Health History Assessment.

Health History Assessment.

Health History Assessment.

Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool.

Review this week’s Learning Resources as well as the Taking a Health History media program in Week 3, and consider how you might incorporate these strategies. Download and review the Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment.

Health History Assessment.

 

 

Health History Results | Turned In Advanced Health Assessment – Chamberlain – April 2019, NR509-April-2019

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Your Results Lab Pass Lab Pass

This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Patient: Tina Jones

Digital Clinical Experience Score

100%

Beginning Developing Proficient

Subjective Data Collection 104 out of 104

Objective Data Collection 1 out of 1

Education and Empathy 3 out of 11

Information Processing 39 out of 40

Interaction with patient 128 minutes

Post-exam activities 145 minutes

Time 273 minutes total spent in assignment

Student Performance Index 147 out of 156

Proficiency Level: Proficient

Students rated as “proficient” demonstrate an entry- level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.

Document: Provider Notes

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Information Processing

Health History Tips and Tricks

Self-Reflection

Experience Overview

Documentation / Electronic Health Record

https://www.coursehero.com/file/41895983/Health-History-Completed-Shadow-Healthpdf/

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Document: Provider Notes

Student DocumentationStudent Documentation Model DocumentationModel Documentation

Identifying Data & Reliability

Tina arrived today complaining about a wound on her right foot. The wound is 2cm x 1.5cm with a depth of 2.5mm. The patient is experiencing pain as a result of the fall and wound. She is taking advil for pain with minium effectiveness. Instructed patient to take medication every 6 to 8 hours as needed for pain. Patient also presented with a fever, a high blood glucose and elevate blood cover. Patient has a family history of high blood pressure. Culture taken of wound and sent to lab. Eduated patient on importance of maintaing a safe blood sugar.

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. 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.

General Survey

Patient is in school and has been understress while in school. Patient not concentrating on health due to stress. Educated patient on the importance of stress relief. Patiet is not currntly in a relationshiop and lives with family. Pt has a history of asthma which is currently mild with albuterol use a couple of times a week.

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.

Chief Complaint

The patient’s chief complaint is an infected wound on the right foot due to a fall. This is a followup visit from the ER.

“I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!”

History Of Present Illness

Patient fell and visited the ER where the wound was cleaned and she was given pain medication. She is in pain currently and stated that she is unable to use it to move independently.

Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site twice a day. She has been applying antibiotic ointment and a bandage. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 7 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports 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 wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a 10-pound, unintentional weight loss over the month and increased appetite. Denies change in diet or level of activity.

https://www.coursehero.com/file/41895983/Health-History-Completed-Shadow-Healthpdf/

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Medications

Patient has an inhaler which she uses multiple times in a week. Patient is also taking tramadol as needed for pain in addition to Avidl or tylenol. Patient was prescribed medication for diabetes but is currently not taking the medication. Educated patitent on blood sugar control.

Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago)

Allergies

Patient is allergic to cats and penicillin

Penicillin: rash • Denies food and latex allergies • 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.

Medical History

Patient has a history of diabetes and asthma. Has family history of high blood pressure which she presented with today in the office.

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats and dust. She uses her inhaler 2 to 3 times per week. She was exposed to cats three days ago and had to use her inhaler once with positive relief of symptoms. She was last hospitalized for asthma “in high school”. Never intubated. Type 2 diabetes, diagnosed at age 24. She previously took metformin, but she stopped three years ago, stating that the pills made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn’t monitor her blood sugar. Last blood glucose was elevated last week in the emergency room. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs four years ago. Hematologic: Denies bleeding, bruising, blood transfusions and history of blood clots. Skin: Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes.

Health Maintenance

Patient is finding it difficult to mainatain a healthy lifestyle. This is due to stress from school and poor diet control. Educated pt on the importantance of diabetes control in wound healing. Encouraged patient to reduce stress and and use protection.

Pt will receive the approriate antibiotic when culture tests are completed. The patient will be

Last Pap smear 4 years ago. Last eye exam in childhood. Last dental exam “a few years ago.” PPD (negative) ~2 years ago. No exercise. 24-hour Diet Recall: States that she skipped breakfast yesterday, and would typically have a baked good for breakfast, a sandwich for lunch, and a meatloaf or chicken for dinner. Her snacks consist of pretzels or French fries. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine in

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encouraged and impowered to address risky behavoirs as well.

college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.

Family History

Patient has a family history of high blood pressure, high cholesterol and asthma. Patient also has a family hisotry of cancer with grandparents.

• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Social History

Patient is not currently in an exclusive relationship. She has stopped birth control. She is sexually active only occassionally and is not consisitent with contraceptives. Educated patient on the importance of condoms in pregagncy and prevention of disease.

Never married, no children. Lived independently since age 20, currently lives with mother and sister in a single family home to support family after death of father one year ago. Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift supervisor. She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company. She has a car, cell phone, and computer. She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs. She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She reports stressors relating to the death of her father and balancing work and school demands, and finances. She states that family and church help her cope with stress. No tobacco. Occasional cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. She drinks 4 caffeinated drinks per day (diet soda). No foreign travel. No pets. Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago. She plans on getting married and having children someday.

Objective

Pt presented with high blood pressure of 142 / 82, weight of 90 kg, blood gluocse of 238, and fever

Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound edges, right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no

https://www.coursehero.com/file/41895983/Health-History-Completed-Shadow-Healthpdf/

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ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS 

 

of 101.1. RR is 19 O2 sat 99% and HR 86. edema, no tracking.

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