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Shadow Health Tine Jones Health History Subjective Data
Adv Hlth Assess/Diagnostic Rea (NSG 510)
University of North Carolina Wilmington
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Health History Results | Turned In
Advanced Health Assessment - Summer 2021, NUR 703
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Subjective Data Collection: 95 of 100 (95%)
Chief Complaint
History of Present Illness
Your Results Lab Pass (/assignment_attempts/9873101/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 Student Survey
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 the 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/
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
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Support
Past Medical History
foot
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
Home Medications
asthma inhaler needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms
Asked about asthma triggers Reports asthma triggered by cats Reports asthma triggered by dust Reports asthma triggered by running up stairs Denies seasonal triggers
Asked about general allergies Reports allergy to cats
Followed up on cat allergy symptoms Reports sneezing, itchy eyes, and wheezing
Asked about latex allergy Denies latex allergy
Asked about medication allergies Reports penicillin allergy
Asked about penicillin reaction Reports that penicillin resulted in hives in childhood
Asked about food allergies Denies food allergies
Asked if the patient has allergies to dust, mold, or pollen
Reports reaction to dust Reports dust causes sneezing, itchy eyes, and wheezing Denies seasonal allergies
Asked about general immunizations received Reports being up to date on shots
Asked about childhood immunizations Reports receiving all necessary childhood immunizations
Asked if the patient has received a flu vaccine Denies receiving annual flu vaccine
Asked if the patient received a tetanus immunization
Reports last tetanus vaccination was in the past year
Asked about hypertension Denies past diagnosis of hypertension Reports that last BP reading was 140 over 80 or 90 Denies checking BP regularly
Asked about use of pain medication Reports taking prescription pain medication Reports medication is tramadol
Followed up on pain medication frequency Reports taking pain medication for 2 days Reports taking tramadol 3 times a day
Social Determinants of Health
Social History
Reports last dose was this morning
Followed up on pain medication dose Reports dosage is 50 mg Reports taking 2 pills each time
Followed up on efficacy of pain medication Reports that pain pills provide partial relief Reports pain returns in full every few hours
Asked about other prescription medications Reports a prescription inhaler
Asked about use of OTC medication Reports occasionally taking Advil (ibuprofen) for cramps Reports occasionally taking Tylenol (acetaminophen) for headaches Denies vitamin supplements Denies herbal supplements
Asked about access to healthcare Denies finances are a barrier to healthcare Denies transportation is a barrier to healthcare
Followed up on diabetes noncompliance Reports that she got sick of the demands of medication compliance Reports disliking metformin side effects Reports disliking checking blood glucose Denies that cost of metformin was reason for discontinuing medication Denies that glucometer-related costs are reason for not checking blood glucose
Asked about patient's level of education Reports currently working toward undergraduate degree Reports her major is accounting
Asked about patient's living situation Reports living with mother and sister Reports family members will be able to help with activities
Asked about stressors Reports she is currently under high stress
Asked about food intake Reports last meal was dinner time the previous night Reports last meal consisted of baked chicken and mashed potatoes Reports breakfast is usually a muffin or pumpkin bread Reports lunch is usually a sandwich Reports dinner is usually a home-cooked meat dish and side of vegetables Reports snacks are pretzels or French fries
Review of Systems
Reports paternal grandmother diagnosed with high cholesterol
Asked about maternal grandfather's health Reports maternal grandfather diagnosed with high blood pressure Reports maternal grandfather diagnosed with high cholesterol
Asked about maternal grandmother's health Reports maternal grandmother diagnosed with high blood pressure Reports maternal grandmother diagnosed with high cholesterol
Asked about brother's health Denies brother having diagnosed health problems
Asked about sister's health Reports sister diagnosed with asthma
Asked about family history of obesity Reports that family members are overweight
Asked about family history of thyroid issues Denies family history of thyroid issues
Asked about family history of substance abuse Reports 1 uncle has alcoholism
Asked about family history of headaches Denies family history of headaches
Asked about constitutional health Reports occasional tiredness or fatigue Reports typical sleep pattern Reports fever Reports chills Denies night sweats
Asked about review of systems for mental health
Denies depression Denies suicidal ideation or attempts
Asked about review of systems for head Reports occasional headaches Denies current headache Denies head injury
Asked about review of systems for ears Denies change in hearing Denies ringing or tinnitus Denies ear pain Denies ear discharge
Asked about review of systems for eyes and vision
Reports periods of blurry vision Denies corrective lenses Denies double vision Reports infrequent itchy eyes Denies eye redness Denies discharge, crusting or wateriness
Denies eye pain Denies dry eyes Reports last eye exam was in childhood
Asked about review of systems for nose Reports infrequent nose problems Reports infrequent runny nose Denies frequent sinus problems Denies change in sense of smell Denies nosebleeds
Asked about review of systems for mouth and jaw
Denies dental problems Reports last dental visit was several years ago Denies change in sense of taste Denies dry mouth Denies mouth pain Denies mouth sores Denies gum problems Denies tongue problems Denies jaw problems
Asked about review of systems for neck, throat, and glands
Denies difficulty swallowing Denies sore throat Denies lymph node problems Denies frequent sore throat Denies swollen glands Denies voice changes Denies general neck problems
Asked about breast health Reports doing occasional breast exams Denies general breast problems Denies breast lumps Denies breast pain Denies nipple changes Denies nipple discharge Denies ever having a mammogram
Asked about review of systems for respiratory Denies current breathing problems Denies current wheezing Denies current chest tightness Denies pain while breathing Denies frequent coughing
Asked about review of systems for cardiovascular
Denies chest pain or discomfort Denies palpitations Denies irregular heartbeat Denies easy bruising Denies edema Denies circulation problems Denies vascular diseases
Asked review of systems for gastrointestinal Denies nausea Denies vomiting Denies stomach pain Denies change in bowel movements Denies heartburn, GERD, or indigestion Denies constipation Denies diarrhea or loose stool
Denies STI symptoms Reports uncertainty about past partners and STI testing
Asked about history of pap smears Reports last pap smear was 4 years ago Reports no abnormal pap smears
Asked about history of pregnancy Denies current pregnancy Denies past pregnancies
Asked review of systems for musculoskeletal Denies muscle pain Denies joint pain Denies muscle weakness Denies joint swelling Denies back pain Denies history of fractures or breaks
Asked review of systems for neurological Denies recent loss of consciousness or fainting Denies dizziness or vertigo Denies lightheadedness Denies vision disturbances Denies tingling Denies loss of coordination Denies loss of sensation Denies history of seizures Denies problems with balance or disequilibrium Denies memory loss
Asked review of systems for skin, hair, and nails
Denies skin rashes Reports rarely using sunscreen Reports acne Reports excessive facial or body hair Reports changes to neck skin Reports moles Reports no body sores (aside from foot wound) Denies dandruff Denies nail abnormalities Reports occasional dry skin
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Shadow Health Tine Jones Health History Subjective Data
Course: Adv Hlth Assess/Diagnostic Rea (NSG 510)
University: University of North Carolina Wilmington
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