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Documentation Health History (Week 1 required) Completed Shadow Health
Advanced Clinical Assessment & Diagnostic Reasoning Across T (NURS 550)
Drexel University
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Health History (Week 1 required) Results | Completed
Advanced Health Assessment and Diagnostic Reasoning - Spring 2021, N
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Documentation / Electronic Health Record
Document: Provider Notes
Student Documentation Model Documentation
Identifying Data & Reliability
TJ is a 28 y/o African American female. 90kg. BMI 31. Temp 101. BP 142/82 RR 19 HR 86 SpO2 99% on room air. Blood glucose of 238. currently single, never married, no children.
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a rece right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Sp is clear and coherent. She maintains eye contact throughout interview.
General Survey
AAOx 4. Generally well appearing. Obese. Pleasant, but quiet affect.
Ms. Jones is alert and oriented, seated upright on the exami table, and is in no apparent distress. She is well-nourished, w developed, and dressed appropriately with good hygiene.
Chief Complaint
TJ presents today to establish primary care and concerns for a scrape on her foot that apprears to have become infected and painful. 7/10 pain.
“I got this scrape on my foot a while ago, and I thought it wo heal up on its own, but now it's looking pretty nasty. And the is killing me!”
Your Results Turn In (/assignment_attempts/9573252/choo
Reopen (/assignment_attempts/9573252/reope
Lab Pass (/assignment_attempts/9573252/lab_pass.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Information Processing
Program Competency Progress
Health History Tips and Tricks
Self-Reflection
Document: Provider Notes
Suppor t
Student Documentation Model Documentation
History Of Present Illness
TJ slipped and scrapped R foot on steps. No break per XR at ED. Give Rx for tramadol. Now presents with c/o of pain, swelling, drainage from wound. Difficulty bearing weight.
Ms. Jones reports that a week ago she tripped while walking concrete stairs outside, twisting her right ankle and scraping ball of her foot. She sought care in a local emergency depart where she had x-rays that were negative; she was treated w tramadol for pain. She has been cleansing the site twice a d She has been applying antibiotic ointment and a bandage. S reports that ankle swelling and pain have resolved but that th bottom of the foot is increasingly painful. The pain is describ “throbbing” and “sharp” with weight bearing. She states her “ached” but is resolved. Pain is rated 7 out of 10 after a rece dose of tramadol. Pain is rated 9 with weight bearing. She re that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the woun shoes feel tight. She has been wearing slip-ons. She reports of 102 last night. She denies recent illness. Reports a 10-po unintentional weight loss over the month and increased appe Denies change in diet or level of activity.
Medications
proventil inhaler 90mcg 2puffs PRN tramadol 50mg ibuprofen 200mg PRN acetaminophen 500mg PRN
Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofe mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO TID (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago)
Allergies
Penicillin, cats, vaccine?
Penicillin: rash • Denies food and latex allergies • Allergic to c and dust. When she is exposed to allergens she states that s has runny nose, itchy and swollen eyes, and increased asthm symptoms.
Medical History
type 2 DM asthma(uncontrolled?)
Asthma diagnosed at age 2 1/2. She uses her albuterol inha when she is around cats and dust. She uses her inhaler 2 to times per week. She was exposed to cats three days ago an to use her inhaler once with positive relief of symptoms. She last hospitalized for asthma “in high school”. Never intubate Type 2 diabetes, diagnosed at age 24. She previously took metformin, but she stopped three years ago, stating that the made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn't monitor her blood sugar. L blood glucose was elevated last week in the emergency room surgeries. OB/GYN: Menarche, age 11. First sexual encount age 18, sex with men, identifies as heterosexual. Never preg Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9- No current partner. Used oral contraceptives in the past. Wh sexually active, reports she did not use condoms. Never test HIV/AIDS. No history of STIs or STI symptoms. Last tested f STIs four years ago. Hematologic: Denies bleeding, bruising blood transfusions and history of blood clots. Skin: Reports since puberty and bumps on the back of her arms when her is dry. Complains of darkened skin on her neck and increase and body hair. She reports a few moles but no other hair or n changes.
Student Documentation Model Documentation
Review of Systems
HEENT: visual problems- headaches with reading. NO recent visit to opthomalogy
Resp: hx of asthma. not well controlled with rescue inhaler.
CV: negative
GI: negative
GU: negative
ENDO/Reprod: hx of type2 DM- noncompliant on medications. Irregular menstrual cycles.
INTEG:
(No Model Documentation Provided)
Objective
2cm x 1 x 2 deep would to sole of right foot below first and second metatarsal. C&S sent to lab.
Wound: 2 cm x 1 cm, 2 mm deep wound, red wound edg right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema, no tracking.
Comments
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Documentation Health History (Week 1 required) Completed Shadow Health
Course: Advanced Clinical Assessment & Diagnostic Reasoning Across T (NURS 550)
University: Drexel University
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