Comprehensive Health History Assignment _ Completed _ Shadow Health Transcript.pdf - Comprehensive Health History Assignment | Completed | Shadow Health

Comprehensive Health History Assignment _ Completed _ Shadow Health Transcript.pdf

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Unformatted text preview: 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Shadow Health will have scheduled maintenance on Friday, July 26th from 7:00 am to 7:30 am Eastern Time. Assignment attempts will be disabled for the duration of the maintenance window. Comprehensive Health History Assignment Results | Turned In Advanced Health Assessment - Chamberlain - June 2019, NR509-June-2019 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: Jul 10, 2019 | Patient Exam Time: 124 min All Lines (291) Interview Questions (245) Statements (34) Exam Actions (12) Objective Data Collection Education & Empathy Height: 170 cm Exam Action 07/10/19 6:45 PM CDT Weight: 90 kg Exam Action 07/10/19 6:45 PM CDT BMI: 31 Exam Action 07/10/19 6:45 PM CDT Random blood glucose: 238 Exam Action 07/10/19 6:45 PM CDT Temperature: 101.1 F Exam Action 07/10/19 6:45 PM CDT Blood pressure: 142/82 Exam Action 07/10/19 6:45 PM CDT Respiratory rate: 19 Exam Action 07/10/19 6:45 PM CDT Documentation Information Processing Health History Tips and Tricks Self-Reflection O2 sat: 99% 1/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Exam Action 07/10/19 6:45 PM CDT Heart rate: 86 hello. My name is Tneshia Richards. I will be your provider today. Exam Action 07/10/19 6:45 PM CDT Greet 07/10/19 6:47 PM CDT Hey. What is your name Question 07/10/19 6:47 PM CDT Tina Jones. what is your date of birth Mrs. Jones Question 07/10/19 6:47 PM CDT February 17th. what year were you born in Question 07/10/19 6:47 PM CDT I was born in . . . [Ms. Jones reports correct birth year.] what brings you in today? Question 07/10/19 6:48 PM 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! I'm sorry to hear that you are having pain. Empathize 07/10/19 6:48 PM CDT I appreciate you saying that. which foot did you scrape Question 07/10/19 6:48 PM CDT 2/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health My right foot. when did the scrape occur Question 07/10/19 6:49 PM CDT Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. which part of the foot is the scrape on (Clarified to Where is the cut on your foot?.) Question 07/10/19 6:49 PM CDT It's on the ball of my foot. (Clarified to where the scrape is on my foot.) what is your pain level Question 07/10/19 6:50 PM CDT I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet. describe how the pain feels Question 07/10/19 6:50 PM CDT It's throbbing and like, sharp if I try to put weight on it. what makes the pain worse Question 07/10/19 6:51 PM CDT 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. what makes the pain better Question 07/10/19 6:51 PM CDT The pain pills help for a few hours. does resting the foot help with the pain Question 07/10/19 6:51 PM CDT Putting my foot up helps a little I guess, but the only thing that makes a real difference is the pain pills. where did you get pain pills from Question 07/10/19 6:52 PM CDT 3/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health The ER doctor prescribed them for me when I was in there a week ago. are you allergic to any medications Question 07/10/19 6:52 PM CDT Yeah, I'm allergic to penicillin. what happens when you take penicillin Question 07/10/19 6:52 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. are you allergic to any food Question 07/10/19 6:53 PM CDT Nope, no food allergies that I know of. what other allergies do you have Question 07/10/19 6:53 PM CDT Well, besides cats, I'm allergic to penicillin. What kind of reaction do you have to cap (Clarified to What happens when you are around a cat?.) Question 07/10/19 6:54 PM CDT Whenever I'm around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up. (Clarified to what the symptoms of my cat allergy are.) When were you diagnosed with asthma Question 07/10/19 6:54 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. How do you manage your asthma now Question 07/10/19 6:55 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. 4/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health What kind of inhaler do you use Question 07/10/19 6:56 PM CDT It's just a regular Proventil inhaler. How often do you use it (Clarified to How often do you use your inhaler?.) Question 07/10/19 6:56 PM CDT Not often. Maybe two or three times a week. (Clarified to how often I use my inhaler.) Do you know what the dosage is of the provincial (Clarified to What dosage of albuterol do you take?.) Question 07/10/19 6:56 PM CDT I usually use two puffs from my albuterol inhaler -- it's 90 micgrograms a spray -- but lately sometimes I need three puffs. [AUDIO COMING SOON] (Clarified to what dose of albuterol I take.) How long have you been taking an inhaler Question 07/10/19 6:57 PM CDT I've had an inhaler since I was two and a half, when I was diagnosed. Do you know how to take your inhaler (No matching questions found.) Question 07/10/19 6:58 PM CDT Using your inhaler properly is important. Educate 07/10/19 6:58 PM CDT Sure, I think I understand what you mean. You should use your inhaler when you have shortness of breath. Educate 07/10/19 6:59 PM CDT Alright, thanks for letting me know. Rinse your mouth after each use. Educate 07/10/19 6:59 PM CDT OK, I understand. 5/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health What happened to cause the scrape on your foot Question 07/10/19 6:59 PM 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. Do you clean the wound at home Question 07/10/19 7:00 PM CDT Yeah, I was really good about cleaning it. How did you clean the wound Question 07/10/19 7:00 PM CDT Since it happened, I've been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off. Do you smoke Question 07/10/19 7:01 PM CDT No. I think it's gross. Do you use any recreational drugs Question 07/10/19 7:01 PM CDT Well, I used to smoke pot. . . but I don't do that anymore. The use of marijuana is not recommended as it is an illegal substance Educate 07/10/19 7:02 PM CDT Thanks for telling me. Do you use any other drugs Question 07/10/19 7:02 PM CDT No way, I have no interest in that. That stuff can mess you up. Do your friends use recreational drugs Question 07/10/19 7:03 PM CDT 6/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health No. No one that I'm friends with does that stuff anymore. Do you drink alcohol Question 07/10/19 7:03 PM CDT I do sometimes, yeah, when I go out with my friends. How often do you consume alcohol Question 07/10/19 7:03 PM CDT No more than once or twice a week, sometimes less. Tell me about your past medical history Question 07/10/19 7:04 PM CDT I've had asthma since I was little, and I have sugar diabetes, too. When were you diagnosed with diabetes Question 07/10/19 7:04 PM CDT I was diagnosed when I was 24. Do you have type 1 or type 2 diabetes Question 07/10/19 7:05 PM CDT It's type 2. How do you have any major illnesses (Clarified to Do you have medical problems?.) Question 07/10/19 7:05 PM CDT Yeah. . . I have asthma and diabetes. (Clarified to if I have medical problems.) Have you ever been hospitalized Question 07/10/19 7:06 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. Why were you in the hospital at 16 7/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Question 07/10/19 7:06 PM CDT I had a bad asthma attack, and my inhaler wasn't working, so I went to the hospital. That happened a lot when I was growing up, but I haven't been since. . . until last week, for my foot. Controlling asthma can be a challenge I'm glad that you were able to decrease the triggers Empathize 07/10/19 7:07 PM CDT Thanks for understanding. Rinse your mouth after each inhaler use Educate 07/10/19 7:07 PM CDT That makes sense. Have you had your flu shot Question 07/10/19 7:07 PM CDT No. Are you at today on immunizations (Clarified to What immunization history do you have?.) Question 07/10/19 7:08 PM CDT 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. (Clarified to what my immunization history is.) Have you had any surgeries Question 07/10/19 7:08 PM CDT Nope. No surgeries... I've been lucky. You said you were student what are you studying Question 07/10/19 7:09 PM CDT I'm going to get my bachelor's in accounting. You sound like a busy person Empathize 07/10/19 7:09 PM CDT 8/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Thanks for saying that. Do you have any hobbies Question 07/10/19 7:09 PM CDT I read a lot, especially since I bought one of those e-book readers. My friends and I have thought about starting a book club actually. Oh, and there's these free talks at church that I like to go to if I have time. I watch TV, but usually on DVD or streaming. I like to marathon the shows I really like. I'm really interested in documentaries too. Reading helps to keep the Mind Sharp Educate 07/10/19 7:10 PM CDT Thanks for telling me. Are you married Question 07/10/19 7:10 PM CDT Nope, never been married. Do you live alone Question 07/10/19 7:11 PM CDT I live at home with my mom and my sister -- we're a pretty tight-knit family. They've been helping me out. Does anyone in your family have diabetes Question 07/10/19 7:11 PM CDT Dad had sugar diabetes, and I think my Grandpa Jones did too. Did anyone die at a early age in the family (No matching questions found.) Question 07/10/19 7:12 PM CDT Are your grandparents still living Question 07/10/19 7:12 PM CDT Granny's the only one who's still alive. What did your grandfather died of 9/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Question 07/10/19 7:13 PM CDT My grandfather on my dad's side died when I was young...he must have been mid-sixties when he passed. My grandfather on my mother's side lived until his late 70s I think...maybe until 80. I'm sorry for your loss Empathize 07/10/19 7:13 PM CDT I appreciate you telling me that. Have you lost any siblings Question 07/10/19 7:14 PM CDT No way! They're both alive. Are both your parents still living Question 07/10/19 7:14 PM CDT No. Dad passed away last year. In a car accident. I'm sorry for your loss Empathize 07/10/19 7:14 PM CDT Thanks. Have you had any fatigue Question 07/10/19 7:15 PM CDT 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. Do you feel weak Question 07/10/19 7:16 PM CDT No, I wouldn't say I feel weak. Have you had a fever or chills (Clarified to Have you had a fever?.) Question 07/10/19 7:16 PM CDT 10/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Yeah, I was running a fever last night. (Clarified to if I have had a fever.) Did you take any medication for the fever Question 07/10/19 7:17 PM CDT I really didn't do much for it at home. Have you had any weight changes recently Question 07/10/19 7:17 PM CDT Yeah, I've lost some weight recently. How much weight have you lost Question 07/10/19 7:17 PM CDT It was about ten pounds in a little over a month, actually. You said you had trouble sleeping how often does this happen (Clarified to How long did your sleep trouble last?.) Question 07/10/19 7:18 PM CDT My sleep problems lasted for a couple of months. They just kind of faded away. (Clarified to how long my sleep trouble lasted.) Does your skin itch Question 07/10/19 7:19 PM CDT Um, no. Do you have any skin rashes Question 07/10/19 7:19 PM CDT I don't have any rashes. Have you had any changes in your nails Question 07/10/19 7:19 PM CDT No...I haven't noticed anything like that. Any changes in the color of your skin Question 07/10/19 7:20 PM CDT 11/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Maybe. I do notice the skin on my neck is looking weird. what does the skin look like on the neck Question 07/10/19 7:20 PM CDT Um, it's red and puffy, and there's pus in it. Have you had any vision changes Question 07/10/19 7:21 PM CDT Um, it's probably gotten a little worse in the past few years. Do you see double Question 07/10/19 7:21 PM CDT No. Do you have eye pain Question 07/10/19 7:22 PM CDT I guess it's not eye pain exactly, but when I read for too long I'll start to get a headache. Is your eyes sensitive to light Question 07/10/19 7:22 PM CDT No. Any problems with hearing Question 07/10/19 7:23 PM CDT No. do you have any ringing in the ears Question 07/10/19 7:23 PM CDT No, I haven't heard anything like that. Have you been busy Question 07/10/19 7:23 PM CDT 12/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health I've just got a lot going on--I work full time, and I go to school part time, too. So I'm either at class or work, and then when I'm home, I'm studying. have you been dizzy Question 07/10/19 7:24 PM CDT No, I can't remember the last time I got dizzy. Have you had any hearing changes Question 07/10/19 7:24 PM CDT No. Do you have any sores in your mouth Question 07/10/19 7:24 PM CDT Nope. Do you have any soreness in your throat Question 07/10/19 7:25 PM CDT No, not that I know of. Have you been congested Question 07/10/19 7:25 PM CDT No. I only really have that problem around cats. . . or sometimes dust. Have you experienced any night sweats Question 07/10/19 7:26 PM CDT I don't get sweaty, but sometimes I wake up hot and have to kick off my sheets. Have you had a cough Question 07/10/19 7:26 PM CDT I don't have a cough, no. Have you had any difficulty breathing 13/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Question 07/10/19 7:27 PM CDT I have breathing problems sometimes, yeah, but I haven't had a full attack in years. Any pain with breathing Question 07/10/19 7:27 PM CDT No. Do you have numbness anywhere Question 07/10/19 7:27 PM CDT No, I don't think so. Do you have tingling in your fingers or feet Question 07/10/19 7:28 PM CDT No, I haven't noticed any tingling. Does it hurt when you walk Question 07/10/19 7:28 PM CDT Yes! I mean, I literally can't put weight on my foot, the pain is so sharp. How has this affected your daily living Question 07/10/19 7:29 PM CDT I mean, the last two days I couldn't walk on my foot, so it's gotten in the way of everything -- I had to basically stay home and off my foot. I didn't think it could get to the point where it caused so many problems. I'm sorry to hear that you're having problems because of your foot pain Empathize 07/10/19 7:29 PM CDT Thanks for saying that. Do you have any swelling in your feet Question 07/10/19 7:30 PM CDT 14/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Yeah, it looks swollen around the scrape. Do you have any drainage from the wound Question 07/10/19 7:30 PM CDT Yeah, there's definitely pus. What does the drainage look like Question 07/10/19 7:31 PM CDT It looks whitish... I don't know, it just looks like pus. It's gross. Is there any odor Question 07/10/19 7:31 PM CDT No way, I always use deodorant. That's your wound have an odor Question 07/10/19 7:31 PM CDT Um, no, not that I know of... That sounds gross. Is there any warrants at your wound Question 07/10/19 7:32 PM CDT Yeah, there's definitely pus. is there any warmth at the wound site (No matching questions found.) Question 07/10/19 7:32 PM CDT Are you able to move your right foot Question 07/10/19 7:32 PM CDT Um, my ankle's starting to hurt when I move it. Did the emergency room do an x-ray of your foot Question 07/10/19 7:33 PM CDT Yeah, they did. 15/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Did they find a fracture (No matching questions found.) Question 07/10/19 7:33 PM CDT Did they find a break (No matching questions found.) Question 07/10/19 7:34 PM CDT what did the er say about your foot Question 07/10/19 7:34 PM CDT She said my ankle was fine, and I should just stay off it. And to keep the scrape clean and dry. Which I did. Did the ER doctor prescribe any medication (Clarified to Did the ER prescribe anything?.) Question 07/10/19 7:34 PM CDT Yes, they wrote me a prescription for some pain pills. (Clarified to if the ER prescribed me any medications.) What is the name of the pain pill Question 07/10/19 7:35 PM CDT It's called tramadol. What milligram was prescribed (No matching questions found.) Question 07/10/19 7:35 PM CDT What milligram of Tramadol was prescribed Question 07/10/19 7:35 PM CDT I'm not 100% sure, but I think they're 50 milligrams. How often do you take the Tramadol Question 07/10/19 7:36 PM CDT I've been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON] How many tablets of Tramadol do you take at a day at a time Question 07/10/19 7:36 PM CDT I take two at a time. 16/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health Does the Tramadol relieve your pain Question 07/10/19 7:36 PM CDT Yeah, the pain pills help, but only for a few hours. Do you elevate your foot when it hurts (Clarified to Does elevating your foot help?.) Question 07/10/19 7:37 PM CDT Putting my foot up helps a little I guess, but the only thing that makes a real difference is the pain pills. (Clarified to if elevating my foot helped.) Have you had any nausea Question 07/10/19 7:37 PM CDT No. . . I don't really feel nauseous much. Have you had any vomiting Question 07/10/19 7:37 PM CDT I don't even remember the last time I threw up--I don't think I have in years. Have you had any diarrhea Question 07/10/19 7:38 PM CDT No, no diarrhea. Have you had any appetite changes Question 07/10/19 7:38 PM CDT Yeah, lately I've definitely been much hungrier than usual. Have you had any heartburn issues Question 07/10/19 7:38 PM CDT No, not at all. Have you had any changes in urination Question 07/10/19 7:39 PM CDT 17/34 7/25/2019 Comprehensive Health History Assignment | Completed | Shadow Health I've been noticing I've been having to pee a lot more recently, but I think that's just because I'm drinking more water than normal. Do you have any burning with urination Question 07/10/19 7:40 PM CDT It doesn't hurt or feel different when I pee. Do you feel stressed Question 07/10/19 7:40 PM CDT 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. I understand your foot injury causes you anxiety Empathize 07/10/19 7:41 PM CDT Thanks. Do you feel like harming yourself Question 07/10/19 7:41 PM CDT No, no. I don't have feelings like that. God never gives you more than you can bear, you know? Have you ever had thoughts of hurting someone else Question 07/10/19 7:42 PM CDT Of course not! Have you had any difficulty with memory (No matching questions found.) Question 07/10/19 7:42 PM CDT Have you had any food intolerance Question 07/10/19 7:43 PM CDT I can eat just about anything. Do you have trouble concentrating Question 07/10/19 7:43 PM CDT 18/34 7/25/2019 Comprehensive Health History Assignme...
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