Comprehensive Assessment | transcript .pdf - Comprehensive Assessment | Completed | Shadow Health Comprehensive Assessment Results | Turned In Advanced

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Unformatted text preview: 6/12/2018 Comprehensive Assessment | Completed | Shadow Health Comprehensive Assessment Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: Jun 10, 2018 | Patient Exam Time: 448 min All Lines (734) Interview Questions (256) Statements (33) Exam Actions (445) Objective Data Collection Documentation Hello my name is Sara and FNP student I will be conducting your interview today Plan My Exam Self-Reflection Greet 06/10/18 3:17 PM CDT Hey. What is your name Question 06/10/18 3:17 PM CDT Tina Jones. Your date of birth? Question 06/10/18 3:17 PM CDT February 17th. And how old are you? Question 06/10/18 3:18 PM CDT I'm 28. 1/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health What brought you into the clinic today? Question 06/10/18 3:23 PM CDT I came in because I'm required to have a recent physical exam for the health insurance at my new job. Do you have any current health problems? Question 06/10/18 3:23 PM CDT I don't have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I'm taking good care of my health these days. Where is your new job? (Clarified to what is your new job.) Question 06/10/18 3:26 PM CDT I'm going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I'll be helping a more experienced accountant with her clients, and then eventually I'll get more responsibility, and build my own client list. I start in two weeks--I'm really excited! That is great that you are excited Empathize 06/10/18 3:27 PM CDT Thanks. When was your last physical? Question 06/10/18 3:28 PM CDT Let's see... I had two doctor's appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear. And what did your kind of gynecologist say? Question 06/10/18 3:28 PM CDT She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things. How much birth control are you taking? (Clarified to How often do you take birth control.) Question 06/10/18 3:29 PM CDT 2/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health I take it every morning, with breakfast. What is the name of your birth control? (Clarified to what was the name of the birth control pill you took.) Question 06/10/18 3:29 PM CDT They're called Yaz. Has your menstrual cycle improved since TAKING YAZ? Question 06/10/18 3:30 PM CDT Now that I'm on the pill I'm getting my period every month. That's great I am really glad that you are having your period every month Empathize 06/10/18 3:32 PM CDT Thanks. How long have you had asthma? Question 06/10/18 3:32 PM CDT I've had asthma a long time. . . since I was really little. What age were you diagnosed with asthma? Question 06/10/18 3:32 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. That sounds frightening Empathize 06/10/18 3:33 PM CDT Thanks. How do you manage your asthma? Question 06/10/18 3:33 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. 3/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health What are your triggers for asthma? Question 06/10/18 3:33 PM CDT Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven't had a full asthma attack in years, though. What happens when you're around DUST? Question 06/10/18 3:34 PM CDT I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn't happened since I got my daily inhaler. What daily inhaler do you use? Question 06/10/18 3:34 PM CDT It's Flovent. How much fLOVENT do you use a day (No matching questions found.) Question 06/10/18 3:34 PM CDT How much flovent do you use? (No matching questions found.) Question 06/10/18 3:35 PM CDT How often do you use flovent? Question 06/10/18 3:35 PM CDT Twice a day. [Nurse confirmed: fluticasone propionate 88 mcg b.i.d./spray MDI] When was your last dose of flovent? Question 06/10/18 3:37 PM CDT Probably. . . well, not for my last period. Maybe for the one before? So six weeks ago? when you last use flovent? (Clarified to when did you last use your inhaler.) Question 06/10/18 3:38 PM CDT 4/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health I used my Flovent inhaler this morning--I have to take it twice a day. My albuterol. . . I've maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too. How much Albuterol do you use? Question 06/10/18 3:40 PM CDT I do two puffs when I need it, but that rarely happens. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] How much metformin do you take ? (Clarified to how many milligrams of metformin did you take.) Question 06/10/18 3:40 PM CDT It's 850 mg. And I take one pill, twice a day. When did you last take Metformin? Question 06/10/18 3:41 PM CDT I took it this morning. When were you diagnosed with asthma? Question 06/10/18 4:14 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. Are you taking any other medication? Question 06/10/18 4:15 PM CDT Um, I take a lot now, so let me list everything I take... I'm taking Yaz for birth control, metformin, and my daily inhaler. And I have the albuterol inhaler that I don't seem to need anymore. That's good to hear (No matching questions found.) Question 06/10/18 4:15 PM CDT That's good to hear Empathize 06/10/18 4:15 PM CDT Thanks. 5/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health Are you using PEAK AND FLOW? Question 06/10/18 4:16 PM CDT I haven't heard that term. Do you feel like your asthma is well controlled? Question 06/10/18 4:16 PM CDT Yeah, ever since I started using my daily inhaler and keeping track of my peak flow I've felt much more in control of my breathing. great Empathize 06/10/18 4:17 PM CDT Thanks. How often do you use your Peak flow meter Question 06/10/18 4:17 PM CDT Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart. What are your Peak flow meter results? Question 06/10/18 4:17 PM CDT Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart. what are your peak flow averages? (Clarified to Do you check your peak flow regularly?.) Question 06/10/18 4:17 PM CDT Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart. What are your Peak flow meter results? Question 06/10/18 4:18 PM CDT Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart. When was your last asthma attack Question 06/10/18 4:20 PM CDT 6/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health I haven't had any asthma problems, really, ever since I started on the daily inhaler. My last breathing problem was three months ago, probably, and it had been months before that. Do you feel you're in good health now? Question 06/10/18 4:21 PM CDT All of my health stuff is a lot better now. I feel like my diabetes is in control, I'm in better shape. . . I'm eating healthier. I'm less stressed. Things are going really well. That sounds really great Empathize 06/10/18 4:22 PM CDT Thanks. It is important that you keep on this regimen in order to stay in Better Health Educate 06/10/18 4:22 PM CDT Thanks for telling me. When were you diagnosed with diabetes? Question 06/10/18 4:22 PM CDT I was diagnosed when I was 24. Sorry to hear that Empathize 06/10/18 4:22 PM CDT Thanks. How long have you been on Metformin? Question 06/10/18 4:23 PM CDT I started taking it five months ago. I went in for my annual physical and talked with the nurse practitioner about taking better care of my diabetes. It's really important to stay on track with your diabetes Educate 06/10/18 4:23 PM CDT 7/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health Thanks for telling me. Do you check your blood sugars? Question 06/10/18 4:23 PM CDT Yeah, I check it once a day, in the morning. When did you last check your blood sugar? Question 06/10/18 4:23 PM CDT I check it around the same time every morning. What is your average blood sugar number? Question 06/10/18 4:24 PM CDT My blood sugar's usually around 90. Do you check your blood sugar before meals? Question 06/10/18 4:24 PM CDT Yeah, I check it once a day, in the morning. According to the American diabetic Association a morning blood glucose taken before meds for some who have diabetes should be around 80-130. So you're doing great with your blood sugar be 90 Educate 06/10/18 4:25 PM CDT Thanks for telling me. Do you have any side effects with the metformin? Question 06/10/18 4:25 PM CDT Last time I took it I felt sick and gassy all the time, and it happened again when I started taking it, but now I eat yogurt every day and it seems to have helped. A common reaction from metformin is flatulence so if the yogurt is helping with a side effect that's great Educate 06/10/18 4:27 PM CDT Thanks for telling me. 8/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health When did you start your birth control? (Clarified to how long have you been taking the pill.) Question 06/10/18 4:27 PM CDT About four months ago. I went to the gynecologist, and she prescribed it. Great following up on the gynecologist but we'd like you to do. American College of Obstetricians and gynecologist to have an annual women's well exam to screen for things like cancer, STDs, or other conditions. Such as PCOS Educate 06/10/18 4:29 PM CDT Thanks for telling me. When was your last menstrual cycle? Question 06/10/18 4:34 PM CDT Um. . . about two weeks ago. Did you take your pill at the same time everyday? Question 06/10/18 4:34 PM CDT I take it every morning, with breakfast. How are your periods before you started birth control? Question 06/10/18 4:35 PM CDT I used to have really bad cramps, but they're not so bad anymore, since I started the pill. You take me over the counter medication? (Clarified to What kind of over the counter medicines do you take?.) Question 06/10/18 4:35 PM CDT I take Advil for cramps sometimes, though those have been a lot better because I'm on birth control. How much Advil do you take? Question 06/10/18 4:36 PM CDT I used to take a lot, but honestly I haven't really had to take it since I started birth control. What kind of Advil do you take? 9/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health Question 06/10/18 4:36 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 use any herbal products? Question 06/10/18 4:37 PM CDT I don't take any supplements. Do you take any vitamins? Question 06/10/18 4:37 PM CDT I don't take any vitamins. When was your first sexual encounter? Question 06/10/18 4:38 PM CDT I was in high school. . . eighteen. At what age should you start your menstrual cycle Question 06/10/18 4:38 PM CDT I think I was eleven. Have you ever been pregnant? Question 06/10/18 4:38 PM CDT I've never been pregnant. Are you currently in a relationship? Question 06/10/18 4:38 PM CDT Yeah. I'm in a new relationship now, actually. It's been about a month. Have you had sexual intercourse in the last month (Clarified to have you had sex in the last six months.) Question 06/10/18 4:39 PM CDT 10/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health It's been a few years, actually, but I have a boyfriend now who I like, and I think we'll probably start having sex soon. Do you plan to use condoms? (Clarified to Will you use condoms when you have sex with your boyfriend.) Question 06/10/18 4:39 PM CDT We'll use condoms for sure. . . I know he's been tested pretty recently, and it was clean, but I want us both to get tested again before I think about not using condoms. Have you been tested for HIV? Question 06/10/18 4:40 PM CDT No. I don't think I need one. I don't know anybody with HIV or AIDS. Have you been tested for STDs? Question 06/10/18 4:40 PM CDT Yeah, I'm sure they did those tests when I went for a pap smear before. Did they test you for HIV when you when to the gynecologist? (No matching questions found.) Question 06/10/18 4:41 PM CDT Have you noticed any new allergies? Question 06/10/18 4:42 PM CDT No new allergies--just cats, dust, and penicillin. Have you been having seasonal allergies? Question 06/10/18 4:42 PM CDT I had those allergy problems I came in about a while ago. . . but that hasn't happened since. Are you taking any medication for allergies? Question 06/10/18 4:43 PM CDT Other than my two inhalers, I don't take anything for allergies. How are you managing your diabetes? 11/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health Question 06/10/18 4:43 PM CDT I take metformin, exercise, eat healthy, and check my blood sugar. That's great Empathize 06/10/18 4:43 PM CDT Thanks. Do you have enough supplies to monitor your blood glucose? Question 06/10/18 4:43 PM CDT Yeah, I have enough. Do you have difficulty breathing? Question 06/10/18 4:44 PM CDT My breathing is fine right now. Do you have any recent asthma symptoms? Question 06/10/18 4:44 PM CDT My asthma has been so much better ever since I started using my daily inhaler--like, I can't believe I lived so long with the breathing problems I was having. I didn't even realize how bad they were until they went away, you know? Have you had a headache recently? Question 06/10/18 4:45 PM CDT I think taking better care of myself and getting these glasses have really helped--I haven't had a headache in a while. That's great Empathize 06/10/18 4:45 PM CDT Thanks. When did you last visit the eye doctor? 12/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health Question 06/10/18 4:45 PM CDT I hadn't gone in a long while, but I went three months ago. She tested my vision and prescribed these glasses. I'm supposed to go back next year. Yearly my doctor's visits are needed especially in diabetic patients for patients with any visual problems Educate 06/10/18 4:46 PM CDT Thanks for telling me. Did you get prescription glasses? Question 06/10/18 4:46 PM CDT I went in to the eye doctor about three months ago, and she said I was near sighted and prescribed these glasses. Do you like your glasses? Question 06/10/18 4:47 PM CDT Yeah, they've definitely helped me. Is your vision blurry? Question 06/10/18 4:48 PM CDT Without my glasses, yeah, it's always blurry. Have you had any surgeries? Question 06/10/18 4:48 PM CDT I've still never had surgery. Can you tell me how you stay healthy? Question 06/10/18 4:48 PM CDT I've been really trying eat healthier, and I've been trying really hard to stay active, so I'm feeling pretty good about my lifestyle fight now. What types of things do you do to stay active? 13/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health Question 06/10/18 4:49 PM CDT I've been exercising more lately, actually. I try to go on a walk for thirty or forty minutes four or five times a week, and Selena and I go swimming at the Y once a week, too. That sounds fun swimming Empathize 06/10/18 4:49 PM CDT Thanks. It's great that you are challenging yourself to exercise regularly. Exercising help keep our bodies active and strengthen muscles to reduce developing chronic conditions when combined with healthy eating habits and lifestyle choices Educate 06/10/18 4:50 PM CDT Thanks for telling me. What kind of foods do you typically eat? Question 06/10/18 4:50 PM CDT Let's see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. When was your last dental exam? Question 06/10/18 4:51 PM CDT I finally went in five months ago, actually. What did the dentist say? Question 06/10/18 4:51 PM CDT I finally went in five months ago, actually. How has your diet changed? Question 06/10/18 4:52 PM CDT I'm not eating less, really, but I'm eating much healthier. What is your average daily meal 14/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health Question 06/10/18 4:53 PM CDT It kind of depends on the meal, but I've been making a lot of meals from recipes I found on a blog for people with diabetes. How do you feel about your nutrition? Question 06/10/18 4:53 PM CDT I've really improved my diet recently. I eat less carbs, and I don't eat sweets at all. I try to eat whole grains, and stuff that's low fat. I've found ways to prepare vegetables that I really like. I think I'm doing really well. What do you eat on an average day? Question 06/10/18 4:53 PM CDT Well. . . for breakfast, a smoothie made with frozen fruit and yogurt or an egg on wheat toast with yogurt on the side. For lunch, I eat leftovers from dinner the night before, or I'll have a sandwich on wheat bread. Then for dinner, I'll have chicken or fish, usually, with vegetables and brown rice or quinoa on the side. Do you enjoy eating healthy? Question 06/10/18 4:54 PM CDT Sort of. I try to stay away from sweets and fast food. I'm not much of a salad person, but I try not to eat, like, pizza and French fries every day. Do you have snacks? Question 06/10/18 4:54 PM CDT I don't really eat snacks that often anymore. If I do, it'll just be carrot sticks or an apple, something like that. Those are really healthy choices that's great that you're making a positive change for your health Empathize 06/10/18 4:55 PM CDT Thanks. How is your appetite? Question 06/10/18 4:55 PM CDT 15/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health I was hungrier for a while because of my diabetes, but since I started taking medication for it, my appetite has been pretty normal. The Experience nausea or vomiting? Question 06/10/18 4:56 PM CDT I haven't thrown up in a long time. Do you ever experience nausea? Question 06/10/18 4:56 PM CDT No, I haven't been nauseous at all. Have you noticed any weight changes? Question 06/10/18 4:56 PM CDT I've lost weight recently, I think. . . I'm not, like, actively trying to lose weight, but I am trying to eat healthier and exercise for my diabetes. That's great to hear Empathize 06/10/18 4:56 PM CDT Thanks. Are you having heart palpitations? Question 06/10/18 4:57 PM CDT My heart has felt fine since I came in. . . I think limiting my caffeine really helped. That sounds great Empathize 06/10/18 4:57 PM CDT Thanks. Have you been having heart palpitations recently? Question 06/10/18 4:57 PM CDT My heart has felt fine since I came in. . . I think limiting my caffeine really helped. 16/36 6/12/2018 Comprehensive Assessment | Completed | Shadow Health How have you been treating your hypertension? Question 06/10/18 4:58 PM CDT I've been eating better and exercising more, so I feel like my blood pressure is probably better--someone checked it a few months ago and said it was fine. Good to hear. Empathize 06/10/18 4:58 PM CDT Thanks. Are your vaccinations up-to-date? Question 06/10/18 5:00 PM CDT I'm pretty sure I am, yeah. When was your last tetanus shot? Question 06/10/18 5:00 PM CDT I got a tetanus booster about a year ago. What was your last influenza vaccine? Question 06/10/18 5:00 PM CDT Oh, probably five or six years ago. Would you like to influenza vaccine? Question 06/10/18 5:00 PM CDT Not today, but I guess I should consider it. It is very important to have your influenza shot every year especially patients with diabetes or any type of immune disorder Educate 06/10/18 5:01 PM CDT Thanks for telling me. Ha...
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