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Tina Jones - SHADOW HEALTH
University of Central Florida
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Comprehensive Assessment Results | Turned In
Health Assess - Spring 1 2020, 322301
Return to Assignment (/assignments/289776/)
Subjective Data Collection: 33 of 33 (100%)
Current Health Status
Your Results Lab Pass (/assignment_attempts/6135509/lab_pass
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Documentation
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 yield better patient data. The following details are facts of t patient's case.
Asked about current health problems Denies current acute health problems Reports diabetes Reports asthma
Asked about last visit to a healthcare provider Reports last visit to a healthcare provider was 4 months ago Reports reason for last visit was annual gynecological exam Reports last general physical examination was 5 months ago
Asked about current prescription medications Reports taking diabetes medication Reports having an inhaler Reports taking prescription birth control pills
Followed up about diabetes medication Reports diabetes medication is metformin Reports starting taking diabetes medication 5 months ago Reports that side effects of diabetes medication abated over time Reports taking diabetes medication twice daily Reports diabetes medication dose is 850 mg Denies adverse effects of diabetes medication
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Asked about asthma medication Reports asthma medication has not changed Reports inhaler is albuterol (Proventil) Reports using inhaler no more than 2 times per week Reports recommended dose is 1-3 puffs as needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms Denies adverse effects of asthma medication
Followed up about birth control prescription Reports starting birth control 4 months ago Reports reason for birth control was to manage PCOS symptoms Reports birth control is drospirenone and ethinyl estradiol (Yaz) Reports taking birth control pill daily Reports taking birth control pill at the same time every day Denies adverse side effects from birth control
Asked about current non-prescription medications
Reports occasional ibuprofen use Denies OTC herbals Denies OTC supplements
Followed up on ibuprofen (Advil) Reports taking ibuprofen for cramps Reports ibuprofen is regular strength Reports ibuprofen is effective Reports last use of ibuprofen was six weeks ago
Asked about allergies Reports allergies have not changed Reports penicillin allergy Reports cat allergy Reports dust allergy
Asked about diabetes management through lifestyle
Reports recently beginning dieting to manage diabetes Reports recently beginning exercising to manage diabetes
Asked about blood glucose monitoring Reports checking blood sugar once a day Reports checking sugar in the morning Reports using glucometer Reports blood sugar number is usually around 90 Reports having adequate supplies
Asked about asthma symptoms Denies change in asthma symptoms Reports belief that asthma is well-controlled Denies current asthma symptoms Reports last use of Proventil inhaler was yesterday
Asked about vision Reports optometrist visit Reports last optometrist visit was 3 months ago Reports recently prescribed eyeglasses Reports that glasses improve overall vision
Reports dust allergy (Available)
Subjective Action
Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important.
Example Question: "Are you allergic to dust?"
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Denies swelling
Asked about HEENT Denies general HEENT issues
Asked about review of systems for respiratory Denies current breathing problems Reports occasional shortness of breath Reports occasional wheezing Reports occasional chest tightness Denies pain while breathing Denies coughing
Asked about review of systems for cardiovascular Denies cardiovascular issues
Asked review of systems for gastrointestinal Denies gastrointestinal issues
Asked review of systems for genitourinary Denies genitourinary issues
Asked review of systems for musculoskeletal Denies musculoskeletal issues
Asked review of systems for neurological Denies neurological issues
Asked review of systems for skin, hair and nails Denies integumentary issues
Comments
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Tina Jones - SHADOW HEALTH
University: University of Central Florida
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