Tina jones foot overview .pdf - Health History | Completed | Shadow Health Health History Results | Turned In Advanced Health Assessment Chamberlain

Tina jones foot overview .pdf - Health History | Completed...

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Unformatted text preview: 5/5/2018 Health History | Completed | Shadow Health Health History Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: May 05, 2018 | Patient Exam Time: 181 min All Lines (233) Interview Questions (204) Statements (14) Exam Actions (15) Objective Data Collection Education & Empathy Height: 170 cm Exam Action 05/05/18 11:43 AM CDT Weight: 90 kg Exam Action 05/05/18 11:43 AM CDT BMI: 31 Exam Action 05/05/18 11:43 AM CDT Random blood glucose: 238 Exam Action 05/05/18 11:43 AM CDT Temperature: 101.1 F Exam Action 05/05/18 11:43 AM CDT Blood pressure: 142/82 Exam Action 05/05/18 11:43 AM CDT Respiratory rate: 19 Exam Action 05/05/18 11:43 AM CDT Documentation Information Processing Health History Tips and Tricks Self-Reflection O2 sat: 99% 1/33 5/5/2018 Health History | Completed | Shadow Health Exam Action 05/05/18 11:43 AM CDT Heart rate: 86 Hello, Tina Jones my name is Sara an FNP student here to interview you today. Exam Action 05/05/18 11:43 AM CDT Greet 05/05/18 11:43 AM CDT Hey. What brings you here today? Question 05/05/18 11:44 AM CDT I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it's looking pretty nasty. And the pain is killing me! Where is the pain on your foot? Question 05/05/18 11:46 AM CDT 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. Can you tell me what foot this is please Question 05/05/18 11:47 AM CDT It's . . . [Ms. Jones reports the correct year.] [AUDIO COMING SOON] Which foot is the pain located? Question 05/05/18 11:47 AM CDT My right foot. How severe is the pain in your right foot? Question 05/05/18 11:48 AM CDT It's really bad. 2/33 5/5/2018 Health History | Completed | Shadow Health Can you rate the pain on a scale of 0 to 10. 10 being the worst pain you have ever had in your life Question 05/05/18 11:48 AM CDT ... I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet. what are you taking for pain? Question 05/05/18 11:49 AM CDT It's called tramadol. Where did you get this medication? Question 05/05/18 11:50 AM CDT The ER doctor prescribed them for me when I was in there a week ago. So the pain started a week ago? (Clarified to did your wound have pus in it all week.) Question 05/05/18 11:50 AM CDT No, I started seeing it two days ago. What caused you to have this pain? Question 05/05/18 11:50 AM CDT Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Why are you having right foot pain? (No matching questions found.) Question 05/05/18 11:51 AM CDT how did your injury happen? Question 05/05/18 11:51 AM CDT I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step. can you please describe the pain? Question 05/05/18 11:52 AM CDT It's throbbing and like, sharp if I try to put weight on it. 3/33 5/5/2018 Health History | Completed | Shadow Health what is the pain like when you stand on your foot? Question 05/05/18 11:52 AM CDT Yes! I mean, I literally can't put weight on my foot, the pain is so sharp. when did the pain start? Question 05/05/18 11:52 AM CDT Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. Has the pain changed over time? Question 05/05/18 11:52 AM CDT At first, it seemed like it was healing up fine and it didn't give me a lot of pain. But the last two days, the pain got way worse. Does your pain radiate? Question 05/05/18 11:53 AM CDT The pain's worse in my foot, but I feel it moving up into my ankle, too. Can you bear weight on your foot? Question 05/05/18 11:54 AM CDT No, I can't. I can't put any weight on it without like, shooting pain. I am sorry I understand how you feel. Empathize 05/05/18 11:54 AM CDT I appreciate you telling me that. Did you injure anything else beside your foot? Question 05/05/18 11:55 AM CDT 4/33 5/5/2018 Health History | Completed | Shadow Health Well, at first I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it, because the ankle felt pretty okay the next day and it wasn't a problem all week. Did you have any alcoholic drinks before injury? Question 05/05/18 11:55 AM CDT No, I was stone-cold sober. It was the middle of the day. Where you wearing shoes when you fell? Question 05/05/18 11:56 AM CDT No, I was barefoot. Always make sure to wear shoes when outside. Educate 05/05/18 11:56 AM CDT OK, I understand. You went to the ER for your injury? Question 05/05/18 11:57 AM CDT Yeah, right after it happened, I worried I might've sprained my ankle so mom drove me to the ER. Did your foot bleed? Question 05/05/18 11:57 AM CDT Yeah, right when I hurt it. Did you notice any discharge from the wound? Question 05/05/18 11:57 AM CDT Yeah, there's definitely pus. When did you first notice pus? Question 05/05/18 11:57 AM CDT Two days ago. 5/33 5/5/2018 Health History | Completed | Shadow Health What color is the drainage from your wound? Question 05/05/18 11:57 AM CDT It's... white or maybe off-white. Does the wound have an odor? Question 05/05/18 11:58 AM CDT Um, no, not that I know of... That sounds gross. I understand it sounds gross but in order to find out what is going on with your foot. I must ask this question. Empathize 05/05/18 11:59 AM CDT Thanks for saying that. How did you treat your foot at home? Question 05/05/18 11:59 AM CDT I made sure to clean it and just keep it bandaged. And I put Neosporin on it. How often did you clean the wound? Question 05/05/18 11:59 AM CDT Twice a day -- every morning and every night. How often did you change the bandage? Question 05/05/18 12:00 PM CDT Every morning and night. I was keeping an eye on it. Is there swelling around the wound? Question 05/05/18 12:00 PM CDT Yeah, it looks swollen around the scrape. 6/33 5/5/2018 Health History | Completed | Shadow Health Does the wound feel warm? Question 05/05/18 12:01 PM CDT Yeah, it feels pretty warm. Does your foot pain affect your work? Question 05/05/18 12:02 PM CDT Well, I tried to go in two days ago but I couldn't walk well enough, so I just went home after a couple hours. And I didn't go in yesterday. My boss was understanding, but I need to be able to work! Has your injury prevented you from going to class? Question 05/05/18 12:04 PM CDT I had a class two days ago, and I skipped it. I haven't missed any classes before this, and I emailed my professor, so I should be okay. I don't want to get behind, so I need to get back to it! Are you feeling feverish right now? Question 05/05/18 12:04 PM CDT I don't feel feverish right now, but last night I had a high temperature. Measured wound: 2 cm x 1.5 cm, 2.5 mm deep Exam Action 05/05/18 12:05 PM CDT Swabbed wound and sent to lab for C & S Exam Action 05/05/18 12:09 PM CDT Cleansed and irrigated wound with normal saline and applied dry sterile dressing. Exam Action 05/05/18 12:09 PM CDT Measured wound: 2 cm x 1.5 cm, 2.5 mm deep Exam Action 05/05/18 12:09 PM CDT Swabbed wound and sent to lab for C & S Exam Action 05/05/18 12:10 PM CDT 7/33 5/5/2018 Health History | Completed | Shadow Health Cleansed and irrigated wound with normal saline and applied dry sterile dressing. a culture was taken of your foot and sent to the lab to find out what is going on with the drainage Exam Action 05/05/18 12:10 PM CDT Educate 05/05/18 12:10 PM CDT That makes sense. the wound was also cleaned and placed a sterile dressing Educate 05/05/18 12:11 PM CDT Alright, thanks for letting me know. Do you have any medical conditions? Question 05/05/18 12:14 PM CDT Yeah. . . I have asthma and diabetes. When were you diagnosed with diabetes? Question 05/05/18 12:16 PM CDT I was diagnosed when I was 24. At age 24 you were diagnosed with diabetes? (Clarified to how old were you when you were diagnosed with diabetes.) Question 05/05/18 12:16 PM CDT I was diagnosed when I was 24. Do you know what type of diabetes you have? Question 05/05/18 12:17 PM CDT It's Type 2. Do you follow a diabetic diet? Question 05/05/18 12:17 PM CDT I really try not to worry about what I eat, other than watching my sugar and trying to make healthy choices. 8/33 5/5/2018 Health History | Completed | Shadow Health Tell me more about any sugars you consume. Question 05/05/18 12:17 PM CDT Once I found out I had diabetes, I started watching my sugar and staying away from regular soda. Do you drink sugary drinks? Question 05/05/18 12:17 PM CDT No. I drink a lot of soda, but only Diet Coke. Do you take any prescribed medication for diabetes? (Clarified to Do you have a prescription for diabetes medication?.) Question 05/05/18 12:18 PM CDT I don't take medicine for it anymore. have you taken medication for diabetes? Question 05/05/18 12:19 PM CDT Yeah, when I was diagnosed they gave me a medicine to try. Do you remember what you were prescribed? Question 05/05/18 12:19 PM CDT It was Metformin. When was the last time you took your diabetes medication? Question 05/05/18 12:20 PM CDT I haven't taken it in about three years, honestly. Why aren't you taking your diabetes medication? Question 05/05/18 12:20 PM CDT I just got sick of dealing with it! I understand but medication is very important for your diabetes. Empathize 05/05/18 12:20 PM CDT 9/33 5/5/2018 Health History | Completed | Shadow Health Thanks. Tell me about your blood sugar monitoring. Question 05/05/18 12:21 PM CDT I don't check it very often, honestly. . . I think the last time was about a month ago. How often do you check your blood sugar? Question 05/05/18 12:22 PM CDT I don't check it very often, honestly. . . I think the last time was about a month ago. What are your usual blood sugar levels? Question 05/05/18 12:22 PM CDT I guess sometimes it's probably high, but I don't know the numbers. I almost never check it. I don't really get what the numbers mean. It is important to check your blood sugars on a regular basis. A diabetic educator will help you with this information in detail if you are interested. Educate 05/05/18 12:24 PM CDT Thanks for telling me. Have you been thirsty lately? Question 05/05/18 12:25 PM CDT You know, I did notice lately that I've been really thirsty. Are you drinking more water than normal? Question 05/05/18 12:25 PM CDT I've definitely been drinking more water lately. Have you been urinating more often than usual? Question 05/05/18 12:26 PM CDT Yeah, but I've been drinking more water. 10/33 5/5/2018 Health History | Completed | Shadow Health How often do you urinate during the day? Question 05/05/18 12:27 PM CDT I don't know. Every hour or two when I'm awake? How often do you wake up at night to urinate? Question 05/05/18 12:27 PM CDT I probably have to get up two or three times a night. With your last meal? Question 05/05/18 12:28 PM CDT I had leftover chicken and mashed potatoes last night. what is your Typical breakfast? Question 05/05/18 12:28 PM CDT I'll usually have a muffin or pumpkin bread from the cafe near my house. what Is your typical lunch? Question 05/05/18 12:29 PM CDT Lunch is the meal I usually pick up near campus because of my schedule. I go to Subway mostly and get a turkey sandwich or something. what is your Typical dinner? Question 05/05/18 12:29 PM CDT The usual stuff. . . meatloaf, chicken, casseroles, pasta. . . stuff like that. what Do you typically eat for snacks? Question 05/05/18 12:30 PM CDT I try to eat snacks that are kind of healthy like pretzels-sometimes I'll treat myself and get french fries, but I try not to do that too often. 11/33 5/5/2018 Health History | Completed | Shadow Health Do you understand that pretzels and french fries are high in carbohydrates and calories. Educate 05/05/18 12:30 PM CDT Sure, I think I understand what you mean. have you noticed Increasing appetite? Question 05/05/18 12:31 PM CDT My appetite's been huge lately. . . I feel like I'm hungry all the time. When did you notice the increase in appetite? Question 05/05/18 12:31 PM CDT I guess I started being starving all the time about a month ago. No matter how much I eat, I'm still hungry. Have you had any recent weight changes? Question 05/05/18 12:32 PM CDT Yeah, I've lost some weight recently. How much weight have you lost? Question 05/05/18 12:32 PM CDT It was about ten pounds in a little over a month, actually. With your weight loss intentional? Question 05/05/18 12:32 PM CDT No, I'm a creature of habit. I eat the same foods all the time. At what age were you diagnosed with asthma? Question 05/05/18 12:33 PM CDT 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 were you diagnosed with asthma? 12/33 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 12:34 PM CDT 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 did you last have issues with asthma? Question 05/05/18 12:34 PM CDT I was at my cousin's house three days ago, and my asthma acted up while I was there. What do your asthma symptoms feel like? Question 05/05/18 12:35 PM CDT 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. Do you ever wheeze? Question 05/05/18 12:35 PM CDT During a full attack, I would wheeze a lot, like I couldn't breathe at all, but that hasn't happened in years. Now I wheeze a little when I have breathing problems, but it's not nearly that bad. When was your last asthma attack? Question 05/05/18 12:36 PM CDT 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. Have you ever been hospitalized in the past? Question 05/05/18 12:36 PM CDT Well, I went a week ago on the day I hurt my foot to get it checked out. That was the first time I've been in the hospital since I was probably sixteen, though. Have you ever been hospitalized in the past for your asthma? Question 05/05/18 12:37 PM CDT I went a bunch of times when I was little, for asthma attacks. 13/33 5/5/2018 Health History | Completed | Shadow Health When was your last hospitalization for asthma? Question 05/05/18 12:38 PM CDT I haven't gone to the hospital for asthma since I was sixteen. Have you been hospitalized for asthma? Question 05/05/18 12:38 PM CDT I went a bunch of times when I was little, for asthma attacks. How do you manage your asthma? Question 05/05/18 12:38 PM CDT I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. What is the name of the inhaler prescription? Question 05/05/18 12:39 PM CDT It's just a regular Proventil inhaler. When did you last use your inhaler? Question 05/05/18 12:40 PM CDT I had to use my inhaler three days ago when I was at my cousin's house. I'm sorry that I sound repetitive but I just want to be accurate about your medical history. Empathize 05/05/18 12:40 PM CDT Thanks for understanding. How many puffs of your inhaler are you prescribed? Question 05/05/18 12:41 PM CDT I usually use two puffs from my inhaler, but lately I sometimes need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] What triggers your asthma problems? 14/33 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 12:45 PM CDT Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven't had a full asthma attack in years, though. Does dust trigger your asthma? Question 05/05/18 12:46 PM CDT Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Does physical activity trigger your asthma? Question 05/05/18 12:46 PM CDT Yeah, if I have a little burst of activity like running up the stairs or hurrying to my class, I sometimes need my inhaler. Do you have seasonal asthma triggers? Question 05/05/18 12:47 PM CDT No, not really. What reaction do you have to cats? Question 05/05/18 12:48 PM CDT Whenever I'm around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up. Are you allergic to latex? Question 05/05/18 12:48 PM CDT Nope. What medication allergies do you have? Question 05/05/18 12:49 PM CDT I'm allergic to penicillin. What is your reaction to penicillin? 15/33 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 12:49 PM CDT 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 any food allergies? Question 05/05/18 12:51 PM CDT Nope, no food allergies that I know of. Do you have any seasonal allergies? Question 05/05/18 12:51 PM CDT No, not really. Are your immunizations current? Question 05/05/18 12:52 PM CDT I'm pretty sure they are all taken care of. Did you receive childhood vaccines? Question 05/05/18 12:52 PM CDT I am pretty sure I received all my vaccines as a kid, like before registering for school. Did you get a flu shot this year? Question 05/05/18 12:53 PM CDT No. When was your last tetanus booster? Question 05/05/18 12:53 PM CDT I got a tetanus booster about a year ago. Want to inform you that there will be some more repetitive questions. 16/33 5/5/2018 Health History | Completed | Shadow Health Educate 05/05/18 12:54 PM CDT Thanks for telling me. What pain medications have you been taking? Question 05/05/18 12:54 PM CDT It's called tramadol. How many times a day do you take pain medication? Question 05/05/18 12:56 PM CDT I've been taking them morning, noon, and night. How many pain pills do you take at a time? Question 05/05/18 12:56 PM CDT I take two at a time. What is the dose of the pain medication? Question 05/05/18 12:57 PM CDT I'm not 100% sure, but I think they're 50 milligrams. How long does the pain medication last? Question 05/05/18 12:57 PM CDT They only help for a few hours at a time. Do you take any over-the-counter medication? Question 05/05/18 12:57 PM CDT I take Tylenol for a headache sometimes, or Advil for cramps, but not often. How often do you take Tylenol for headaches? Question 05/05/18 12:59 PM CDT 17/33 5/5/2018 Health History | Completed | Shadow Health Yeah. Usually I'll take a Tylenol and go to bed, and that'll get rid of it. Do you know the dose of the Tylenol? Question 05/05/18 12:59 PM CDT I take the extra-strength Tylenol, the gel kind. It's what we usually have around the house. [Nurse confirmed with Pharmacy: 1-2x acetaminophen 500mg] How many Tylenol do you take at a time? Question 05/05/18 1:00 PM CDT I take the extra-strength Tylenol, the gel kind. It's what we usually have around the house. [Nurse confirmed with Pharmacy: 1-2x acetaminophen 500mg] How much ibuprofen do you take for cramps? Question 05/05/18 1:01 PM CDT I take three at a time. And I'd bet I take it up to three times a day. [Nurse confirmed with Pharmacy: 3-4x ibuprofen 200mg] What is the strength of ibuprofen you take? Question 05/05/18 1:01 PM CDT I just take the regular kind I think. It's not extra strength or anything. [Nurse confirmed with Pharmacy: 3-4x ibuprofen 200mg] Do you take any vitamins? Question 05/05/18 1:01 PM CDT No, I don't take any vitamins. Do you take any herbal supplements? Question 05/05/18 1:02 PM CDT No, I don't take anything herbal. What is your highest level of Education? Question 05/05/18 1:02 PM CDT 18/33 5/5/2018 Health History | Completed | Shadow Health Well, I'm finishing up my Bachelor's degree right now. What do you study? Question 05/05/18 1:02 PM CDT I'm going to get my bachelor's in accounting. Can you tell me about your stress level? Question 05/05/18 1:03 PM CDT I ...
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