Tina jones health history transcript

Height: 170 cm

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05/22/20 12:11 PM EDT

Weight: 90 kg

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BMI: 31

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Random blood glucose: 238

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05/22/20 12:11 PM EDT

Temperature: 101.1 F

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05/22/20 12:11 PM EDT

Blood pressure: 142/82

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05/22/20 12:11 PM EDT

Respiratory rate: 19

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05/22/20 12:11 PM EDT

O2 sat: 99%

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05/22/20 12:11 PM EDT

Heart rate: 86

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05/22/20 12:11 PM EDT

Hello. My name is Joan and I will be interviewing you today and later examine you.

Greet
05/22/20 12:12 PM EDT

Hey.

What is your name?

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05/22/20 12:12 PM EDT

Tina Jones.

Why are you here today?

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05/22/20 12:13 PM EDT

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!

Am sorry to hear that?

Empathize
05/22/20 12:13 PM EDT

I appreciate you saying that.

When did you get the scrape?

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05/22/20 12:14 PM EDT

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

How severe is the pain?

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05/22/20 12:14 PM EDT

It’s really bad.

Can you describe the pain?

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05/22/20 12:15 PM EDT

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

Did you hurt any other part?

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05/22/20 12:15 PM EDT

No, I caught myself on the railing so I didn’t fall on the ground. Only my foot got hurt.

how has the pain changed over time?

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05/22/20 12:16 PM EDT

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.

Does the pain radiate anywhere else?

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05/22/20 12:17 PM EDT

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

How painful is the ankle? (Clarified to How did you hurt your ankle?.)

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05/22/20 12:18 PM EDT

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. (Clarified to how I hurt my ankle.)

is it possible for you to stand on your foot?

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05/22/20 12:18 PM EDT

No, I can’t put weight on my foot without really sharp pain.

How do yo rate the pain on a scale of 0 o 10 (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)

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05/22/20 12:19 PM EDT

I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. (Clarified to how I would rate my pain on a scale.)

can you tell me where the pain is located?

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05/22/20 12:19 PM EDT

It feels like the pain is just centered around the scrape, like around the ball of my foot. That’s where it hurts the most, but my whole foot feels some pain.

Which foot did you injure?

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05/22/20 12:20 PM EDT

My right foot.

Were you wearing shoes?

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05/22/20 12:20 PM EDT

Seems you love your work

Empathize
05/22/20 12:40 PM EDT

Thanks for saying that.

Do you have other health problems?

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05/22/20 12:40 PM EDT

Um, the only things I know I’m diagnosed with are diabetes. And asthma.

When were you diagnosed with asthma?

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05/22/20 12:42 PM EDT

My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.

when dod you last have an asthma attack (Clarified to When was your last asthma attack?.)

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05/22/20 12:43 PM EDT

It’s really rare for me to have an attack now. Three days ago I had some breathing problems, but I guess probably my last full attack was in high school. (Clarified to when my last asthma attack was.)

How was your asthma when you were in high school?

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05/22/20 12:44 PM EDT

I was always a pretty average student. . . never the best, never the worst.

how do you know when you have asthma attack? (Clarified to What happens when you have an asthma attack?.)

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05/22/20 12:44 PM EDT

I haven’t had an asthma attack in a while, but I used to get them growing up, and my chest would feel really tight, like I couldn’t take in air, and I would wheeze really bad and get all sweaty. It was way worse than now, especially because I would use my inhaler and it wouldn’t help. It was really scary. (Clarified to to tell you about my asthma attacks.)

Do you get tight chest?

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05/22/20 12:45 PM EDT

Well. . . when my asthma gets bad my chest feels pretty tight, like I can’t take in air.

Do you get breathing difficult? (No matching questions found.)

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05/22/20 12:46 PM EDT

Do you get breathing difficulties during asthma attacks?

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05/22/20 12:46 PM EDT

I haven’t had a full attack in years, but when my breathing gets bad, I just use my inhaler.

What about wheezing? (Clarified to How is your wheezing?.)

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05/22/20 12:47 PM EDT

I’m not wheezing right now . . . But I did wheeze a little bit a few days ago at my cousin’s house. I had to use my inhaler. (Clarified to how my wheezing is.)

What do you use for your asthma? inhaler?

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05/22/20 12:48 PM EDT

It’s just a regular Proventil inhaler.

how many times do you use the inhaler?

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05/22/20 12:49 PM EDT

I don’t use it every day. Maybe two or three times a week. Although I guess lately, once I have to use it once, sometimes I need it again that day.

have you been been hospitalized for asthma?

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05/22/20 12:50 PM EDT

I went a bunch of times when I was little, for asthma attacks.

What else have you used for the asthma? (No matching questions found.)

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05/22/20 12:51 PM EDT

What else have you used for the asthma?what causes your asthma?

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05/22/20 12:51 PM EDT

When I used to have asthma attacks all the time, all different things could cause them. . . sometimes I couldn’t tell what was doing it. My breathing problems haven’t turned into a full attack in years, though.

What happens when you are around cats?

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05/22/20 12:52 PM EDT

Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up.

Do you have latex allergies?

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05/22/20 12:53 PM EDT

Nope.

Do you have food allergies?

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05/22/20 12:53 PM EDT

Nope, no food allergies that I know of.

are you allergic to dust?

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05/22/20 12:53 PM EDT

Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust.

Are you allergic to pollen ?

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05/22/20 12:54 PM EDT

Not that I’ve noticed.

are you allergic to mold?

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05/22/20 12:54 PM EDT

None that I know of.

Are you allergic to penicillin ?

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05/22/20 12:55 PM EDT

Yes.

what type of reaction do you have to penicillin?

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05/22/20 12:55 PM EDT

I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.

Do you have other allergies?

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05/22/20 12:55 PM EDT

Well, besides cats, I’m allergic to penicillin.

any other seasonal asthma triggers?

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05/22/20 12:58 PM EDT

No, not really.

Any past asthma medications? (No matching questions found.)

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05/22/20 12:59 PM EDT

Any past asthma medications?When were you diagnosed of Diabetes? (Clarified to How old were you when you were diagnosed with diabetes?.)

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05/22/20 1:00 PM EDT

I was diagnosed when I was 24. (Clarified to when I was diagnosed with diabetes.)

What type of diabetes do you have?

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05/22/20 1:01 PM EDT

It’s type 2.

do you take any medication for diabetes?

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05/22/20 1:02 PM EDT

I don’t take anything for my diabetes anymore.

why did you stop? (Clarified to Why did you stop taking diabetes medication?.)

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05/22/20 1:02 PM EDT

I just got sick of dealing with it! (Clarified to why I stopped taking my diabetes medication.)

Were you unable to afford the medication? (No matching questions found.)

Question
05/22/20 1:02 PM EDT

WIts not advisable to stop medication without consulting your doctor, it can have negative effects?

Educate
05/22/20 1:04 PM EDT

Sure, I think I understand what you mean.

What diabetes medication were you taking?

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05/22/20 1:04 PM EDT

It was Metformin.

would you afford the metformin? (Clarified to Did you have issues affording the metformin?.)

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05/22/20 1:05 PM EDT

I haven’t had trouble affording medication . . . Cost wasn’t really the issue with the metformin. I just got really sick of having to take it, and I hated the side effects. [AUDIO COMING SOON] (Clarified to if I had problems affording the metformin.)

had you any other challenges accessing metformin? (No matching questions found.)

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05/22/20 1:06 PM EDT

what dosage of metformin were you taking?

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05/22/20 1:07 PM EDT

Honestly, I don’t remember what the dose was when I was taking it.

How many times were you taking metformin?

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05/22/20 1:07 PM EDT

I think it was one pill, twice a day.

when did you stop taking metformin?

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05/22/20 1:08 PM EDT

About three years ago, honestly.

when did you start taking metformin?

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05/22/20 1:09 PM EDT

When I was 24, right after I was first diagnosed.

did you tell your doctor that you stopped taking metformin?

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05/22/20 1:10 PM EDT

No, I just stopped taking it because I was sick of dealing with taking it everyday and feeling gassy all the time.

Its good to have a plan with the doctor before stopping medication

Educate
05/22/20 1:11 PM EDT

OK, I understand.

How old are you now?

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05/22/20 1:11 PM EDT

I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets.

How is your appetite?

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05/22/20 1:31 PM EDT

My appetite’s been huge lately. . . I feel like I’m hungry all the time.

Do you notice any change in weight?

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05/22/20 1:31 PM EDT

Yeah, I’ve lost some weight recently.

Are you trying to lose weight?

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05/22/20 1:31 PM EDT

No, I’m not trying to lose weight, but I did lose a little recently without meaning to. About ten pounds in the last month. [AUDIO COMING SOON]

Do you have hypertension?

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05/22/20 1:32 PM EDT

No, I’ve never been diagnosed with blood pressure problems.

Do you check your blood pressure regularly?

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05/22/20 1:33 PM EDT

I almost never check it. I mean, maybe twice a year I might? It’s not something I think about.

do you know your blood pressure range?

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05/22/20 1:33 PM EDT

It’s . . . oh, I don’t remember exactly because I never write it down. Let me try to remember . . . I feel like it’s usually around 140. And the bottom number is 80 or 90. I do know the last time in the ER it was something like 141/92. They said it was on the high side. [AUDIO COMING SOON]

The standard rate reading 12 120/80. Sure that on the higher side, you need to monitor it as well.

Educate
05/22/20 1:35 PM EDT

Alright, thanks for letting me know.

When did you have your last immunization?

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05/22/20 1:37 PM EDT

I think the last time I got shots was when I enrolled in college the first time. Oh, and I got a tetanus booster about a year ago.

Have you received the influenza vaccine ?

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05/22/20 1:38 PM EDT

No.

Did you complete your childhood immunizations? (Clarified to Are you up to date on immunizations?.)

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05/22/20 1:39 PM EDT

I’m pretty sure they are all taken care of. (Clarified to if I am up to date on shots.)

Do you use over the counter medications?

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05/22/20 1:41 PM EDT

I take Tylenol for a headache sometimes, or Advil for cramps, but not often.

What dosage of tylenol?

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05/22/20 1:41 PM EDT

I just take one or two of the 500 mg acetaminophen. I usually get the headaches at night from reading — squinting I guess — and so I take one or two and go to bed. [AUDIO COMING SOON]

what dosage of advil do you take?

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05/22/20 1:42 PM EDT

I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]

How long have you been taking tramadol ?

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05/22/20 1:44 PM EDT

I started needing them two days ago.

when did you take the last tramadol?

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05/22/20 1:44 PM EDT

This morning I took two pain pills right before I came here, at around 8:30.

Do you take vitamin supplements?

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05/22/20 1:46 PM EDT

I don’t take vitamins or supplements.

Do you take herbal drugs? (Clarified to Do you take any herb supplements?.)

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05/22/20 1:46 PM EDT

No, I don’t take anything herbal. (Clarified to if I take herbal supplements.)

What is your highest level of educations?

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05/22/20 1:47 PM EDT

Well, I’m finishing up my Bachelor’s degree right now.

How is college life? (Clarified to Is college a stressful time?.)

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05/22/20 1:48 PM EDT

I don’t get stressed out much, but sometimes having such a hectic schedule can be a lot. Right now, though, I’m mostly worried about my foot. (Clarified to if college is stressful.)

Do you have financial problems accessing education ?

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05/22/20 1:49 PM EDT

I’m doing okay–I earn a pretty good wage at my job, but I do have to be careful with money since I’m still paying tuition. Right now I’m lucky to be able to save some money by living at my Mom’s house instead of paying rent.

Any financial problems accessing healthcare?

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05/22/20 1:50 PM EDT

I’m doing okay–I earn a pretty good wage at my job, but I do have to be careful with money since I’m still paying tuition. Right now I’m lucky to be able to save some money by living at my Mom’s house instead of paying rent.

Great, its good to continue with education nd also save money when you can.

Educate
05/22/20 1:51 PM EDT

OK, I understand.

What is your major at the college?

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05/22/20 1:52 PM EDT

I’m going to get my bachelor’s in accounting.

Do you have a belief system?

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05/22/20 1:53 PM EDT

Yeah. We go to First Baptist, and we do a lot with our church community. Even before a service, it’s pretty social; we go early so we can meet and talk with everybody. And I go to the Wednesday night Bible study group. There’s other events, too, pot-lucks, all of that. Oh, and once a month the church organizes like a volunteer event, so I try to do that. We spend a lot of time with our church family.

sounds like you have great social and religious conections

Empathize
05/22/20 1:54 PM EDT

I appreciate you telling me that.

Do you smoke tobacco?

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05/22/20 1:54 PM EDT

No. I think it’s gross.

Do you hang around people who smoke?

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05/22/20 1:55 PM EDT

Yeah, a couple of my friends smoke when we go out. I don’t like being around smokers, though.

Its good to avoid smoke, it is not good for asthma

Educate
05/22/20 1:55 PM EDT

That makes sense.

Do you smoke marijuana?

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05/22/20 1:56 PM EDT

Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.

how old were you then? (No matching questions found.)

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05/22/20 1:57 PM EDT

why did you stop smoking?

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05/22/20 1:58 PM EDT

It just wasn’t that fun anymore, plus it started to bother my asthma.

Do you vape?

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05/22/20 1:59 PM EDT

I’ve never vaped or smoked an e-cigarette. [AUDIO COMING SOON]

do you smoke the pot?

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05/22/20 1:59 PM EDT

Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.

At what age did you smoke?

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05/22/20 2:00 PM EDT

I started when I was about fifteen, and I stopped when I was twenty or twenty-one.

Do you drink alcohol?

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05/22/20 2:00 PM EDT

I do sometimes, yeah, when I go out with my friends.

How much alcohol do you take in a sitting? (Clarified to How much alcohol do you usually drink in one sitting?.)

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05/22/20 2:01 PM EDT

I never have more than two or three. If I go over that, I feel like hell the next day, so I stick to just a few. (Clarified to how much alcohol I drink in one sitting.)

How often do you drink?

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05/22/20 2:01 PM EDT

No more than once or twice a week, sometimes less.

Its good not to take a lot of alcohol and also to stop taking recreational drugs, they are addictive. (No matching questions found.)

Question
05/22/20 2:04 PM EDT

Its good not to take a lot of alcohol and also to stop taking recreational drugs, they are addictive.

Educate
05/22/20 2:04 PM EDT

Sure, I think I understand what you mean.

Do you take coffee?

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05/22/20 2:05 PM EDT

Never. I don’t like it. Too bitter for my taste.

Do you take carbonated sodas? (No matching questions found.)

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05/22/20 2:09 PM EDT

Do you take sodas? (No matching questions found.)

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05/22/20 2:10 PM EDT

Do you smoke the pot?

Question
05/22/20 2:10 PM EDT

Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.

Am happy that you stooped smoking pot, its not good for your health, especially asthma. (No matching questions found.)

Question
05/22/20 2:11 PM EDT

Am happy that you stooped smoking pot, its not good for your health, especially asthma.

Educate
05/22/20 2:11 PM EDT

Alright, thanks for letting me know.

Who do you love with? (Clarified to Who do you live with?.)

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05/22/20 2:12 PM EDT

Right now I live back at home with my mom and my sister. (Clarified to who I live with.)

Have you been abused?

Question
05/22/20 2:12 PM EDT

No, no way. I’ve never been hurt or anything in the way that you’re talking about.

Sorry for the discomforts

Empathize
05/22/20 2:27 PM EDT

Thanks for understanding.

Do you have a boyfriend?

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05/22/20 2:27 PM EDT

Um, not right now.

Have you had a boyfriend in the past?

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05/22/20 2:28 PM EDT

Um, not right now.

How many boyfriends you had? (Clarified to How many boyfriends have you had?.)

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05/22/20 2:28 PM EDT

Oh, gosh…I guess four or five. (Clarified to how many boyfriends I have had.)

Have you tested for HIV/AIDS?

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05/22/20 2:54 PM EDT

No. I don’t think I need one. I don’t know anybody with HIV or AIDS.

Have you tested for STDs? (Clarified to Have you been tested for STDs?.)

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05/22/20 2:54 PM EDT

Yeah, I’m sure they did those tests when I went for a pap smear before. (Clarified to if I have ever been tested for STDs.)

Have you been tested for STDs with your boyfriend? (Clarified to Has your friend been checked for sexually transmitted infections?.)

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05/22/20 2:55 PM EDT

When we were together, he told me he didn’t have any STDs, and I believed him. I don’t know if he was ever tested. (Clarified to if my sexual partner has been tested for STIs.)

It is good to be tested for STDs to be sure

Educate
05/22/20 2:56 PM EDT

Sure, I think I understand what you mean.

When were you tested for stds?

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05/22/20 2:56 PM EDT

I guess probably the last time I went for a pap smear…that was, um, maybe four years ago now.

Do you have any symptoms for STDs?

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05/22/20 2:57 PM EDT

No. I’ve never had any symptoms like that.

Any vaginal discharge?

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05/22/20 2:58 PM EDT

Um, I have hardly any discharge, and it’s, like, clear.

Have you had any muscle pain?

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05/22/20 2:59 PM EDT

No.

Any joint pain?

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05/22/20 3:00 PM EDT

No.

Joint swelling? (Clarified to Do you have any joint pain or swelling?.)

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05/22/20 3:00 PM EDT

Not really. (Clarified to if I have any joint pain or swelling.)

what about back pain?

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05/22/20 3:01 PM EDT

My back’s fine.

How are your eyes?

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05/22/20 3:01 PM EDT

I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry.

Do you wear eye glasses?

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05/22/20 3:02 PM EDT

I don’t wear glasses–or contacts.

Do you have any problem with moth or jaw? (Clarified to Do you have mouth or jaw problems?.)

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05/22/20 3:02 PM EDT

No, neither. (Clarified to if I have mouth or jaw problems.)

Have you had any dental problems?

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05/22/20 3:03 PM EDT

Nope, no problems.

Any change in sense of taste?

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05/22/20 3:04 PM EDT

No, I think my sense of taste is fine.

Do have a painful mouth?

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05/22/20 3:04 PM EDT

No.

Any difficulties swallowing?

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05/22/20 3:05 PM EDT

Nope.

Any sore throat?

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05/22/20 3:05 PM EDT

No, it’s fine.

Any swollen glands?

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05/22/20 3:05 PM EDT

No, not that I noticed.

Have you had a breast exam?

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05/22/20 3:05 PM EDT

I haven’t had a mammogram. I’ve just had the exam where the doctor felt around for lumps.

any pain in the breasts

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05/22/20 3:06 PM EDT

No. Maybe some soreness before my period, but that seems pretty typical.

any discharge from nipples?

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05/22/20 3:06 PM EDT

Uh, no, definitely not.

have you nosebleed?

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05/22/20 3:07 PM EDT

No.

Any chest pains?

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05/22/20 3:07 PM EDT

No, my chest feels tight when I have breathing problems, but it doesn’t hurt.

Any irregular heartbeat? (Clarified to Have you ever had an irregular heartbeat?.)

Question
05/22/20 3:08 PM EDT

I think my heart’s fine. I don’t really notice how it beats. (Clarified to if I have had an irregular heartbeat.)

do you have problems with your bowel problems? (Clarified to Do you have difficulty moving your bowels?.)

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05/22/20 3:09 PM EDT

No. No problems like that. (Clarified to if I have trouble moving my bowels.)

Have you noticed any changes with your skin?

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05/22/20 3:11 PM EDT

Well…I guess I was noticing the other day that the skin around my neck is looking weird. Like the skin is getting darker. And my skin’s breaking out, but that’s how it is.

What is your general heath condition?

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05/22/20 3:12 PM EDT

Generally? My foot has just been hurting from a scrape I got. [AUDIO COMING SOON]

Are you tired or fatigued?

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05/22/20 3:13 PM EDT

Most days I feel pretty exhausted by the end of the day…I’m tired now, too, but I think that’s just because I slept terribly.

How is your sleep pattern?

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05/22/20 3:13 PM EDT

I try to be in bed by eleven or midnight, and I get up at seven or eight.

Do eyes itch?

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05/22/20 3:14 PM EDT

No. That only happens around cats or dust.

Any hearing problem?

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05/22/20 3:14 PM EDT

No.

Any ear discharge?

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05/22/20 3:15 PM EDT

No.

does your mother have any health problem?

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05/22/20 3:17 PM EDT

Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

Does your father have medical problems?

Question
05/22/20 3:17 PM EDT

Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure.

Am sorry to hear that.

Empathize
05/22/20 3:17 PM EDT

I appreciate you telling me that.

When did your farther pass away? (Clarified to When did your father pass away?.)

Question
05/22/20 3:17 PM EDT

It was last year… I guess a little over a year ago. (Clarified to when my dad died.)

How old was your father when he passed away?

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05/22/20 3:18 PM EDT

Last year when Dad passed, he was only 58.

How did you cope with your fathers death?

Question
05/22/20 3:18 PM EDT

Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kinda depressed. So I guess at first I just focused on getting things done–groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kinda helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out, and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months.

You are lucky you have a great support system that helped you cope easily.

Empathize
05/22/20 3:20 PM EDT

Thanks for saying that.

What was the cause of your fathers death?

Question
05/22/20 3:20 PM EDT

He died in a car accident.

Am sorry to hear that

Empathize
05/22/20 3:20 PM EDT

I appreciate you saying that.

No, I’m fine right now.

Measured wound: 2 cm x 1.5 cm, 2.5 mm deep

Exam Action
05/22/20 4:25 PM EDT

Swabbed wound and sent to lab for C & S

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05/22/20 4:25 PM EDT

Cleansed and irrigated wound with normal saline and applied dry sterile dressing.

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05/22/20 4:25 PM EDT

 Height: 170 cm

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 Weight: 90 kg

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 BMI: 31

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 Random blood glucose: 238

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 Temperature: 101.1 F

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 Blood pressure: 142/82

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 Respiratory rate: 19

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 O2 sat: 99%

Exam Action
03/08/20 3:43 PM PDT

 Heart rate: 86

Exam Action
03/08/20 3:43 PM PDT

Hallo M. Tina, my name is Mary and i will taking care of you today

Greet
03/08/20 3:44 PM PDT

Hey.

how are you doing today?

Question
03/08/20 3:45 PM PDT

Not so great… My foot really hurts right now.

im sorry to hear that can you tell me more about it

Empathize
03/08/20 3:46 PM PDT

I appreciate you telling me that.

what brings you to the clinic today?

Question
03/08/20 3:46 PM PDT

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!

tell me about your more about the pain

Question
03/08/20 3:47 PM PDT

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

how long have you been experiencing the pain?

Question
03/08/20 3:47 PM PDT

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

did you see any doctor?

Question
03/08/20 3:48 PM PDT

To be honest, I haven’t been to a doctor for just a check-up in. . . at least two years. But I did see a doctor at the ER about my foot.

were you given any medication? (Clarified to Did the ER prescribe anything?.)

Question
03/08/20 3:48 PM PDT

Yes, they wrote me a prescription for some pain pills. (Clarified to if the ER prescribed me any medications.)

what type of pain pills

Question
03/08/20 3:49 PM PDT

It’s called tramadol.

how many mg

Question
03/08/20 3:49 PM PDT

I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]

how often do you take it

Question
03/08/20 3:49 PM PDT

I don’t take anything now, but I used to be on the pill.

how many pills of tramadol do you take

Question
03/08/20 3:50 PM PDT

I take two at a time.

how often do you take it

Question
03/08/20 3:50 PM PDT

I don’t take anything now, but I used to be on the pill.

on a scale of 1-10 how much is your pain (Clarified to On a scale of 0-10 how would you rate the pain in your right foot?.)

Question
03/08/20 3:51 PM PDT

I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. (Clarified to how I would rate my foot pain on a scale.)

have you noticed any drainage

Question
03/08/20 3:52 PM PDT

Yeah, there’s definitely pus.

is the pus has any color

Question
03/08/20 3:52 PM PDT

Yeah, there’s definitely pus.

are you allergic to any medication

Question
03/08/20 3:53 PM PDT

Yeah, I’m allergic to penicillin.

do you have food allergies

Question
03/08/20 3:53 PM PDT

Nope, no food allergies that I know of.

do you have any environmental allergies

Question
03/08/20 3:54 PM PDT

No, unless cats count.

tell me about the cat allergy

Question
03/08/20 3:54 PM PDT

Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up.

do you take anything for the allergies

Question
03/08/20 3:55 PM PDT

I don’t take anything, unless my inhaler counts.

do you have any other medical conditions

Question
03/08/20 3:56 PM PDT

Um, the only things I know I’m diagnosed with are diabetes. And asthma.

do you take anything for diabetes

Question
03/08/20 3:57 PM PDT

I don’t take anything for my diabetes anymore.

how do you control your diabetes

Question
03/08/20 3:57 PM PDT

I just watch what I eat and try to stay away from sweets.

do you take any asthma medication

Question
03/08/20 3:57 PM PDT

I just use my inhaler.

what is the name of your inhaler

Question
03/08/20 3:58 PM PDT

It’s just a regular Proventil inhaler.

how many mg

Question
03/08/20 3:58 PM PDT

I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON]

how many cg is your inhaler (Clarified to How many times did you use your inhaler?.)

Question
03/08/20 3:59 PM PDT

At my cousin’s? I did two puffs, and then I had to do another one a little later. . . that’s been happening sometimes lately. (Clarified to how many times I used my inhaler.)

do you have any medical history

Question
03/08/20 4:00 PM PDT

Yeah. . . I have asthma and diabetes.

does your family have any medical history

Question
03/08/20 4:01 PM PDT

My mom has some issues, and I think some of my grandparents did, too.

what kind of issues does you mother have

Question
03/08/20 4:01 PM PDT

Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

any other medical history in the family (Clarified to What health problems run in your family?.)

Question
03/08/20 4:02 PM PDT

My mom has some issues, and I think some of my grandparents did, too. (Clarified to what health problems run in my family.)

does you father have any medical issues

Question
03/08/20 4:02 PM PDT

Well, he passed away. But he had a couple things . . . Type 2 diabetes, like me, and high cholesterol and blood pressure.

do you smoke?

Question
03/08/20 4:03 PM PDT

No. I think it’s gross.

do you drink alcohol

Question
03/08/20 4:03 PM PDT

I do sometimes, yeah, when I go out with my friends.

how many drinks do you have when you drink

Question
03/08/20 4:03 PM PDT

Just a few. I’m not a big drinker.

do you take any illegal drugs

Question
03/08/20 4:04 PM PDT

Well, I used to smoke pot. . . but I don’t do that anymore.

do your friends smoke pot

Question
03/08/20 4:04 PM PDT

Yeah, a couple of my friends smoke when we go out. I don’t like being around smokers, though.

what do you plan to stop smoking with your friends

Question
03/08/20 4:05 PM PDT

I’m pretty optimistic about the future actually. In a couple of months I’ll have my degree, and I’ll probably get my own place again. I’m planning on trying for one of the accounting jobs in our regional office, too. If that works out, I would like to start dating again… maybe I’ll find someone I want to marry, start a family with?

do you have shortness of breath

Question
03/08/20 4:06 PM PDT

No, my breathing is fine right now.

are you in pain

Question
03/08/20 4:06 PM PDT

Yeah, my foot’s really bothering me.

what makes it worse

Question
03/08/20 4:06 PM PDT

I’d say the pain is at its worst when I have to put any weight on my foot. . . otherwise, it’s when the pain pills wear off.

can i take a look on your foot (Clarified to May I take a look at your foot now?.)

Question
03/08/20 4:07 PM PD

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Transcript

All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394)

I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church.

Subjective Data Collection: 50 of 50 (100.0%)

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.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Current Health Status

Finding: Confirmed reason for visit

Finding: Reports needing a pre-employment physical

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question: Can I confirm that you are here for a physical?

Finding: Reports no current acute health problems

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question: Do you have any current health problems?

Finding: Asked about last visit to a healthcare provider

Finding: Last visit to a healthcare provider was 4 months ago

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

Example Question: When did you see a healthcare provider?

Finding: Reason for last visit was annual gynecological exam

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.

Example Question: Why did you see a healthcare provider?

Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

Example Question: When was your last physical exam? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding: Asked about current prescription medications

Finding: Reports taking diabetes medication

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.

Example Question: Have you been taking medication for your diabetes?

Finding: Reports using a daily inhaler

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.

Example Question: Do you use a daily inhaler?

Finding: Reports taking prescription birth control pills

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.

Example Question: Are you taking any form of birth control?

Finding: Followed up about diabetes medication

Finding: Medication is metformin

Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history.

Example Question: What is the name of your diabetes medication?

Finding: Started taking metformin 5 months ago

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question: How long have you been taking metformin?

Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question: Have you noticed any side effects from the metformin?

Finding: Followed up on metformin frequency and dose

Finding: Reports taking metformin twice daily

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question: How many times a day do you take metformin?

Finding: Metformin dose is 850 mg

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question: What is the dose of your metformin?

Finding: Asked about asthma medication

Finding: Reports using Flovent inhaler twice daily

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question: How often do you use your daily inhaler?

Finding: Has a Proventil rescue inhaler

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.

Example Question: Do you have a rescue inhaler?

Finding: Last use of Proventil inhaler was three months ago

Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.

Example Question: When did you last use your rescue inhaler?

Finding: Has used Proventil inhaler twice in the last year

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question: How often do you use your rescue inhaler?

Finding: Followed up about birth control prescription

Finding: Started taking birth control 4 months ago

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.

Example Question: How long ago did you start taking birth control?

Finding: Reason for birth control was to manage PCOS symptoms

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.

Example Question: Why did you decide to start taking birth control?

Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question: What type of birth control do you use?

Finding: Takes birth control pill daily

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question: How often do you take your birth control pill?

Finding: Takes birth control pill at the same time every day

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question: Do you take your pill at the same time every day?

Finding: Reports no skipped days

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question: Have you missed any days of your birth control pill?

Finding: Asked about current non-prescription medications

Finding: Reports rare Advil use for cramps

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan.

Example Question: Do you take Advil?

Finding: Reports no OTC herbal products

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan.

Example Question: Do you use any herbal products?

Finding: Reports no OTC vitamins

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan.

Example Question: Do you take any vitamins?

Finding: Reports no OTC supplements

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question: Do you take any supplements?

Finding: Asked about allergies

Finding: Confirms allergies

Pro Tip: Discerning what is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina’s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina’s health literacy.

Example Question: Can you confirm your allergies?

Finding: Reports no new allergies

Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question: Have you noticed any new allergies?

Finding: Followed up on seasonal allergies

Finding: Reports no recent seasonal allergy symptoms

Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question: Have you been having seasonal allergies?

Finding: Reports no current medication for allergies

Pro Tip: Tina’s response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question: Are you taking any medication for your allergies?

Finding: Asked about diabetes

Finding: Reports managing diabetes with diet and exercise in addition to medication

Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she is complied with previous treatment plans. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question: How are you managing your diabetes?

Finding: Asked about blood glucose monitoring

Finding: Reports checking blood sugar once a day

Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question: How often do you monitor your blood glucose?

Finding: Checks sugar in the morning

Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she is complied with previous treatment plans. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question: When do you check your blood glucose?

Finding: Blood sugar number is usually around 90

Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question: What is your average blood sugar number?

Finding: Reports having adequate supplies

Objective Data Collection: 70 of 73 (95.9%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips.

Found: Indicates an item that you found.

Available: Indicates an item that is available to be found.

Category

Scored Items

Experts selected these examinations as essential components of objective data collection for this patient.

Patient Data

Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient’s case. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

HEENT

Finding: Inspected head and neck

Finding: Scattered pustules on face and facial hair on upper lip

Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.

Finding: Head is normocephalic, atraumatic

Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient’s head can identify any indications of trauma.

Finding: Normal scalp hair distribution

Pro Tip: It’s important to inspect your patient’s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.

Finding: Acanthosis nigricans noted on neck

Pro Tip: Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient’s skin, especially in folds around the neck, axilla, and groin.

Finding: Inspected eyebrows and orbital area

Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema

Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.

Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema

Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.

Finding: Palpated scalp

Finding: No masses

Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.

Finding: Palpated sinuses

Finding: No frontal sinus tenderness

Pro Tip: Palpating the frontal sinuses checks for sinusitis.

Finding: No maxillary sinus tenderness

Pro Tip: Palpating the maxillary sinuses checks for sinusitis.

Finding: Palpated jaw

Finding: No clicks, full ROM

Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury.

Finding: Palpated lymph nodes

Finding: No axillary lymphadenopathy

Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.

Finding: No supraclavicular lymphadenopathy

Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding: Palpated thyroid

Finding: Thyroid smooth without nodules, no goiter

Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.

Finding: Inspected eyelids and conjunctiva

Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera

Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.

Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera

Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.

Finding: Tested PERRL with penlight

Finding: Right pupil: equal, round, reactive to light

Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.

Finding: Left pupil: equal, round, reactive to light

Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.

Finding: Tested eye movements

Finding: Normal convergence

Pro Tip: This test accommodation assesses the eye’s ability to focus on close objects.

Finding: EOMs intact bilaterally, no nystagmus

Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions.

Finding: Tested peripheral vision

Finding: Peripheral vision intact in both eyes, all fields

Finding: Inspected interior eyes with ophthalmoscopeComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding: Mild retinopathic changes on right

Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. By visualizing the fundus, you can look for any retinopathic changes.

Finding: Left fundus with sharp disc margins, no hemorrhages

Finding: Palpated abdomen – deep

Finding: Right upper quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Right lower quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding: Left upper quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Left lower quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Palpated organs

Finding: Liver: palpable 1 cm below right costal margin

Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems.

Finding: Spleen: not palpable

Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions.

Finding: Right kidney: not palpable, no masses

Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.

Finding: Left kidney: not palpable, no masses

Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.

Musculoskeletal

Finding: Inspected neck

Finding: Neck without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Inspected upper extremities

Finding: Right shoulder without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right arm without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right elbow without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right wrist and hand without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left shoulder without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left arm without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left elbow without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left wrist and hand without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds

Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding: Inspected hips

Finding: Hips without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding: Inspected lower extremities

Finding: Right leg without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right knee without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right ankle without swelling, masses, deformity, or discoloration

Pro Tip: A thorough inspection of your patient’s affected ankle aids in the estimation of the extent of tissue injury and disability.

Finding: Right foot without swelling, masses, or deformity

Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status.

Finding: Left leg without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left knee without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left ankle without swelling, masses, or deformity

Pro Tip: The inspection of your patient’s unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall.

Finding: Left foot without swelling, masses, or deformity

Pro Tip: Your patient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy.

Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds

Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease.

Finding: Tested ROM for upper extremities

Finding: Right and left shoulders: full ROM

Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.

Finding: Right and left elbows: full ROM

Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.

Finding: Right and left wrists: full ROM

Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.

Finding: Tested ROM for spine

Finding: Rotate left: full ROM

Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.

Finding: Rotate right: full ROM

Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.

Finding:  Extension: full ROM

Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding:    Flexion: full ROM

Documentation / Electronic Health Record

Vitals

Health History

Neurological

Skin, Hair & Nails

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Health History Tips & Tricks:

…

Student: Hello!

Diana Shadow: Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.

Student: What is the situation?

Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones’ health history, a key component of her admission process.

Student: What are my objectives in this assessment?

Diana Shadow: A health history requires you to ask questions related to Ms. Jones’ past and present health, from her current foot wound to her pre-existing conditions. You will also want to review Ms. Jones’ systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones’ overall health. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. Jones’ health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses.

Student: What else will this exam involve?

Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation.

Student: How will I be evaluated?

Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically.

Student: How does this assignment prepare me for the real world?

Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient’s risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses.

Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient’s complete health history?

Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition.

Diana Shadow: Time to begin.

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Patient Exam – Vital Signs:

Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%

Patient Exam – Interview:

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Student: Hello, my name is Catlain, I am your nurse today.

Tina Jones: Hey.

Student: Can you confirm your name?

Tina Jones: Tina Jones:.

Student: Why did you come in today?

Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It’s killing me.

Student: What additional symptoms have you experienced?

Tina Jones: I mean, it’s all red and swollen, and there’s pus, it feels hot, it hurts like hell… It’s got all that going on.

Student: Can you rate your current pain level on a scale of 0 to 10?

Tina Jones: …Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit.

Student: Please describe the pain.

Tina Jones: It’s throbbing and like, sharp if I try to put weight on it.

Student: How did you hurt your foot?

Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn’t realize how sharp the edge was!

Student: Has your foot been draining any liquids?

Tina Jones: Yeah, there’s definitely pus.

Student: What color was the pus?

Tina Jones: It’s… white or maybe off-white.

Student: How have you treated the wound?

Tina Jones: I’ve been taking Advil for my foot for a few days.

Student: What did you do to treat your foot after your accident?

Tina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it.

Student: How effective was the Neosporin?

Tina Jones: Well, I’m here, so I guess it didn’t do its job.

Student: Can you walk with your foot being injured?

Tina Jones: No, I can’t. I can’t put any weight on it without like, shooting pain.

Student: What preexisting medical conditions do you have?

Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot!

Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly.

Tina Jones: Thanks.

Student: When were you diagnosed with diabetes?

Tina Jones: I was diagnosed when I was 24.

Student: What do you do to manage your asthma?

Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

Student: What medications did you take for your diabetes?

Tina Jones: It was metformin.

Student: Do you currently take medicine for your diabetes?

Tina Jones: No, I don’t take anything for my diabetes anymore.

Student: What made you stop taking medication for your diabetes?

Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I’m just eating healthier than I did when I was taking the pills.

Student: Do you monitor your blood glucose?

Tina Jones: I have a monitor at home, but to be honest I don’t really use it that often.

Student: How frequently do you urinate?

Tina Jones: I don’t know. Every hour or two when I’m awake?

Student: What is your current diet?

Tina Jones: It’s pretty good, I think. I’m not a huge health nut or anything.

Student: Have you had any change in appetite?

Tina Jones: Yeah, lately I’ve definitely been much hungrier than usual.

Student: Has your weight changed?

Tina Jones: Yeah, I’ve lost some weight recently.

Student: Do you know why you lost weight?

Tina Jones: I don’t know what caused it, I just lost weight.

Student: How often do you have asthma exacerbations?

Tina Jones: I haven’t had a full attack in years. But my breathing definitely acts up. . .not always. Max twice a week.

Student: What asthma symptoms have you experienced?

Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can’t take in air, like I can’t get enough air into my lungs.

Student: How many puffs do you take when using your asthma inhaler?

Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]

Student: What are some things that trigger your asthma?

Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too.

Student: What allergies do you have?

Tina Jones: I’m allergic to cats.

Student: When did you realize you were allergic to cats?

Tina Jones: For as long as I’ve been around.

Student: How effective was your pain medication at home?

Tina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn’t doing much for me — it would only last a couple of hours.

Student: What medication allergies do you have?

Tina Jones: I’m allergic to penicillin.

Student: What food allergies do you have?

Tina Jones: I don’t have any food allergies that I know of.

Student: Are you allergic to dust, mold, or pollen?

Tina Jones: Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust.

Student: What immunizations have you received?

Tina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college…I’m sure I have a record somewhere at home.

Student: Have you received a flu vaccine?

Tina Jones: No.

Student: Have you had any prior hospitalizations?

Tina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I’ve been in the hospital since I was probably sixteen, though.

Student: Have you had any gastrointestinal problems?

Tina Jones: No. I’ve never really had stomach or bowel problems.

Student: Do you have a family history of psychiatric illness?

Tina Jones: No. They’re crazy, but nobody’s diagnosed with anything.

Student: Do you have any neck, throat or gland problems?

Tina Jones: No, not that I noticed.

Student: Do you have any problems with your head?

Tina Jones: I don’t think I have any problems. I get headaches sometimes, but that’s all.

Student: Any problems with your ears?

Tina Jones: No.

Student: Any problems with your eyes and vision?

Tina Jones: I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry.

Student: Any problems with your nose?

Tina Jones: My nose is fine right now. Sometimes it runs, but not very often.

Student: Do you have problems with your mouth?

Tina Jones: No.

Student: Do you have a history of cardiovascular problems?

Tina Jones: My heart’s fine, thank God!

Student: Any problems with your heart?

Tina Jones: No, my heart’s always been fine.

Student: Have you had any problems with your breasts?

Tina Jones: I haven’t noticed any pain there.

Student: Have you had any reproductive problems?

Tina Jones: I don’t think I have problems in that area. I just get really bad periods, that’s all.

Student: Have you had any neurological problems?

Tina Jones: No, I haven’t.

Student: Have you had any musculoskeletal problems?

Tina Jones: No.

Student: Do you have a history of skin disease?

Tina Jones: Um, I have acne, if that counts.

Student: Does your paternal grandfather have any health problems?

Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes. And high cholesterol like everyone else in my family.

Student: Does your mother have any health problems?

Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

Student: Does your father have any health problems?

Tina Jones: Well, he passed away. But he had a couple things… Type 2 diabetes, like me, and high cholesterol and blood pressure.

Student: How did your father die?

Tina Jones: He died in a car accident.

Student: Where is your wound located?

Tina Jones: It’s on the ball of my foot.

Student: Do you get thirsty often?

Tina Jones: You know, I did notice lately that I’ve been really thirsty.

Student: What happened with your father’s car accident?

Tina Jones: It was last year… I guess a little over a year ago.

Student: How long ago was your dad’s car accident?

Tina Jones: It was last year… I guess a little over a year ago.

Student: How did you cope with your fathers death?

Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kind of depressed. So, I guess at first I just focused on getting things done–groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months.

Student: What caused your dads accident?

Tina Jones: He was driving to work, and it was raining…and his car hydroplaned. And hit a tree. So, it was really sudden.

Student: How is your paternal grandmother’s health?

Tina Jones: Granny’s doing good. She’s still living on her own. She’s slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy.

Student: How is your paternal grandfather’s health?

Tina Jones: Grandpa Jones passed away when I was really little.

Student: How is your maternal grandfather’s health?

Tina Jones: Well, Poppa died about five years ago.

Student: How is your maternal grandmother’s health?

Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.

Student: How is your brother’s health?

Tina Jones: He’s a healthy guy. Kind of big like me.

Student: How is your sister’s health?

Tina Jones: She’s pretty healthy. She has asthma too, but she almost never has attacks.

Student: Does your family have a history of obesity?

Tina Jones: No, I don’t think so. My brother and my dad are kind of big, but I wouldn’t say they were obese or anything.

Student: Does your family have a history thyroid issue?

Tina Jones: No, I don’t think so.

Student: Does your family have a history of substance abuse?

Tina Jones: One person in the family, my dad’s brother, has an alcohol problem, but we never see him.

Student: Does your family have a history of headaches?

Tina Jones: No, not that I know of.

Student: How much alcohol do you drink?

Tina Jones: I only have a few drinks when I go out.

Student: What is your level of education?

Tina Jones: Well, I’m finishing up my bachelor’s degree right now.

Student: What are stressors?

Tina Jones: I feel really stressed out right now! Honestly, I didn’t realize that I’d be admitted to the hospital for my foot. I don’t want to miss work or school but now it looks like I’ll have to. And I want my foot to stop hurting. I know I need sleep, too.

Student: We are going to take care of everything as quickly as possible.

Tina Jones: Thanks.

Student: Where do you live?

Tina Jones: Right now, I’m living at my mom’s place, which is out in the suburbs a bit. It’s like a half hour from here.

Student: What is your belief system?

Tina Jones: I’m Baptist. My faith is a big part of my life–when things get hard like they’ve been this past year, I know I can trust that God’s looking out for me. I’ve been going to the same church since I was a kid, too, so the people at church are practically part of my family.

Student: Have you experienced abuse?

Tina Jones: I’ve never had been in any kind of situation like that… It’s scary to think about.

Student: Have you used illicit drugs?

Tina Jones: Well, I used to smoke pot. . . but I don’t do that anymore.

Student: What type of drugs did you use?

Tina Jones: Um…I’ve smoked pot before. In high school, and after high school… I definitely don’t anymore, though.

Student: Have you used drugs other than marijuana?

Tina Jones: No.

Student: When did you last use drugs?

Tina Jones: I haven’t smoked pot since I was twenty or twenty-one.

Student: Have you ever smoked cigarettes?

Tina Jones: No. I think it’s gross.

Student: Have you been around people that are smoking?

Tina Jones: Some of my friend’s smoke when we go out drinking. But I don’t smoke, and nobody at home smokes.

Student: How old were you when your father died?

Tina Jones: He died last year, so I was 27.

Student: Did your father die from any disease?

Tina Jones: He died in a car accident.

Student: Can you tell me about your father’s health?

Tina Jones: He had high blood pressure and cholesterol. And diabetes — we have diabetes in common.

Student: I can’t even imagine how you feel about losing your father

Tina Jones: Thanks.

Student: Tell me about your father.

Tina Jones: Dad was a little stricter than Mom growing up. . . he would sometimes get kind of mad at us when we did something wrong. But he never hit us or anything. He would just get really calm and quiet and tell us to go to our rooms without supper, or that we were grounded when we were older. Or like, he’d make us rake the yard or wash his car or something. It’s pretty sad to

Student: How old was your father when he died?

Tina Jones: Last year when Dad passed, he was only 58.

Subjective Data Collection – Checklist:

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Chief Complaint

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Finding: Established chief complaint

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Finding: Reports pain (Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question: Do you have any pain?

Finding: Reports foot wound (Found)Pro Tip: If a patient mentions pain, it’s important to determine what specifically is causing her pain, if she knows.

Example Question: What’s causing your pain?

History of Presenting Illness

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Finding: Asked to rate current pain level on a scale

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Finding: Reports current pain is 7/10 (Found)Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care.

Example Question: Can you rate the pain on a scale of 0 to 10?

Finding: Asked for details about the pain

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Finding: Reports pain is throbbing (Found)Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.

Example Question: Can you please describe the pain?

Finding: Reports pain is sharp when she attempts to stand (Found)Pro Tip: Determining what physical activities and movements exacerbate the patient’s pain can help you better understand the problems and assess treatment needs. This can also alert you if a patient’s activities of daily living are hindered.

Example Question: What is the pain like when you stand on your foot?

Finding: Reports pain has increased in the past 2 days (Available)Pro Tip:Finding out how the patient’s pain has changed will give you insight into the acceleration of infection.

Example Question: How has the pain changed over time?

Finding: Reports feeling pain radiating into ankle (Available)Pro Tip: Asking about where else the patient’s pain radiates can help determine the progression of infection.

Example Question: Does the pain radiate anywhere else?

Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care.

Example Question: Can you bear weight on your foot?

Finding: Asked location of wound

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Finding: Reports right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patient’s safety.

Example Question: Which foot is in pain?

Finding: Reports wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient’s biggest complaint.

Example Question: Where is the wound?

Finding: Asked details of the injury

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Finding: Reports she scraped foot on bottom rung of a step stool (Found)Pro Tip: Discovering how an injury happened helps to assess your patient’s risk factors for injury.

Example Question: How did your injury happen?

Finding: Reports injury occurred 1 week ago (Available)Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute.

Example Question: When did your injury occur?

Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury.

Example Question: Did you injure anything besides your foot?

Finding: Reports being barefoot at the time of injury (Available)Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances.

Example Question: Were you wearing shoes when you fell?

Finding: Denies seeing a healthcare provider for the injury until now (Available)Pro Tip: It’s crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound.

Example Question: Have you seen a healthcare provider for this injury?

Finding: Asked about drainage from the foot wound

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Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound.

Example Question: Did your foot bleed?

Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound.

Example Question: Did you notice any discharge from the wound?

Finding: Reports noticing pus 2 days ago (Available)Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began.

Example Question: When did you first notice the pus?

Finding: Followed up on drainage

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Finding: Reports pus as white or yellow (Found)Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics.

Example Question: What color is the drainage from your wound?

Finding: Denies odor from the wound (Available)Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics.

Example Question: Does the wound have an odor?

Finding: Asked about home treatment of foot wound

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Finding: Reports wound care regimen of bandaging (Available)Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.

Example Question: How often do you change your bandage?

Finding: Reports cleaning wound twice a day (Available)Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.

Example Question: How often did you clean the wound?

Finding: Reports applying bacitracin, neomycin and polymyxin B (Neosporin) (Found)Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy.

Example Question: Did you use any ointment on the wound?

Finding: Followed up on effectiveness of ointment

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Finding: Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective (Found)Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Tina’s diabetes diagnosis will have a large impact on her body’s healing ability, which should be taken into consideration during your exam.

Example Question: Did the ointment help?

Finding: Asked about other foot wound symptoms

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Finding: Reports swelling around foot wound (Found)Pro Tip: Asking about the presence of swelling helps you gather information about your patient’s complaint, as well as potential related illnesses.

Example Question: Is there swelling around the wound?

Finding: Reports swelling worsened in the past 2 days (Available)Pro Tip:Finding out how long swelling appeared will help you understand the timeline for the infection progression.

Example Question: How long have you noticed swelling around the wound?

Finding: Reports redness around the wound (Found)Pro Tip: Asking about redness will help you understand the timeline for the infection progression.

Example Question: Did you notice any redness around the wound?

Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression.

Example Question: Does the wound feel warm?

Finding: Explored impact of patient’s foot injury on activities of daily living

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Finding: Reports pain affects ability to walk (Available)Pro Tip: Understanding the impact of your patient’s wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can walk or not, as a lack of mobility can compromise quality of life.

Example Question: Does your injury impact your ability to walk?

Finding: Reports pain affects ability to stand at work for long periods of time (Available)Pro Tip: Understanding the impact of your patient’s wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance.

Example Question: Does your foot pain affect your work?

Finding: Reports pain prevented her from being able to walk to class (Available)Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don’t fall behind.

Example Question: Has your injury prevented you from going to class?

Past Medical History

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Finding: Asked about preexisting medical conditions

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Finding: Reports diabetes (Found)Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. Existing conditions can also inform your treatment and understanding of the patient’s current health issues. In Tina’s case, it is important to identify her diabetes diagnosis because that condition has a direct relationship with her current foot infection.

Example Question: Do you have any existing conditions?

Finding: Reports asthma (Found)Pro Tip: It is important to identify any existing medical conditions, such as Tina’s asthma, because that information is an integral part of her health history. Existing conditions can also inform your treatment and understanding of the patient’s current health issues.

Example Question: Do you have any other conditions?

Finding: Followed up on diabetes diagnosis

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Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patient’s illness is an essential element of the illnesses history.

Example Question: At what age were you diagnosed with diabetes?

Finding: Reports that her diabetes is Type 2 (Available)Pro Tip: The type of diabetes your patient has will drastically affect how you care for her.

Example Question: Do you know what type of diabetes you have?

Finding: Asked about diabetes management through lifestyle changes

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Finding: Reports staying away from sweets (Available)Pro Tip: Asking your patient specifically about sugar intake can help you understand the history of her diabetes as well as her health literacy.

Example Question: Tell me more about any sugars you consume.

Finding: Reports drinking diet coke instead of regular (Available)Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider.

Example Question: Do you drink sugary drinks?

Finding: Asked about current diabetes medication use

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Finding: Reports that she does not currently take medication for diabetes (Found)Pro Tip: Asking about diabetes medication is important to understanding if your patient’s disease is under control.

Example Question: Do you take prescribed medication for your diabetes?

Finding: Asked about past diabetes medication use

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Finding: Reports that she used to take diabetes medication (Found)Pro Tip: Asking about Tina’s medication history for asthma will provide a timeline of treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment.

Example Question: Have you ever taken medication for your diabetes?

Finding: Reports previous medication was prescription metformin (Found)Pro Tip: Asking about a patient’s medication history for a particular condition, such as Tina’s past prescription for metformin, will provide a timeline of her asthma treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment.

Example Question: Do you remember what you were prescribed for diabetes?

Finding: Reports last use of medication was 3 years ago (Available)Pro Tip: It important to discover when Tina stopped taking any medications and what caused her to stop. Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment.

Example Question: When was the last time you took your diabetes medication on a regular basis?

Finding: Followed up on stopping diabetes regimen

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Finding: Reports disliking diabetes medication side effects (Found)Pro Tip: Asking about side effects from medication can provide information about your patient’s reaction to treatment.

Example Question: Did the metformin cause any side effects?

Finding: Reports that she didn’t like checking sugar and taking daily pills (Found)Pro Tip: Asking reasons for noncompliance can reveal information about your patient’s health literacy, side effects, financial situation, and more.

Example Question: What’s preventing you from taking your diabetes medication?

Finding: Asked about blood glucose monitoring

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Finding: Reports infrequent blood glucose monitoring (Found)Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment.

Example Question: Tell me about your blood sugar monitoring.

Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment.

Example Question: How often do you check your blood sugar?

Finding: Reports confusion about what the numbers mean (Available)Pro Tip: Your patient’s blood sugar monitoring habits are an important part of her health literacy and home treatment. If you find gaps in the patient’s literacy, that is your opportunity to provide education.

Example Question: What are your usual blood sugar levels?

Finding: Asked about thirst

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Finding: Reports increased thirst (Found)Pro Tip: Your patient’s thirst can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition.

Example Question: Have you been more thirsty lately?

Finding: Reports increased water intake (Available)Pro Tip: Your patient’s fluid intake can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition.

Example Question: Are you drinking more water than normal?

Finding: Asked about frequency of urination

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Finding: Reports more frequent urination (Found)Pro Tip: Your patient’s urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition.

Example Question: Have you been urinating more often than usual?

Finding: Reports urinating every hour or two during the day (Found)Pro Tip: Your patient’s urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition.

Example Question: How often do you urinate during the day?

Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health.

Example Question: How often do you wake up at night to urinate?

Finding: Asked about diet

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Finding: Reports eating a bowl of cereal for breakfast yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient’s typical dietary patterns. This can be achieved by asking for a 24-hour diet recall.

Example Question: What did you eat for breakfast yesterday?

Finding: Reports eating mac and cheese for lunch yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient’s typical dietary patterns. This can be achieved by asking for a 24-hour diet recall.

Example Question: What did you eat for lunch yesterday?

Finding: Reports eating chicken and roll for dinner yesterday (Available)Pro Tip:Finding out the foods a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status and can affect medications given while in your care.

Example Question: What did you eat for your last meal?

Finding: Asked about change in appetite

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Finding: Reports increased appetite (Found)Pro Tip: Identifying if a patient has recently experienced a change in appetite is important, as it could indicate an underlying endocrine or psychiatric condition.

Example Question: Have you noticed an increase in appetite?

Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions.

Example Question: When did you notice the increase in your appetite?

Finding: Asked about weight change

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Finding: Reports recent loss of 10 lbs (Available)Pro Tip: Determining the exact amount of weight loss can indicate whether it’s within expected ranges, or extreme, which may indicate an underlying health problem. Example Question: How much weight have you lost?

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Finding: Reports weight loss occurred over the past month (Available)Pro Tip:Finding out the timeline for weight loss can indicate if it’s sudden or gradual.

Example Question: How long did it take you to lose 10 pounds?

Finding: Followed up on reason for weight change

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Finding: Reports weight loss was unintentional (Found)Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan.

Example Question: Was your weight loss intentional?

Finding: Asked about history of asthma exacerbations

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Finding: Reports last asthma attack was in high school (Available)Pro Tip: Discovering the patient’s most recent asthma attack can provide a timeline of exacerbations and help you better understand the patient’s condition and effectiveness of any treatments.

Example Question: When was your last asthma attack?

Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient’s most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient’s condition and effectiveness of any treatments.

Example Question: When did you last have issues with asthma?

Finding: Asked about asthma symptoms

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Finding: Reports chest tightness during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness.

Example Question: What do your asthma symptoms feel like?

Finding: Reports difficulty breathing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as difficulty breathing.

Example Question: Do you have trouble breathing?

Finding: Reports wheezing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as wheezing.

Example Question: Do you ever wheeze?

Finding: Asked about prior hospitalizations

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Finding: Reports past hospitalizations (Found)Pro Tip: Finding out if the patient has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina’s case, it will help you better understand her asthma and create a timeline.

Example Question: Have you been hospitalized in the past?

Finding: Reports last hospitalization was for asthma (Available)Pro Tip: Finding out if Tina has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina’s case, it will help you better understand her asthma and create a timeline.

Example Question: Why were you hospitalized last time?

Finding: Reports last hospitalization was age 16 (Available)Pro Tip: Finding out the date of Tina’s last hospitalization is important for understanding the timeline of her medical issues, asthma in particular.

Example Question: When was your last hospitalization?

Finding: Reports about 5 total hospitalizations for asthma as a child and teen (Available)Pro Tip: Finding out the number of Tina’s previous hospitalizations is important for understanding the history of her asthma.

Example Question: How many times have you been hospitalized?

Finding: Reports past nebulizer use (Available)Pro Tip: Finding out what treatments Tina received during her hospitalizations will give you a fuller picture of the history of her condition.

Example Question: Have you ever used a nebulizer?

Finding: Asked about asthma diagnosis

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Finding: Reports specific age of diagnosis is 2.5 years old (Available)Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the patient’s history of the condition, including the age of diagnosis.

Example Question: At what age were you diagnosed with asthma?

Finding: Asked about asthma management

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Finding: Reports using an inhaler (Found)Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy.

Example Question: How do you manage your asthma?

Finding: Reports inhaler is albuterol (Proventil) (Found)Pro Tip: Finding out the specific medication type or brand is essential in understanding whether it’s a maintenance or rescue medication.

Example Question: What is the name of the inhaler prescription?

Finding: Reports last use of inhaler was 3 days ago (Available)Pro Tip: Determining the patient’s last use of an inhaler clues you in to any recent breathing problems.

Example Question: When did you last use your inhaler?

Finding: Reports using inhaler no more than 2 times per week (Available)Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition.

Example Question: How often do you use your inhaler?

Finding: Asked about number of puffs when using asthma inhaler

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Finding: Reports recommended dose is 1-3 puffs as needed (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication.

Example Question: How many puffs of your inhaler are you prescribed?

Finding: Reports typically taking 2 puffs (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication.

Example Question: How many puffs do you typically take?

Finding: Reports sometimes needing 3 puffs to control symptoms (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication.

Example Question: What’s the most puffs you ever take?

Finding: Asked about asthma triggers

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Finding: Reports asthma triggered by cats (Found)Pro Tip: Discovering occasional environmental triggers, such as animal allergies, gives you insight into exacerbating factors of your patient’s condition.

Example Question: What triggers your asthma problems?

Finding: Reports asthma triggered by dust (Found)Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important.

Example Question: Does dust trigger your asthma?

Finding: Denies seasonal triggers (Available)Pro Tip: Asking about seasonal triggers can help you understand a patient’s complete set of asthma triggers over the course of a year.

Example Question: Do you have seasonal asthma triggers?

Finding: Asked about general allergies

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Finding: Reports allergy to cats (Found)Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies.

Example Question: What allergies do you have?

Finding: Followed up on cat allergy symptoms

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Finding: Reports sneezing, itchy eyes, and wheezing (Available)Pro Tip: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening.

Example Question: What is your reaction to cats?

Finding: Asked about latex allergy

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Finding: Denies latex allergy (Available)Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts.

Example Question: Are you allergic to latex?

Finding: Asked about medication allergies

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Finding: Reports penicillin allergy (Found)Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient’s safety while she is in your care, as it affects what medications will be safe and appropriate.

Example Question: What medication allergies do you have?

Finding: Asked about penicillin reaction

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Finding: Reports that penicillin resulted in hives (Available)Pro Tip: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening.

Example Question: What is your reaction to penicillin?

Finding: Reports last penicillin reaction was in childhood (Available)Pro Tip: Determining a patient’s last reaction to penicillin is part of gathering thorough information about her allergy.

Example Question: When was your last penicillin reaction?

Finding: Asked about food allergies

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Finding: Denies food allergies (Found)Pro Tip: Inquiring about food allergies is important for an admitted patient, who will be receiving food during her stay.

Example Question: Do you have any food allergies?

Finding: Asked if the patient has allergies to dust, mold, or pollen

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Finding: Reports reaction to dust (Found)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important.

Example Question: Do you have any reaction to dust?

Finding: Reports dust causes sneezing, itchy eyes, and wheezing (Available)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important.

Example Question: Do you have any environmental allergies?

Finding: Denies seasonal allergies (Available)Pro Tip: Asking about seasonal allergies can help you understand a patient’s complete set of allergies over the course of a year.

Example Question: Do you have any seasonal allergies?

Finding: Asked about general immunizations received

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Finding: Reports being up to date on shots (Found)Pro Tip: Discovering your patient’s immunization history is important to her safety and reveals any susceptibilities she may have to infectious disease.

Example Question: Are your immunizations current?

Finding: Asked about childhood immunizations

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Finding: Reports receiving measles-mumps-rubella shot (Available)Pro Tip: Discovering what childhood immunizations a patient has received reveals information about both her medical history and her susceptibility to infectious disease.

Example Question: Did you receive the measles vaccine?

Finding: Reports receiving polio shot (Available)Pro Tip: Discovering if a patient received a childhood polio vaccination reveals information about both her medical history and her susceptibility to infectious disease.

Example Question: Did you receive the polio vaccine?

Finding: Reports receiving varicella shot (Available)Pro Tip: Discovering if a patient has received a childhood varicella shot reveals information about both her medical history and her susceptibility to infectious disease.

Example Question: Did you receive the chicken pox vaccine?

Finding: Reports receiving Hepatitis A and B shot (Available)Pro Tip: Discovering if a patient has received a childhood Hepatitis A and B vaccination reveals information about both her medical history and her susceptibility to infectious disease.

Example Question: Did you receive the Hepatitis vaccine?

Finding: Reports receiving meningococcal shot (Available)Pro Tip: Discovering if a patient has received a childhood meningococcal vaccination reveals information about both her medical history and her susceptibility to infectious disease.

Example Question: Did you receive the meningitis vaccine?

Finding: Reports receiving HPV vaccine series (Available)Pro Tip: Discovering if a patient has received the HPV vaccination reveals information about both her medical history and her susceptibility to infectious disease.

Example Question: Did you receive the HPV vaccine?

Finding: Asked if the patient has received a flu vaccine

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Finding: Denies receiving annual flu vaccine (Found)Pro Tip: The flu virus can be particularly hazardous in a hospital setting. It is important to ask your patient about the flu vaccine.

Example Question: Did you get a flu shot this year?

Finding: Asked if the patient received a tetanus immunization

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Finding: Reports last tetanus vaccination was in the past year (Found)Pro Tip: For a patient with a recent scrape on a metal surface, confirming the last date of a tetanus shot is essential to prevent any diseases from contact.

Example Question: When was your last tetanus booster?

Finding: Asked about use of pain medication

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Finding: Reports taking ibuprofen (Advil) at home (Found)Pro Tip: Discovering how a patient has been medicating for pain is a crucial element of understanding and treating her condition or injury.

Example Question: What pain medication have you been taking?

Finding: Reports ER administered pain medication (Found)Pro Tip: The differences between prescription and over-the-counter pain medications can be vast and asking about the type of pain medication your patient has been using will help you fully understand her home treatment habits.

Example Question: Have you taken any prescription pain medications?

Finding: Followed up on home pain medication

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Finding: Reports taking ibuprofen (Advil) for 2 days (Found)Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury.

Example Question: How many days have you needed pain medication?

Finding: Reports taking doses at morning, noon and night (Available)Pro Tip: The frequency with which your patient takes pain medication can indicate the severity of her condition or injury.

Example Question: How many times a day do you take pain medication?

Finding: Reports taking 2 pills each time (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan.

Example Question: How many pain pills do you take at a time?

Finding: Reports ibuprofen is regular strength (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan.

Example Question: What is the dose of the pain medication?

Finding: Asked about the effectiveness of pain medication at home

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Finding: Reports ibuprofen helped a little (Found)Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient’s individual response to pain medication is an important factor in your overall treatment plan.

Example Question: How effective is the pain medication?

Finding: Reports pain returned in full every few hours (Found)Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient’s individual response to pain medication is an important factor in your overall treatment plan.

Example Question: How long does the pain medication last?

Finding: Asked about prescription medications

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Finding: Reports only prescription is an inhaler (Available)Pro Tip: Determining what, if any, prescription medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.

Example Question: What prescription medications do you take?

Finding: Asked about use of OTC medication

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Finding: Reports occasionally taking ibuprofen for cramps (Available)Pro Tip: Finding out about your patient’s use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions.

Example Question: Do you take any over the counter medications?

Finding: Reports occasionally taking acetaminophen (Tylenol) for headaches (Available)Pro Tip: Finding out about your patient’s use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions.

Example Question: Do you take any over the counter medications?

Finding: Denies taking supplements (Available)Pro Tip: Finding out about your patient’s use of supplements will help you get a complete health history and avoid unwanted drug interactions.

Example Question: Do you take any supplements?

Finding: Denies taking herbals (Available)Pro Tip: Finding out about your patient’s use of herbals will help you get a complete health history and avoid unwanted drug interactions.

Example Question: Do you take any herbal supplements?

Social History

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Finding: Asked about patient’s level of education

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Finding: Reports currently working toward undergraduate degree (Found)Pro Tip: Finding out a patient’s level of education can give you a baseline for her health literacy.

Example Question: What is your highest level of education?

Finding: Reports her major is accounting (Available)Pro Tip: Asking about a patient’s course of study is a good practice to establish rapport with your patient.

Example Question: What do you study?