Exam (elaborations) NURSING 111 SHADOW HEALTH TINA JONES Health Histor

Exam (elaborations) NURSING 111 SHADOW HEALTH TINA JONES Health Histor tient Data items below to reveal important information, including Pro Tips and Example Questions. Reports pain prevents bearing weight on foot Asked location of wound Reports right foot is injured Reports wound is on the plantar surface of her foot Asked details of the injury Reports she scraped foot on bottom rung of a step stool Reports injury occurred 1 week ago Denies other injuries besides foot wound Reports being barefoot at the time of injury Denies seeing a healthcare provider for the injury until now Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the injury Reports seeing pus draining from wound Reports noticing pus 2 days ago Followed up on drainage Reports pus as white or yellow Denies odor from the wound Asked about home treatment of foot wound Reports wound care regimen of bandaging Reports cleaning wound twice a day Reports applying bacitracin, neomycin and polymyxin B (Neosporin) Followed up on effectiveness of ointment Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective Asked about other foot wound symptoms Reports swelling around foot wound Reports swelling worsened in the past 2 days Reports redness around the wound Reports that the wound feels warm Explored impact of patient's foot injury on activities of daily living Reports pain affects ability to walk Reports pain affects ability to stand at work for long periods of time Reports pain prevented her from being able to walk to class Past Medical History Asked about preexisting medical conditions Reports diabetes Reports asthma Followed up on diabetes diagnosis Reports specific age of diagnosis was 24 Reports that her diabetes is Type 2 Asked about diabetes management through lifestyle changes Reports staying away from sweets Reports drinking diet coke instead of regular Asked about current diabetes medication use Reports that she does not currently take medication for diabetes Asked about past diabetes medication use Reports that she used to take diabetes medication Reports previous medication was prescription metformin Reports last use of medication was 3 years ago Followed up on stopping diabetes regimen Reports disliking diabetes medication side effects Reports that she didn't like checking sugar and taking daily pills Asked about blood glucose monitoring Reports infrequent blood glucose monitoring Reports she last checked blood sugar a month ago Reports confusion about what the numbers mean Asked about thirst Reports increased thirst Reports increased water intake Asked about frequency of urination Reports more frequent urination Reports urinating every hour or two during the day Reports urinating 2 to 3 times during the night Asked about diet Reports eating a bowl of cereal for breakfast yesterday Reports eating mac and cheese for lunch yesterday Reports eating chicken and roll for dinner yesterday Asked about change in appetite Reports increased appetite Reports change in appetite began a month ago Asked about weight change Reports recent loss of 10 lbs Reports weight loss occurred over the past month Followed up on reason for weight change Reports weight loss was unintentional Asked about history of asthma exacerbations Reports last asthma attack was in high school Reports last exacerbation was three days ago Asked about asthma symptoms Reports chest tightness during exacerbation Reports difficulty breathing during exacerbation Reports wheezing during exacerbation Asked about prior hospitalizations Reports past hospitalizations Reports last hospitalization was for asthma Reports last hospitalization was age 16 Reports about 5 total hospitalizations for asthma as a child and teen Reports past nebulizer use Asked about asthma diagnosis Reports specific age of diagnosis is 2.5 years old Asked about asthma management Reports using an inhaler Reports inhaler is albuterol (Proventil) Reports last use of inhaler was 3 days ago Reports using inhaler no more than 2 times per week Asked about number of puffs when using asthma inhaler Reports recommended dose is 1-3 puffs as needed Reports typically taking 2 puffs Reports sometimes needing 3 puffs to control symptoms Asked about asthma triggers Reports asthma triggered by cats Reports asthma triggered by dust Denies seasonal triggers Asked about general allergies Reports allergy to cats Followed up on cat allergy symptoms Reports sneezing, itchy eyes, and wheezing Asked about latex allergy Denies latex allergy Asked about medication allergies Reports penicillin allergy Asked about penicillin reaction Reports that penicillin resulted in hives Reports last penicillin reaction was in childhood Asked about food allergies Denies food allergies Asked if the patient has allergies to dust, mold, or pollen Reports reaction to dust Reports dust causes sneezing, itchy eyes, and wheezing Denies seasonal allergies Asked about general immunizations received Reports being up to date on shots Asked about childhood immunizations Reports receiving measles-mumpsrubella shot Reports receiving polio shot Reports receiving varicella shot Reports receiving Hepatitis A and B shot Reports receiving meningococcal shot Reports receiving HPV vaccine series Asked if the patient has received a flu vaccine Denies receiving annual flu vaccine Asked if the patient received a tetanus immunization Reports last tetanus vaccination was in the past year Asked about use of pain medication Reports taking ibuprofen (Advil) at home Reports ER administered pain medication Followed up on home pain medication Reports taking ibuprofen (Advil) for 2 days Reports taking doses at morning, noon and night Reports taking 2 pills each time Reports ibuprofen is regular strength Asked about the effectiveness of pain medication at home Reports ibuprofen helped a little Reports pain returned in full every few hours Asked about prescription medications Reports only prescription is an inhaler Asked about use of OTC medication Reports occasionally taking ibuprofen for cramps Reports occasionally taking acetaminophen (Tylenol) for headaches Denies taking supplements Denies taking herbals Social History Asked about patient's level of education Reports currently working toward undergraduate degree Reports her major is accounting Asked about stressors Reports she is currently under high stress Asked about patient's living situation Reports living with mother and sister Reports living in a house Reports house is one-story Reports family members will be able to help with activities Asked about patient belief system Reports her religious affiliation is Baptist Asked if patient has experienced abuse Denies experiencing abuse Asked about illicit drug use Reports history of recreational marijuana smoking Followed up on drug use Reports last use was at age 20 or 21 Reports she stopped because of health reasons and waning interest Asked about alcoholic intake Reports last alcoholic drink was 3 weeks ago Reports no more than 2 or 3 alcoholic drinks in one sitting Reports no more than 1 or 2 nights a week drinking alcohol Asked about tobacco use Denies smoking tobacco Denies Vaping Asked about secondhand smoke Denies exposure to secondhand smoke Family Medical History Asked about mother's health Reports mother diagnosed with high blood pressure Reports mother diagnosed with high cholesterol Asked about father's health Reports father was diagnosed with Type 2 diabetes Reports father was diagnosed with high blood pressure Reports father was diagnosed with high cholesterol Followed up on father's death Reports cause of death was a car accident Reports father died at age 58 Followed up on coping with father's death Reports past grief Reports feeling at peace now Asked about paternal grandfather's health Reports paternal grandfather diagnose