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

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Unformatted text preview: 10/29/2017 Comprehensive Assessment | Completed | Shadow Health Comprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A Return to Assignment Your Results Overview Lab Pass Subjective Data Collection: 11 of 50 (22.0%) Transcript Subjective Data Collection Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Objective Data Collection Documentation Indicates an item that you found. Indicates an item that is available to be found. Plan My Exam Self-Reflection Category Scored Items Patient Data Not Scored Experts selected these topics as essential components of a strong, thorough interview with this patient. A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Current Health Status Confirmed reason for visit Reports needing a pre-employment physical Reports no current acute health problems Asked about last visit to a healthcare provider Last visit to a healthcare provider was 4 months ago Reason for last visit was annual gynecological exam Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler Asked about current prescription medications Reports taking diabetes medication Reports using a daily inhaler Reports taking prescription birth control pills Followed up about diabetes medication Medication is metformin Started taking metformin 5 months ago Reports that eating probiotic yogurt helps with side effects and they have abated over time 1/6 10/29/2017 Comprehensive Assessment | Completed | Shadow Health Followed up on metformin frequency and dose Asked about asthma medication Reports taking metformin twice daily Metformin dose is 850 mg Reports using Flovent inhaler twice daily Has a Proventil rescue inhaler Last use of Proventil inhaler was three months ago Has used Proventil inhaler twice in the last year Followed up about birth control prescription Started taking birth control 4 months ago Reason for birth control was to manage PCOS symptoms Birth control type is Yaz (drospirenone and ethinyl estradiol) Takes birth control pill daily Takes birth control pill at the same time every day Reports no skipped days Asked about current non-prescription medications Reports rare Advil use for cramps Reports no OTC herbal products Reports no OTC vitamins Reports no OTC supplements Asked about allergies Confirms allergies Reports no new allergies Followed up on seasonal allergies Reports no recent seasonal allergy symptoms Reports no current medication for allergies Asked about diabetes Asked about blood glucose monitoring Reports managing diabetes with diet and exercise in addition to medication Reports checking blood sugar once a day Checks sugar in the morning Blood sugar number is usually around 90 Reports having adequate supplies Asked about asthma symptoms Reports no current asthma symptoms Reports no recent asthma exacerbations Reports last asthma exacerbation was three months ago Asked about headache symptoms Reports no recent headache Asked about vision Reports optometrist visit Optometrist visit 3 months ago Reports prescription eyeglasses Reports that glasses improve overall vision Reports reduction in blurry vision 2/6 10/29/2017 Comprehensive Assessment | Completed | Shadow Health Asked about palpitations Reports no current palpitations Reports no recent palpitations Asked about hypertension treatment Asked about GERD Reports that blood pressure responded to diet and exercise changes Reports no recent GERD symptoms Reports no current GERD symptoms Reports no current medication for GERD Asked about back pain Reports no current back pain Reports no recent back pain Asked date of last menstrual period Last menstrual period was 2 weeks ago Asked about menstrual patterns Reports a period every 4 weeks Reports that period lasts 5 days Reports some cramping Reports a medium flow Asked about weight changes Reports recent weight loss Reports weight loss of about 10 pounds Reports that weight loss was result of change in diet and increased exercise Psychosocial History Asked about diet Typical breakfast is fruit smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt Typical lunch is dinner leftovers or tuna or chicken sandwich on wheat bread Typical dinner is vegetables with a protein and brown rice or quinoa Typical snack is carrot sticks or an apple Asked about caffeine intake Reports limiting caffeine since heart and sleep problems Reports no coffee drinking Reports only caffeine is diet Coke Reports drinking 2 diet Cokes per day Asked about alcohol intake Drinks 2-3 nights per month Has 2 or 3 drinks when out with friends Orders single drinks Usually orders rum and diet Coke Asked about exercise Reports mild to moderate exercise Reports walking four or five times a week Reports that a typical walk is thirty or forty minutes Reports weekly swimming at YMCA 3/6 10/29/2017 Comprehensive Assessment | Completed | Shadow Health Reports no asthma exacerbation during exercise Asked about relationship status and current sexual activity Reports no new sexual partners Reports new month-old relationship Plans to use condoms if sexually active in the future Asked about education Asked about work Graduated with accounting degree Hired at Smith, Stevens, Stewart, Silver & Company Job title is Accounting Clerk Will start work in 2 weeks Asked about living situation Currently living at home with mom and sister Moving into her own apartment near work in 1 month Mental Health Asked about support system Reports strong friendships Reports strong familial relationships Reports church remains a strong support system Asked about stress Reports feeling less stress after graduation and passing CPA exam Reports improved ability to cope with stress Asked about indicators of depression Reports no depression Reports feeling positive about upcoming life changes Asked about anxiety Reports anxiety improved with relief of stressors and passing of time Reports coping well with upcoming life changes Asked about sleep Reports no current difficulties falling asleep Reports sleeping 8 or 9 hours a night Review of Systems Asked general indicators of health Reports no recent or frequent illness Reports no fatigue Reports no fever Reports no chills Reports no night sweats 4/6 10/29/2017 Comprehensive Assessment | Completed | Shadow Health Asked about review of systems for head Reports no current or recent head problems Reports no head injury Asked about review of systems for ears Reports no general ear problems Reports no change in hearing Reports no ear pain Reports no ear discharge Asked about review of systems for eyes Reports no eye pain Reports no itchy eyes Reports no eye redness Reports no dry eyes Asked about review of systems for nose Reports no general nose problems Reports no change in sense of smell Reports no sneezing Reports no nosebleeds Reports no sinus pain Reports no sinus pressure Reports no runny nose Asked about review of systems for mouth and jaw Reports no general mouth problems Reports no change in sense of taste Reports no dry mouth Reports no mouth pain Reports no mouth sores Reports no gum problems Reports no tongue problems Reports no jaw problems Reports no current dental problems Reports last dental visit was 5 months ago Asked about review of systems for neck and throat Reports no difficulty swallowing Reports no sore throat Reports no history of throat problems Reports no voice changes Reports no general neck problems Reports no history of lymph node problems Reports no swollen glands Asked about review of systems for respiratory Reports no current breathing problems Reports no wheezing Reports no chest tightness Reports no pain while breathing Reports no coughing Asked about review of systems for cardiovascular Reports no palpitations Reports no irregular heartbeat Reports no easy bruising Reports no edema Reports no circulation problems 5/6 10/29/2017 Comprehensive Assessment | Completed | Shadow Health Asked review of systems for gastrointestinal Reports no nausea Reports no vomiting Reports no stomach pain Reports no constipation Reports no diarrhea Reports no flatulence Asked review of systems for genitourinary Reports no dysuria Reports reduction in nocturia Reports no polyuria Reports no blood in urine Reports no flank pain Reports no vaginal itching or irritation Reports normal vaginal discharge Asked review of systems for breasts Reports no general breast problems Reports no breast lumps Reports no breast pain Asked review of systems for musculoskeletal Reports no muscle pain Reports no joint pain Reports no muscle weakness Reports no muscle swelling Asked review of systems for neurological Reports no dizziness or lightheadedness Reports no vision disturbance Reports no numbness or tingling Reports no loss of coordination Reports no loss of sensation Reports no seizures Reports no problems with balance Asked review of systems for skin, hair and nails Reports no recent slow-healing wounds Reports improving acne Reports some male-pattern hair growth Reports no changes in moles Reports no sores Reports no dandruff Reports no nail fungus Reports no dry skin Reports no rashes Reports using sunscreen while exercising outdoors Comments If your instructor provides individual feedback on this assignment, it will appear here. © Shadow Health® 2017 6/6 ...
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