/p>\n
HEENT<\/p>\n
Fining: Inspected head and neck<\/p>\n
Finding: Scattered pustules on face and facial hair on upper lip<\/p>\n
Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.<\/p>\n
Finding: Head is normocephalic, atraumatic<\/p>\n
Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient\u2019s head can identify any indications of trauma.<\/p>\n
Finding: Normal scalp hair distribution<\/p>\n
Pro Tip: It\u2019s important to inspect your patient\u2019s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.<\/p>\n
Finding: Acanthosis nigricans noted on neck<\/p>\n
Pro Tip: Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient\u2019s skin, especially in folds around the neck, axilla, and groin.<\/p>\n
Finding: Inspected eyebrows and orbital area<\/p>\n
Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema<\/p>\n
Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.<\/p>\n
Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema<\/p>\n
Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.<\/p>\n
Finding: Palpated scalp<\/p>\n
Finding: No masses<\/p>\n
Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.<\/p>\n
Finding: Palpated sinuses<\/p>\n
Finding: No frontal sinus tenderness<\/p>\n
Pro Tip: Palpating the frontal sinuses checks for sinusitis.<\/p>\n
Finding: No maxillary sinus tenderness<\/p>\n
Pro Tip: Palpating the maxillary sinuses checks for sinusitis.<\/p>\n
Finding: Palpated jaw<\/p>\n
Finding: No clicks, full ROM<\/p>\n
Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury.<\/p>\n
Finding: Palpated lymph nodes<\/p>\n
Finding: No axillary lymphadenopathy<\/p>\n
Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.<\/p>\n
Finding: No supraclavicular lymphadenopathy<\/p>\n
Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.<\/p>\n
Finding: Palpated thyroid<\/p>\n
Finding: Thyroid smooth without nodules, no goiter<\/p>\n
Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.<\/p>\n
Finding: Inspected eyelids and conjunctiva<\/p>\n
Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera<\/p>\n
Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.<\/p>\n
Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera<\/p>\n
Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.<\/p>\n
Finding: Tested PERRL with penlight<\/p>\n
Finding: Right pupil: equal, round, reactive to light<\/p>\n
Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.<\/p>\n
Finding: Left pupil: equal, round, reactive to light<\/p>\n
Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.<\/p>\n
Finding: Tested eye movements<\/p>\n
Finding: Normal convergence<\/p>\n
Pro Tip: This test accommodation assesses the eye\u2019s ability to focus on close objects.<\/p>\n
Finding: EOMs intact bilaterally, no nystagmus<\/p>\n
Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions.<\/p>\n
Finding: Tested peripheral vision<\/p>\n
Finding: Peripheral vision intact in both eyes, all fields<\/p>\n
Finding: Inspected interior eyes with ophthalmoscope<\/p>\n
Finding: Mild retinopathic changes on right<\/p>\n
Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. By visualizing the fundus, you can look for any retinopathic changes.<\/p>\n
Finding: Left fundus with sharp disc margins, no hemorrhages<\/p>\n
Finding: Palpated abdomen \u2013 deep<\/p>\n
Finding: Right upper quadrant: no masses, guarding or rebound<\/p>\n
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.<\/p>\n
Finding: Right lower quadrant: no masses, guarding or rebound<\/p>\n
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.<\/p>\n
Finding: Left upper quadrant: no masses, guarding or rebound<\/p>\n
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.<\/p>\n
Finding: Left lower quadrant: no masses, guarding or rebound<\/p>\n
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.<\/p>\n
Finding: Palpated organs<\/p>\n
Finding: Liver: palpable 1 cm below right costal margin<\/p>\n
Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems.<\/p>\n
Finding: Spleen: not palpable<\/p>\n
Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions.<\/p>\n
Finding: Right kidney: not palpable, no masses<\/p>\n
Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.<\/p>\n
Finding: Left kidney: not palpable, no masses<\/p>\n
Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.<\/p>\n
Musculoskeletal<\/p>\n
Finding: Inspected neck<\/p>\n
Finding: Neck without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Inspected upper extremities<\/p>\n
Finding: Right shoulder without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Right arm without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Right elbow without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Right wrist and hand without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Left shoulder without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Left arm without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Left elbow without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Left wrist and hand without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds<\/p>\n
Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease.<\/p>\n
Finding: Inspected hips<\/p>\n
Finding: Hips without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Inspected lower extremities<\/p>\n
Finding: Right leg without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Right knee without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Right ankle without swelling, masses, deformity, or discoloration<\/p>\n
Pro Tip: A thorough inspection of your patient\u2019s affected ankle aids in the estimation of the extent of tissue injury and disability.<\/p>\n
Finding: Right foot without swelling, masses, or deformity<\/p>\n
Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status.<\/p>\n
Finding: Left leg without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Left knee without swelling, masses, or deformity<\/p>\n
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.<\/p>\n
Finding: Left ankle without swelling, masses, or deformity<\/p>\n
Pro Tip: The inspection of your patient\u2019s unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall.<\/p>\n
Finding: Left foot without swelling, masses, or deformity<\/p>\n
Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy.<\/p>\n
Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds<\/p>\n
Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease.<\/p>\n
Finding: Tested ROM for upper extremities<\/p>\n
Finding: Right and left shoulders: full ROM<\/p>\n
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.<\/p>\n
Finding: Right and left elbows: full ROM<\/p>\n
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.<\/p>\n
Finding: Right and left wrists: full ROM<\/p>\n
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.<\/p>\n
Finding: Tested ROM for spine<\/p>\n
Finding: Rotate left: full ROM<\/p>\n
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.<\/p>\n
Finding: Rotate right: full ROM<\/p>\n
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.<\/p>\n
Finding: Extension: full ROM<\/p>\n
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury.<\/p>\n
Finding:<\/p>\n
Flexion: full ROM<\/p>\n
Documentation \/ Electronic Health Record<\/p>\n
Vitals<\/p>\n
Student Documentation Model Documentation
\n128\/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs \u2022 Height: 170 cm \u2022 Weight: 84 kg \u2022 BMI: 29.0 \u2022 Blood Glucose: 100 \u2022 RR: 15 \u2022 HR: 78 \u2022 BP:128 \/ 82 \u2022 Pulse Ox: 99% \u2022 Temperature: 99.0 F
\nHealth History<\/p>\n
Student Documentation Model Documentation
\nIdentifying Data & ReliabilityThe patient is a 28-year-old female who presented for a pre-employment physical exam. She provided the health information freely during the interview. Ms. Jones\u2019 speech is clear and coherent Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
\nGeneral SurveyMs. Jones appears alert and oriented She is appropriately dressed She appears to be in good health Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
\nReason for VisitMs. Jones visited to have a physical exam for the health insurance at her new workplace \u201cI came in because I\u2019m required to have a recent physical exam for the health insurance at my new job.\u201d
\nHistory of Present IllnessMs. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Comprehensive Assessment Tina Jones Shadow Health TranscriptMs. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects currently. She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job.
\nMedicationsMetformin 850 PO BID Flovent 2 puffs 88 mcg\/spray BID Albuterol 90 mcg\/spray MDI 2 puffs Q4H Drospirenone PO QD \u2022 Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) \u2022 Metformin, 850 mg PO BID (last use: this morning) \u2022 Drospirenone and ethinyl estradiol PO QD (last use: this morning) \u2022 Albuterol 90 mcg\/spray MDI 2 puffs Q4H prn (last use: three months ago) \u2022 Acetaminophen 500-1000 mg PO prn (headaches) \u2022 Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)
\nAllergiesAllergic to cats and dust Allergic to penicillin Denies any food or latex allergy \u2022 Penicillin: rash \u2022 Denies food and latex allergies \u2022 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.
\nMedical HistoryDiagnosed with asthma at 2 1\/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Asthma diagnosed at age 2 1\/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB\/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV\/AIDS and STIs four months ago.
\nNeurological<\/p>\n
Student Documentation Model Documentation
\nSubjectiveDenies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.Comprehensive Assessment Tina Jones Shadow Health Transcript
\nObjectiveNormal graphesthesia, stereognosis and rapid alternating movements bilaterally Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.
\nSkin, Hair & Nails<\/p>\n
Student Documentation Model Documentation
\nSubjectiveReports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changes Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.
\nScattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridges Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities.
\nReferences on Comprehensive Assessment Tina Jones Shadow Health Transcript
\nNational Institute of Health. https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK493211\/<\/p>\n","protected":false},"excerpt":{"rendered":"
Building a Health History: A Patient-Centered Approach to Tina Jones. Effective communication forms the bedrock of accurate and detailed patient history, a cornerstone of quality healthcare. Advanced practice nurses must remain cognizant of the diverse factors influencing a patient’s health, including age, gender, ethnicity, and environmental setting, tailoring their communication techniques to each individual. This […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[815,2118,2429,1352,2465],"tags":[2462,2466,2461,1949,2464,2463,1894],"class_list":["post-5805","post","type-post","status-publish","format-standard","hentry","category-shadow-health-exam","category-help-writing-nursing-case-study-homework","category-nursing-case-study-discussion","category-sample-nursing-case-studies-with-answers","category-shadow-health-assessment-assignment-help","tag-communication-techniques","tag-diabetes","tag-health-history","tag-nurs-6512","tag-nurs-6512-week-1-discussion","tag-risk-assessment","tag-social-determinants"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/5805","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/comments?post=5805"}],"version-history":[{"count":2,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/5805\/revisions"}],"predecessor-version":[{"id":5808,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/5805\/revisions\/5808"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/media?parent=5805"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/categories?post=5805"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/tags?post=5805"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}