NR 509 Shadow Health - Comprehensive Assessment Transcript

Comprehensive Assessment | Completed | Shadow Health

NR 509 Shadow Health - Comprehensive Assessment Transcript



Comprehensive Assessment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2018
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Overview
Transcript
Transcript
Started: Jun 10, 2018 | Patient Exam Time: 448 min
Subjective Data Collection
All Lines (734) Interview Questions (256) Statements (33) Exam Actions (445)
Objective Data Collection

Documentation Greet
Hello my name is Sara and FNP student I will be conducting your
06/10/18 3:17 PM
Plan My Exam interview today
CDT

Self-Reflection
Hey.


Question
What is your name 06/10/18 3:17 PM
CDT



Tina Jones.


Question
Your date of birth? 06/10/18 3:17 PM
CDT



February 17th.


Question
And how old are you? 06/10/18 3:18 PM
CDT



I'm 28.

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What brought you into the clinic today? Question
06/10/18 3:23 PM
CDT


I came in because I'm required to have a recent physical exam for
the health insurance at my new job.


Question
y y 06/10/18 3:23 PM
CDT


y y me
asthma and diabetes, but both of those are under control. I'm taking
good care of my health these days.


Question
y y 06/10/18 3:26 PM
CDT


I'm going to be an Accounting Clerk at Smith, Stevens, Stewart,
y
y y



Empathize
06/10/18 3:27 PM
CDT



Thanks.


Question
y y 06/10/18 3:28 PM
CDT


y
five months ago, I came in here for a check-up, and the nurse
practitioner got me on metformin. Then a few weeks later I saw a
gynecologist for a pap smear.


Question
And what did your kind of gynecologist say? 06/10/18 3:28 PM
CDT


She said everything looked good, except that I had PCOS, which the
nurse here had said was possible. She started me on birth control,
and it seems to be helping things.


Question
How much birth control are you taking? (Clarified to How often do
06/10/18 3:29 PM
you take birth control.)
CDT




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Question
y
06/10/18 3:29 PM
name of the birth control pill you took.)
CDT



y z


Question
Has your menstrual cycle improved since TAKING YAZ? 06/10/18 3:30 PM
CDT



Now that I'm on the pill I'm getting my period every month.


Empathize
y y y y
06/10/18 3:32 PM
month
CDT



Thanks.


Question
06/10/18 3:32 PM
CDT




Question
What age were you diagnosed with asthma? 06/10/18 3:32 PM
CDT




then.


Empathize
That sounds frightening 06/10/18 3:33 PM
CDT



Thanks.


Question
06/10/18 3:33 PM
CDT


I try to avoid things that give me breathing problems, but when my
y




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What are your triggers for asthma? Question
06/10/18 3:33 PM
CDT


Being around cats is the worst, but dust and running up stairs can
y
years, though.


Question
y 06/10/18 3:34 PM
CDT


I used to have a reaction when I was in a dusty house for a long time.

y y


Question
What daily inhaler do you use? 06/10/18 3:34 PM
CDT




Question
How much fLOVENT do you use a day (No matching questions
06/10/18 3:34 PM
found.)
CDT


Question
How much flovent do you use? (No matching questions found.) 06/10/18 3:35 PM
CDT


Question
How often do you use flovent? 06/10/18 3:35 PM
CDT


Twice a day. [Nurse confirmed: fluticasone propionate 88 mcg
b.i.d./spray MDI]


Question
When was your last dose of flovent? 06/10/18 3:37 PM
CDT




So six weeks ago?


Question
when you last use flovent? (Clarified to when did you last use your
06/10/18 3:38 PM
inhaler.)
CDT




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