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NR 509 Comprehensive Assessment | transcript

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NR 509 Comprehensive Assessment | transcript NR 509 Comprehensive Assessment | transcript NR 509 Comprehensive Assessment | transcript

Institution
NR599
Course
NR599

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1


Comprehensive Assessment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
Return to Assignment




Your Results Lab Pass




Overview
Transcript
Transcript
Started: Jun 10, 2018 | Patient Exam Time: 448 min
Subjective Data Collection
All Lines (734) Interview Questions (256) Statements (33) Exam Actions (445)
Objective Data Collection
Greet
Documentation Hello my name is Sara and FNP student I will be conducting your
06/10/18 3:17 PM
interview today
CDT
Plan My Exam

Self-Reflection
Hey.


Question
What is your name 06/10/18 3:17 PM
CDT



Tina Jones.


Question
Your date of birth? 06/10/18 3:17 PM
CDT



February 17th.


Question
And how old are you? 06/10/18 3:18 PM
CDT



I'm 28.




https://chamberlain.shadowhealth.com/assignment_attempts/3569767 1/36

, 2 What brought you into the clinic today? Question
06/10/18 3:23 PM
CDT


I came in because I'm required to have a recent physical exam for
the health insurance at my new job.


Question
Do you have any current health problems? 06/10/18 3:23 PM
CDT


I don't have anything specific going on today. I mean, I still have
asthma and diabetes, but both of those are under control. I'm taking
good care of my health these days.


Question
Where is your new job? (Clarified to what is your new job.) 06/10/18 3:26 PM
CDT


I'm going to be an Accounting Clerk at Smith, Stevens, Stewart,
Silver & Company. I'll be helping a more experienced accountant
with her clients, and then eventually I'll get more responsibility, and
build my own client list. I start in two weeks--I'm really excited!


Empathize
That is great that you are excited 06/10/18 3:27 PM
CDT



Thanks.


Question
When was your last physical? 06/10/18 3:28 PM
CDT


Let's see... I had two doctor's appointments earlier this year. About
five months ago, I came in here for a check-up, and the nurse
practitioner got me on metformin. Then a few weeks later I saw a
gynecologist for a pap smear.


Question
And what did your kind of gynecologist say? 06/10/18 3:28 PM
CDT


She said everything looked good, except that I had PCOS, which the
nurse here had said was possible. She started me on birth control,
and it seems to be helping things.


Question
How much birth control are you taking? (Clarified to How often do
06/10/18 3:29 PM
you take birth control.)
CDT




https://chamberlain.shadowhealth.com/assignment_attempts/3569767 2/36

, 3 I take it every morning, with breakfast.



Question
What is the name of your birth control? (Clarified to what was the
06/10/18 3:29 PM
name of the birth control pill you took.)
CDT



They're called Yaz.


Question
Has your menstrual cycle improved since TAKING YAZ? 06/10/18 3:30 PM
CDT



Now that I'm on the pill I'm getting my period every month.


Empathize
That's great I am really glad that you are having your period every
06/10/18 3:32 PM
month
CDT



Thanks.


Question
How long have you had asthma? 06/10/18 3:32 PM
CDT



I've had asthma a long time. . . since I was really little.


Question
What age were you diagnosed with asthma? 06/10/18 3:32 PM
CDT


My doctor told me when I was pretty little... I think I was about two
and a half? I used to have a lot of trouble with asthma attacks back
then.


Empathize
That sounds frightening 06/10/18 3:33 PM
CDT



Thanks.


Question
How do you manage your asthma? 06/10/18 3:33 PM
CDT


I try to avoid things that give me breathing problems, but when my
asthma starts to act up, I just use my inhaler.




https://chamberlain.shadowhealth.com/assignment_attempts/3569767 3/36

, 4 What are your triggers for asthma? Question
06/10/18 3:33 PM
CDT


Being around cats is the worst, but dust and running up stairs can
make my breathing bad, too. I haven't had a full asthma attack in
years, though.


Question
What happens when you're around DUST? 06/10/18 3:34 PM
CDT


I used to have a reaction when I was in a dusty house for a long time.
. . I would get allergies, like sneezing and stuff, and then my asthma
would act up. But that hasn't happened since I got my daily inhaler.


Question
What daily inhaler do you use? 06/10/18 3:34 PM
CDT




Question
How much fLOVENT do you use a day (No matching questions
06/10/18 3:34 PM
found.)
CDT


Question
How much flovent do you use? (No matching questions found.) 06/10/18 3:35 PM
CDT


Question
How often do you use flovent? 06/10/18 3:35 PM
CDT


Twice a day. [Nurse confirmed: fluticasone propionate 88 mcg
b.i.d./spray MDI]


Question
When was your last dose of flovent? 06/10/18 3:37 PM
CDT


Probably. . . well, not for my last period. Maybe for the one before?
So six weeks ago?


Question
when you last use flovent? (Clarified to when did you last use your
06/10/18 3:38 PM
inhaler.)
CDT




https://chamberlain.shadowhealth.com/assignment_attempts/3569767 4/36

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