NR 509 Advanced Health Assessment Chamberlain Tina Jones Completed Shadow Health (NR509)

Exam (elaborations) NR 509 Advanced Health Assessment Chamberlain Tina Jones Completed Shadow Health (NR509) Health History Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Lab Passss Started: May 05, 2018 | Patient Exam Time: 181 min Transcript Exam Action 05/05/18 11:43 AM CDT Exam Action 05/05/18 11:43 AM CDT Exam Action 05/05/18 11:43 AM CDT Exam Action 05/05/18 11:43 AM CDT Exam Action 05/05/18 11:43 AM CDT Exam Action 05/05/18 11:43 AM CDT Exam Action 05/05/18 11:43 AM CDT Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Self-Reflection IIntterrvviiew Quessttiionss (()) Sttattementtss ((1144)) Exxam Acttiionss ((1155)) Heiightt:: 170 cm Weiightt:: 90 kkg BMII:: 31 Random bllood gllucosse:: 238 Temperratturre:: 101..1 F Bllood prressssurre:: 142//82 Resspiirrattorryy rratte:: 19 O2 ssatt:: 99% Allll Liiness (()) 5/5/2018 Health History | Completed | Shadow Health Exam Action 05/05/18 11:43 AM CDT Exam Action 05/05/18 11:43 AM CDT Greet 05/05/18 11:43 AM CDT Question 05/05/18 11:44 AM CDT Question 05/05/18 11:46 AM CDT Question 05/05/18 11:47 AM CDT Question 05/05/18 11:47 AM CDT Question 05/05/18 11:48 AM CDT Heart rate: 86 Hello, Tina Jones my name is Sara an FNP student here to interview you today. Hey. What brings you here today? 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! Where is the pain on your foot? It feels like the pain is just centered around the scrape, like around the ball of my foot. That's where it hurts the most, but my whole foot feels some pain. Can you tell me what foot this is please It's . . . [Ms. Jones reports the correct year.] [AUDIO COMING SOON] Which foot is the pain located? My right foot. How severe is the pain in your right foot? It's really bad. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 11:48 AM CDT Question 05/05/18 11:49 AM CDT Question 05/05/18 11:50 AM CDT Question 05/05/18 11:50 AM CDT Question 05/05/18 11:50 AM CDT Question 05/05/18 11:51 AM CDT Question 05/05/18 11:51 AM CDT Question 05/05/18 11:52 AM CDT Can you rate the pain on a scale of 0 to 10. 10 beiing tthe worrsstt paiin yyou havve evverr had iin yyourr lliiffe ... I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet. whatt arre yyou ttakkiing fforr paiin? It's called tramadol. Wherre diid yyou gett tthiiss mediicattiion? The ER doctor prescribed them for me when I was in there a week ago. So tthe paiin ssttarrtted a weekk ago? ((Cllarriifified tto diid yyourr wound havve puss iin iitt allll weekk..)) No, I started seeing it two days ago. Whatt caussed yyou tto havve tthiiss paiin? Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Whyy arre yyou havviing rriightt ffoott paiin? ((No mattchiing quessttiionss ffound..)) how diid yyourr iinjjurryy happen? I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step. can yyou plleasse desscrriibe tthe paiin? It's throbbing and like, sharp if I try to put weight on it. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 11:52 AM CDT Question 05/05/18 11:52 AM CDT Question 05/05/18 11:52 AM CDT Question 05/05/18 11:53 AM CDT Question 05/05/18 11:54 AM CDT Empathize 05/05/18 11:54 AM CDT Question 05/05/18 11:55 AM CDT what is the pain like when you ssttand on yyourr ffoott? Yes! I mean, I literally can't put weight on my foot, the pain is so sharp. when diid tthe paiin ssttarrtt? Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. Hass tthe paiin changed ovverr ttiime? At first, it seemed like it was healing up fine and it didn't give me a lot of pain. But the last two days, the pain got way worse. Doess yyourr paiin rradiiatte? The pain's worse in my foot, but I feel it moving up into my ankle, too. Can yyou bearr weiightt on yyourr ffoott? No, I can't. I can't put any weight on it without like, shooting pain. II am ssorrrryy II underrssttand how yyou ffeell.. I appreciate you telling me that. Diid yyou iinjjurre anyytthiing ellsse bessiide yyourr ffoott? 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 11:55 AM CDT Question 05/05/18 11:56 AM CDT Educate 05/05/18 11:56 AM CDT Question 05/05/18 11:57 AM CDT Question 05/05/18 11:57 AM CDT Question 05/05/18 11:57 AM CDT Question 05/05/18 11:57 AM CDT Well, at first I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it, because the ankle felt pretty okay the next day and it wasn't a problem all week. Did you have any alcoholic drinks befforre iinjjurryy? No, I was stone-cold sober. It was the middle of the day. Wherre yyou wearriing sshoess when yyou ffellll? No, I was barefoot. Allwayyss makke ssurre tto wearr sshoess when outtssiide.. OK, I understand. You wentt tto tthe ER fforr yyourr iinjjurryy? Yeah, right after it happened, I worried I might've sprained my ankle so mom drove me to the ER. Diid yyourr ffoott blleed? Yeah, right when I hurt it. Diid yyou nottiice anyy diisscharrge ffrrom tthe wound? Yeah, there's definitely pus. When diid yyou fifirrsstt nottiice puss? Two days ago. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 11:57 AM CDT Question 05/05/18 11:58 AM CDT Empathize 05/05/18 11:59 AM CDT Question 05/05/18 11:59 AM CDT Question 05/05/18 11:59 AM CDT Question 05/05/18 12:00 PM CDT Question 05/05/18 12:00 PM CDT What color is the drainage ffrrom yyourr wound? It's... white or maybe off-white. Doess tthe wound havve an odorr? Um, no, not that I know of... That sounds gross. II underrssttand iitt ssoundss grrossss butt iin orrderr tto fifind outt whatt iiss goiing on wiitth yyourr ffoott.. II musstt asskk tthiiss quessttiion.. Thanks for saying that. How diid yyou ttrreatt yyourr ffoott att home? I made sure to clean it and just keep it bandaged. And I put Neosporin on it. How offtten diid yyou cllean tthe wound? Twice a day -- every morning and every night. How offtten diid yyou change tthe bandage? Every morning and night. I was keeping an eye on it. IIss ttherre sswelllliing arround tthe wound? Yeah, it looks swollen around the scrape. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 12:01 PM CDT Question 05/05/18 12:02 PM CDT Question 05/05/18 12:04 PM CDT Question 05/05/18 12:04 PM CDT Exam Action 05/05/18 12:05 PM CDT Exam Action 05/05/18 12:09 PM CDT Exam Action 05/05/18 12:09 PM CDT Exam Action 05/05/18 12:09 PM CDT Exam Action 05/05/18 12:10 PM CDT Does the wound ffeell warrm? Yeah, it feels pretty warm. Doess yyourr ffoott paiin affffectt yyourr worrkk? Well, I tried to go in two days ago but I couldn't walk well enough, so I just went home after a couple hours. And I didn't go in yesterday. My boss was understanding, but I need to be able to work! Hass yyourr iinjjurryy prrevventted yyou ffrrom goiing tto cllassss? I had a class two days ago, and I skipped it. I haven't missed any classes before this, and I emailed my professor, so I should be okay. I don't want to get