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Comprehensive_Health_History_Assignment___Completed___Shadow_Health_Subjective_Data.pdf

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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
Return to Assignment




Your Results Lab Pass




Overview
Subjective Data Collection: 101 of 104 (97.1%)
Transcript

Subjective Data Collection Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
Objective Data Collection
below to reveal important information, found.
including Pro Tips and Example
Education & Empathy
Questions.

Documentation

Information Processing Category Scored Items Patient Data
Health History Tips and Tricks Not Scored

Experts selected these topics as essential A combination of open and closed questions
Self-Reflection
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.



Chief Complaint


Established chief complaint Reports pain
Reports open foot wound




History of Present Illness


Asked for details about the pain Describes the pain as throbbing
Describes the pain as sharp when she
attempts to stand
Initial injury occurred 1 week ago
Pain has increased in the past 2 days
Reports feeling pain radiating into ankle
Pain prevents bearing weight on foot




https://chamberlain.shadowhealth.com/assignment_attempts/5079759 1/13

, 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health
Asked to rate pain on a scale Rates present pain at a 7 out of 10




Clarified location of wound Confirmed that right foot is injured
Confirmed that wound is on the plantar
surface of her foot




Determined details of the injury Scraped foot on a cement step
Reports mild ankle injury
Was not drinking at the time of the injury
Was not wearing shoes at the time of
injury




Asked about the assessment of the Went to the ER after sustaining the injury
injury at the ER Decided to go because she suspected an
ankle sprain
Received an x-ray
X-ray showed no broken bones
Received a prescription for pain pills




Asked about drainage from the foot Reports that the wound bled a little after
wound sustaining the injury
Reports seeing pus draining from wound
Began noticing pus 2 days ago




Followed up about character of drainage Describes pus as white or yellow in color
from the foot wound Reports no odor from the wound




Asked about home treatment of foot Describes wound care regimen of
wound cleaning and bandaging
Cleaned wound twice a day
Cleaned wound with hydrogen peroxide
Changed bandage twice a day
Applied neosporin




Asked about other foot wound Reports swelling around foot wound
symptoms Noticed swelling getting worse in the past
2 days
Reports redness around the wound
Reports that the wound feels warm




Explored impact of patient's foot injury Pain affects ability to walk
on activities of daily living Pain affects job performance
Pain prevented her from attending class




Asked about recent fever Reports a fever last night




https://chamberlain.shadowhealth.com/assignment_attempts/5079759 2/13

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