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Shadow Health - Tina Jones Comprehensive Assessment Subjective Week 9
Advanced Health Assessment & Diagnostic Reasoning (6512c)
Walden University
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Week 9 - Comprehensive Assessment, Tina Jones - REQUIRED Results | Turned I
Advanced Health Assessment and Diagnostic Reasoning - NP - August 2022, nurs6512-laureate_higher_education_group-
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Subjective Data Collection: 50 of 50 (100%)
Current Health Status
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Overview
Transcript
Subjective Data Collection
Objective Data Collection
Documentation
Program Competency Progress
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 y better patient data. The following details are facts patient's case.
Confirmed reason for visit Reports needing a pre-employment physical Reports no current acute health problems
Asked about last visit to a healthcare provider Last visit to a healthcare provider was 4 months ago Reason for last visit was annual gynecological exam Last general physical examination was 5 month ago when she was prescribed metformin and dail inhaler
Asked about current prescription medications Reports taking diabetes medication Reports using a daily inhaler Reports taking prescription birth control pills
Followed up about diabetes medication Medication is metformin Started taking metformin 5 months ago Reports that eating probiotic yogurt helps with side effects and they have abated over time
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Followed up on metformin frequency and dose Reports taking metformin twice daily Metformin dose is 850 mg
Asked about asthma medication Reports using Flovent inhaler twice daily Has a Proventil rescue inhaler Last use of Proventil inhaler was three months ago Has used Proventil inhaler twice in the last year
Followed up about birth control prescription Started taking birth control 4 months ago Reason for birth control was to manage PCOS symptoms Birth control type is Yaz (drospirenone and ethinyl estradiol) Takes birth control pill daily Takes birth control pill at the same time every day Reports no skipped days
Asked about current non-prescription medications
Reports rare Advil use for cramps Reports no OTC herbal products Reports no OTC vitamins Reports no OTC supplements
Asked about allergies Confirms allergies Reports no new allergies
Followed up on seasonal allergies Reports no recent seasonal allergy symptoms Reports no current medication for allergies
Asked about diabetes Reports managing diabetes with diet and exercise in addition to medication
Asked about blood glucose monitoring Reports checking blood sugar once a day Checks sugar in the morning Blood sugar number is usually around 90 Reports having adequate supplies
Asked about asthma symptoms Reports no current asthma symptoms Reports no recent asthma exacerbations Reports last asthma exacerbation was three months ago
Asked about headache symptoms Reports no recent headache
Asked about vision Reports optometrist visit Optometrist visit 3 months ago Reports prescription eyeglasses Reports that glasses improve overall vision Reports reduction in blurry vision
Asked about palpitations Reports no current palpitations Reports no recent palpitations
Social Determinants of Health
Mental Health
Review of Systems
Asked about education Reports graduated with accounting degree
Asked about work Reports being hired at Smith, Stevens, Stewart Silver & Company Reports job title is Accounting Clerk Reports will start work in 2 weeks
Asked about living situation Reports currently living at home with mom and sister Reports moving into her own apartment near work in 1 month
Asked about support system Reports strong friendships Reports strong familial relationships Reports church remains a strong support system
Asked about stress Reports feeling less stress after graduation and passing CPA exam Reports improved ability to cope with stress
Asked about indicators of depression Reports no depression Reports feeling positive about upcoming life changes
Asked about anxiety Reports anxiety improved with relief of stressor and passing of time Reports coping well with upcoming life changes
Asked about sleep Reports no current difficulties falling asleep Reports sleeping 8 or 9 hours a night
Asked general indicators of health Reports no recent or frequent illness Reports no fatigue Reports no fever Reports no chills Reports no night sweats
Asked about review of systems for head Reports no current or recent head problems Reports no head injury
Asked about review of systems for ears Reports no general ear problems Reports no change in hearing Reports no ear pain Reports no ear discharge
Asked about review of systems for eyes Reports no eye pain
Reports no itchy eyes Reports no eye redness Reports no dry eyes
Asked about review of systems for nose Reports no general nose problems Reports no change in sense of smell Reports no sneezing Reports no nosebleeds Reports no sinus pain Reports no sinus pressure Reports no runny nose
Asked about review of systems for mouth and jaw
Reports no current dental problems Reports last dental visit was 5 months ago Reports no general mouth problems Reports no change in sense of taste Reports no dry mouth Reports no mouth pain Reports no mouth sores Reports no gum problems Reports no tongue problems Reports no jaw problems
Asked about review of systems for neck and throat
Reports no difficulty swallowing Reports no sore throat Reports no history of throat problems Reports no voice changes Reports no general neck problems Reports no history of lymph node problems Reports no swollen glands
Asked about review of systems for respiratory Reports no current breathing problems Reports no wheezing Reports no chest tightness Reports no pain while breathing Reports no coughing
Asked about review of systems for cardiovascular
Reports no palpitations Reports no irregular heartbeat Reports no easy bruising Reports no edema Reports no circulation problems
Asked review of systems for gastrointestinal Reports no nausea Reports no vomiting Reports no stomach pain Reports no constipation Reports no diarrhea Reports no flatulence
Asked review of systems for genitourinary Reports no dysuria Reports reduction in nocturia Reports no polyuria Reports no blood in urine Reports no flank pain Reports no vaginal itching or irritation Reports normal vaginal discharge
Shadow Health - Tina Jones Comprehensive Assessment Subjective Week 9
Course: Advanced Health Assessment & Diagnostic Reasoning (6512c)
University: Walden University
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