Exam (elaborations)
Shadow Health Health History Tina Jones Advance Assessment Subjective Data Collection
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Shadow Health Health History Tina Jones Advance Assessment Subjective Data Collection
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lOMoARcPSD|36440097Studyclock
10/1/2020 Health History | Completed | Shadow Health
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Health History Results | Turned In
Advanced Health Assessment - Fall 2020, NGR 6002
Return to Assignment (/assignments/355942/)
Your Results Lab Pass (/assignment_attempts/7742024/lab_pass.p
Overview
Subjective Data Collection: 100 of 100 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
Documentation
Example Questions.
Information Processing
Program Competency Progress
Category Scored Items Patient Data
Health History Tips and Tricks
Not Scored
Self-Reflection Experts selected these topics as essential components A combination of open and closed questions will yie
of a strong, thorough interview with this patient. better patient data. The following details are facts of
patient's case.
Chief Complaint
Established chief complaint Reports pain
Reports foot wound
History of Present Illness
Asked to rate current pain level on a scale Reports current pain is 7/10
Asked for details about the pain Reports pain is throbbing
Reports pain is sharp when she attempts to
stand
Reports pain has increased in the past 2 days
Reports feeling pain radiating into ankle
Reports pain prevents bearing weight on foot
Asked location of wound Reports right foot is injured
Reports wound is on the plantar surface of her
foot
Support
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10/1/2020 Health History | Completed | Shadow Health
Asked details of the injury Reports she scraped foot on a cement step
Reports initial injury occurred 1 week ago
Reports mild ankle injury
Reports being barefoot at the time of injury
Asked about the assessment of the injury at the Reports going to the ER after sustaining the
ER injury
Reports going to the ER because she suspected
an ankle sprain
Reports receiving an X-ray at the ER
Reports X-ray showed no broken bones
Reports receiving a prescription for pain pills
Asked about drainage from the foot wound Reports that the wound bled a little after
sustaining the injury
Reports seeing pus draining from wound
Reports noticing pus 2 days ago
Followed up on drainage Reports pus as white or yellow
Denies odor from the wound
Asked about home treatment of foot wound Reports wound care regimen of bandaging
Reports cleaning wound twice a day
Reports cleaning wound with hydrogen peroxide
Reports applying bacitracin, neomycin and
polymyxin B (Neosporin)
Asked about other foot wound symptoms Reports swelling around foot wound
Reports swelling worsened in the past 2 days
Reports redness around the wound
Reports that the wound feels warm
Explored impact of patient's foot injury on Reports pain affects ability to walk
activities of daily living Reports pain affects ability to stand at work for
long periods of time
Reports pain prevented her from being able to
walk to class
Past Medical History
Asked about preexisting medical conditions Reports diabetes
Reports asthma
Followed up on diabetes diagnosis Reports specific age of diagnosis was 24
Reports that her diabetes is Type 2
Asked about diabetes management through Reports staying away from sweets
lifestyle changes Reports drinking diet soda instead of regular
Asked about current diabetes medication use Reports that she does not currently take
medication for diabetes
Asked about past diabetes medication use Reports that she used to take diabetes
medication
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