NR 509 Comprehensive Health History Assignment _ Completed _ Shadow Health Transcript: LATEST,CHAMBERLAIN COLLEGE OF NURSING

7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health

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Comprehensive Health History Assignment Results | Turned In
Advanced Health Assessment - Chamberlain - June 2019, NR509-June-2019
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Overview
Transcript
Transcript
Started: Jul 10, 2019 | Patient Exam Time: 124 min
Subjective Data Collection
All Lines (291) Interview Questions (245) Statements (34) Exam Actions (12)
Objective Data Collection
Exam Action
Education & Empathy Height: 170 cm 07/10/19 6:45 PM
CDT
Documentation

Information Processing Exam Action
Weight: 90 kg 07/10/19 6:45 PM
Health History Tips and Tricks CDT

Self-Reflection
Exam Action
BMI: 31 07/10/19 6:45 PM
CDT


Exam Action
Random blood glucose: 238 07/10/19 6:45 PM
CDT


Exam Action
Temperature: 101.1 F 07/10/19 6:45 PM
CDT


Exam Action
Blood pressure: 142/82 07/10/19 6:45 PM
CDT


Exam Action
Respiratory rate: 19 07/10/19 6:45 PM
CDT


O2 sat: 99%

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,7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health

Exam Action
07/10/19 6:45 PM
CDT


Exam Action
Heart rate: 86 07/10/19 6:45 PM
CDT


Greet
hello. My name is Tneshia Richards. I will be your provider today. 07/10/19 6:47 PM
CDT



Hey.


Question
What is your name 07/10/19 6:47 PM
CDT



Tina Jones.


Question
what is your date of birth Mrs. Jones 07/10/19 6:47 PM
CDT



February 17th.


Question
what year were you born in 07/10/19 6:47 PM
CDT



I was born in . . . [Ms. Jones reports correct birth year.]


Question
what brings you in today? 07/10/19 6:48 PM
CDT


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!


Empathize
I'm sorry to hear that you are having pain. 07/10/19 6:48 PM
CDT



I appreciate you saying that.


Question
which foot did you scrape 07/10/19 6:48 PM
CDT




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,7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health

My right foot.



Question
when did the scrape occur 07/10/19 6:49 PM
CDT


Well, I got the scrape a week ago, but the scrape and the pain got
a lot worse in the last few days.


Question
which part of the foot is the scrape on (Clarified to Where is the cut
07/10/19 6:49 PM
on your foot?.)
CDT


It's on the ball of my foot. (Clarified to where the scrape is on my
foot.)


Question
what is your pain level 07/10/19 6:50 PM
CDT



I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet.


Question
describe how the pain feels 07/10/19 6:50 PM
CDT



It's throbbing and like, sharp if I try to put weight on it.


Question
what makes the pain worse 07/10/19 6:51 PM
CDT


I'd say the pain is at its worst when I have to put any weight on my
foot. . . otherwise, it's when the pain pills wear off.


Question
what makes the pain better 07/10/19 6:51 PM
CDT



The pain pills help for a few hours.


Question
does resting the foot help with the pain 07/10/19 6:51 PM
CDT


Putting my foot up helps a little I guess, but the only thing that
makes a real difference is the pain pills.


where did you get pain pills from Question
07/10/19 6:52 PM
CDT

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, 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health


The ER doctor prescribed them for me when I was in there a week
ago.


Question
are you allergic to any medications 07/10/19 6:52 PM
CDT



Yeah, I'm allergic to penicillin.


Question
what happens when you take penicillin 07/10/19 6:52 PM
CDT


I don't remember that well because the last time I had penicillin I
was pretty little. . . I think I got a rash, like, hives. The doctor told
me not to take it again after that.


Question
are you allergic to any food 07/10/19 6:53 PM
CDT



Nope, no food allergies that I know of.


Question
what other allergies do you have 07/10/19 6:53 PM
CDT



Well, besides cats, I'm allergic to penicillin.


Question
What kind of reaction do you have to cap (Clarified to What
07/10/19 6:54 PM
happens when you are around a cat?.)
CDT


Whenever I'm around cats, I start sneezing, my eyes get itchy. . .
and my asthma starts to act up. (Clarified to what the symptoms of
my cat allergy are.)


Question
When were you diagnosed with asthma 07/10/19 6:54 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.


Question
How do you manage your asthma now 07/10/19 6:55 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.


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