Comprehensive Health History Assignment Results | Turned In

9/4/2019 Comprehensive Health History Assignment | Completed | Shadow Health


Comprehensive Health History Assignment Results | Turned In
Advanced Health Assessment - Chamberlain - August 2019, NR509-August-2019
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Overview Transcript
Transcript
Started: Sep 03, 2019 | Patient Exam Time: 95
min
Subjective Data Collection
All Lines Interview Questions Statements Exam Actions
(220) (183) (25) (12)
Objective Data Collection
Exam Action
Education & Empathy Height: 170 cm 09/03/19 6:37 PM
CDT
Documentation

Information Processing Exam Action
Weight: 90 kg 09/03/19 6:37 PM
Health History Tips and CDT
Tricks

Exam Action
Self-Reflection
BMI: 31 09/03/19 6:37 PM
CDT


Exam Action
Random blood glucose: 238 09/03/19 6:37 PM
CDT


Exam Action
Temperature: 101.1 F 09/03/19 6:37 PM
CDT


Exam Action
Blood pressure: 142/82 09/03/19 6:37 PM
CDT


Exam Action
Respiratory rate: 19 09/03/19 6:37 PM
CDT


Exam Action
O2 sat: 99% 09/03/19 6:37 PM
CDT


Exam Action
Heart rate: 86 09/03/19 6:37 PM
CDT


Hi Tina my name is Jessica I'll be your nurse today.


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,9/4/2019 Comprehensive Health History Assignment | Completed | Shadow Health

Greet
09/03/19 6:38 PM
CDT


Hey.



Question
What brings you into see us today
09/03/19 6:39 PM
CDT


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!



Empathize
I'm sorry you're in pain
09/03/19 6:39 PM
CDT


Thanks for saying that.



What is your pain on a scale of 0 to 10 (Clarified to How would you rate your Question
pain at its worst on a scale from 0 to 10?.) 09/03/19 6:41 PM
CDT


If I put all my weight on my foot, it'd be like a 10, but it hurts too much to do
that. (Clarified to how I would rate my pain on a scale at its worst.)



Question
Can you rate your pain right now
09/03/19 6:41 PM
CDT


I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet.



What are you taking for this (Clarified to What is the name of the pain Question
medication you have been taking?.) 09/03/19 6:41 PM
CDT


It's called tramadol. (Clarified to what I am taking for pain.)



Question
Do you know the milligrams of tramadol you were taking
09/03/19 6:42 PM
CDT


I'm not 100% sure, but I think they're 50 milligrams.



Question
How often do you take Tramadol
09/03/19 6:42 PM
CDT




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, 9/4/2019 Comprehensive Health History Assignment | Completed | Shadow Health
I've been taking the Tramadol morning, noon, and night. [AUDIO COMING
SOON]



Question
When did you start taking the Tramadol
09/03/19 6:42 PM
CDT


Two days ago the pain started going up, so I asked Mom to get the
prescription filled and started taking them.


Question
Can you describe the pain
09/03/19 6:42 PM
CDT


It's throbbing and like, sharp if I try to put weight on it.



Question
Does the pain radiate to any other parts of your body
09/03/19 6:42 PM
CDT


The pain's worse in my foot, but I feel it moving up into my ankle, too.




Question
When did the chainsaw (No matching questions found.)
09/03/19 6:43 PM
CDT


Question
When did the pain start
09/03/19 6:43 PM
CDT


Well, I got the scrape a week ago, but the scrape and the pain got a lot worse
in the last few days.


Question
How did you get the scrape on your foot
09/03/19 6:43 PM
CDT


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.


How has the pain changed over the week (Clarified to How has your foot pain Question
changed since you fell?.) 09/03/19 6:43 PM
CDT


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. (Clarified to how my foot pain
has changed since I fell.)


Which foot hurts
Question
09/03/19 6:44 PM
CDT


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