NUR 347-Health History | Completed | Shadow Health

11/30/2017 Health History | Completed | Shadow Health NUR 347-Health History | Completed | Shadow Health Health History Results | Turned In Return to Assignment Your Results Subjective Data Collection: 74 of 88 (84.1%) Lab Pass Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Indicates an item that you found. Indicates an item that is available to be found. Catego ry Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. History of Presenting Illness: Foot Wound Established chief complaint Reports pain Reports open foot wound Asked to rate pain on a scale Rates present pain at a 7 out of 10 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 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 bottom rung of a step stool Reports no other injuries besides foot wound Was not drinking at the time of the injury Was not wearing shoes at the time of injury Has not seen a healthcare provider for the injury 1/ Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the injury Reports seeing pus draining from wound Began noticing pus 2 days ago Followed up about character of drainage from the foot wound Describes pus as white or yellow in color Reports no odor from the wound Asked about home treatment of foot wound Describes wound care regimen of 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 symptoms Reports swelling around foot wound 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 on activities of daily living Pain affects ability to walk Pain affects job performance Pain prevented her from attending class Asked about recent fever Reports recent feverish episode Past Medical History: Diabetes Asked details about diabetes diagnosis Diagnosed as an adult Specific age of diagnosis is 24 years old Reports that her diabetes is Type 2 Asked about diabetes management through diet Reports that she tries to manage diabetes with diet Reports "staying away from sweets" Reports drinking diet coke instead of regular Asked about current diabetes medication use Does not currently take medication for diabetes Asked about past diabetes medication use Used to take diabetes medication Previous medication was prescription metformin Last use of medication was 3 years ago Explored the reasons the patient stopped her diabetes regimen it" Reports that she "got sick of dealing with Reports disliking metformin side effects Describes that she didn't like checking sugar and taking daily pills Asked about blood glucose monitoring Does not monitor blood glucose Last checked blood sugar a month ago Reports confusion about "what the numbers mean" Asked about increased thirst Reports increased thirst Reports increased water intake Asked about frequency of urination Reports more frequent urination Reports urinating "every hour or so" during the day Reports urinating 2 to 3 times during the night Asked about food intake Last meal was dinner at home Last meal consisted of baked chicken and a dinner roll Breakfast is usually a muffin or pumpkin n or pumpkin bread Lunch is usually a sandwich Dinner is usually a home-cooked meat dish and side of vegetables Snacks are pretzels or French fries Asked about change in appetite Reports an increase in appetite Reports increase in appetite began a month ago Asked about weight loss Reports recent weight loss Lost 10 lbs Weight loss occurred over the past month Followed up on weight loss by asking if it was intentional Weight loss was not caused by intent or lifestyle changes Past Medical History: Asthma Asked details about asthma and breathing problems Last breathing problem was 3 days ago Describes asthma symptoms as chest tightness and inability to "take in air" Describes wheezing as an asthma symptom Reports last asthma attack was in high school Asked about prior hospitalizations Reports past hospitalizations Last hospitalization was for asthma Last hospitalization was age 16 Estimates 5 total hospitalizations for asthma as a child and teen Reports that she has never been intubated during a hospitalization Asked about asthma diagnosis Diagnosed with asthma in childhood Specific age of diagnosis is 2.5 years old Asked about asthma management Uses an inhaler Inhaler is Proventil (albuterol) Last use of inhaler was 3 days ago Uses inhaler 2 or 3 times per week Asked about number of puffs when using asthma inhaler Prescribed usage is 2 puffs Sometimes needs more than 2 puffs to control symptoms shAsked aabout astrhma treiggers d vAsthma triiggeared by cats Asthma triggered by dust Asthma triggered by running up stairs Reports no seasonal triggers Past Medical History: Allergies Asked about general allergies Reports allergy to cats Asked follow up on cat allergy reaction Reports sneezing, itchy eyes, and wheezing Asked if the patient is allergic to latex Denies latex allergy Asked if the patient is allergic to any medications Reports a penicillin allergy Asked about penicillin reaction Reports that penicillin resulted in hives in childhood Asked if the patient has any food allergies Denies food allergies Asked if the patient has allergies to dust, mold, or pollen Reports reaction to dust Dust causes sneezing, itchy eyes, and wheezing Denies seasonal allergies Past Medical History: Immunizations Asked about general immunizations received Reports being "up to date on shots" Asked about childhood immunizations Reports receiving all necessary childhood immunizations Asked if the patient has received a flu vaccine Has not received annual flu vaccine Asked if the patient received a tetanus immunization Last tetanus vaccination was in the past year Past Medical History: Medication Use Asked about use of pain medication Has been taking OTC Advil (ibuprofen) at home ER administered pain medication CourseH Asked about the effin or pumpkin cacy of pain medication at home Reports that Advil (ibuprofen) "only helped a little" Pain returned in full every few hours Asked about prescription medications Only prescription is an inhaler Asked about use of OTC medication Occasionally takes Advil (ibuprofen) for cramps Occasionally takes Tylenol (acetaminophen) for headaches Does not take vitamin supplements Does not take herbal supplements PsychoSocial History: Education Asked about patient's level of education Currently working toward undergraduate degree Asked what subject the patient is studying in college Majoring in accounting Psychosocial History: Daily Life Discussed the patient's stress level Reports stress related to injury, missing work and school, and cost of care Asked about patient's living situation Lives at home with mother and sister Reports that family members will be able to help with activities PsychoSocial History: Substances Asked about illicit drug use Reports past history of marijuana smoking Followed up on patient's marijuana use Last use was at age 20 or 21 Stopped because of health reasons and lost interest Asked about the quantity of Last alcoholic drink was 3 weeks ago Thsihsasrteuddvyia Reports no more than 6 to 10 alcoholic drinks per month Asked about tobacco use Denies smoking tobacco Asked about secondhand smoke Denies exposure to secondhand smoke Family History: 3 Generations Asked about mother's health Mother diagnosed with hypertension Mother diagnosed with high cholesterol Asked about father's health Father diagnosed with Type 2 diabetes Father diagnosed with hypertension Father diagnosed with high cholesterol Followed up to ask about coping after father's death Reports grief at the time but feeling "at peace" with it now Asked father's age at death Died at age 58 Asked cause of father's death Cause of death: car accident Asked about paternal grandfather's health Paternal grandfather diagnosed with Type 2 diabetes Paternal grandfather diagnosed with hypertension Paternal grandfather diagnosed with high cholesterol Asked about paternal grandmother's health Paternal grandmother diagnosed with hypertension Asked about maternal grandfather's health Maternal grandfather diagnosed with hypertension Maternal grandfather diagnosed with high cholesterol Asked about maternal grandmother's health Maternal grandmother diagnosed with hypertension Maternal grandmother diagnosed with high cholesterol Asked about brother's health Reports no diagnosed health problems Asked about sister's health Sister diagnosed with asthma Family History: Inherited Risk Factors Asked about family story of diabetes Father and paternal grandfather have diabetes Asked about family history of asthma Younger sister has asthma Asked about family history of obesity Confirms that family members are overweight Asked about family history of cancer Paternal grandfather died of colon cancer Asked about family history of thyroid issues No known family history of thyroid issues Asked about family history of substance abuse Reports 1 uncle has alcoholism Asked about family history of headaches No known family history of headaches Review of Systems Asked general indicators of health Reports no recent or frequent illness Reports occasional tiredness or fatigue Reports typical sleep pattern Reports no chills Reports no night sweats Asked about review of systems for mental health Reports no history of depression Reports no history of suicidal ideation or attempts Reports no diagnosed mental health conditions Asked about review of systems for head Reports occasional headaches Reports no current headache Reports no head injury Asked about review of systems for ears Reports no general ear problems Reports no change in hearing Reports no ringing or tinnitus Reports no ear pain Reports no ear discharge Thsihsasrteuddvyia Reports infrequent discharge, crusting or wateriness Reports no eye pain Reports no dry eyes Asked about review of systems for nose Reports infrequent nose problems Reports no current nose problems Reports occasional sneezing around cats and dust Reports infrequent runny nose Reports no frequent sinus problems Reports no nosebleeds Reports no change in sense of smell Asked about review of systems for mouth and jaw Reports no general mouth problems Reports no change in sense of taste Reports no dry mouth Reports no mouth pain Reports no mouth sores Reports no gum problems Reports no tongue problems Reports no jaw problems Reports no current dental problems Reports last dental visit was several years ago Asked about review of systems for neck, throat and glands Reports no diffin or pumpkin culty swallowing Reports no sore throat Reports no general lymph node problems Reports no history of frequent throat problems Reports no swollen glands Reports no voice changes Reports no general neck pain Asked about review of systems for respiratory Reports no current breathing problems Reports no current wheezing Reports no current chest tightness Reports no pain while breathing Reports no frequent coughing Asked about review of systems for cardiovascular Reports no chest pain or discomfort Reports no palpitations Reports no irregular heartbeat Reports no easy bruising Reports no edema Reports no circulation problems Asked review of systems for gastrointestinal Reports no general gastrointestinal problems Reports no nausea Reports no vomiting Reports no stomach pain Reports no changes in bowel movements Reports no heartburn, GERD, or indigestion Reports no constipation Reports no diarrhea or loose stool Reports no flatulence or bloating Asked review of systems for urinary Reports no dysuria Reports nocturia Reports polyuria Reports no hematuria Reports no flank pain Reports no incontinence Reports no history of urinatry tract or bladder infection Asked review of systems for reproductive Last menstrual period was 3 weeks ago Reports that periods are irregular Reports no past pregnancies Reports no vaginal itching or discomfort Reports normal vaginal discharge Reports no history of STIs Reports past condom use Reports no current birth control Asked review of systems for musculoskeletal Reports no muscle pain Reports no joint pain Reports no muscle weakness Reports no muscle swelling Asked review of systems for neurological Reports no dizziness or vertigo Reports no light-headedness Reports no tingling Reports no loss of coordination