NURS 6512 Week 4 Health History Results Paper
NURS 6512 Week 4 Health History Results Paper
Turned In Advanced Health Assessment and
Diagnostic Reasoning
nurs6512-usw1.504.202050
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Lab Pass
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Information Processing
Health History Tips and Tricks
Self-Reflection
Student Submission…
Experience Overview
Patient: Tina Jones
Digital Clinical Experience Score
100%
This score measures your performance on the Student Performance Index in relation to other
students in comparable academic programs. Your instructor has chosen to scale your Student
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Performance Index score so that the average score on the index is a 80.0%. This score may not
be your final grade if your instructor chooses to include additional components, such as
documentation or time spent.
Student Performance Index
150
out of
152
Proficiency Level:
Proficient
Beginning
Developing
Proficient
Students rated as “proficient” demonstrate an entry-level expertise in advanced practice
competencies and clinical reasoning skills. In comparable programs, the top 25% of students
perform at the level of a proficient practitioner.
Subjective Data Collection
100
out of
100
Objective Data Collection
1
out of
1
Education and Empathy
9
out of
11
Information Processing
40
out of
40
Time
1421 minutes total spent in assignment
Interaction with patient
1179 minutes
Post-exam activities
242 minutes
Documentation / Electronic Health
Record
Document: Provider Notes
Document: Provider Notes
Student Documentation Model Documentation
Identifying Data & Reliability
Name: Tina Jones Age: 28 Sex: Female Race: African American
Historian: patient
N/A
General Survey
Miss Jones is alert, awake, and oriented. She appears well
nourished. She appears in moderate pain to her right foot. She
maintains good eye contact during the interview and interacts
appropriately. Patient’s speech is clear and coherent. She is well
groomed and is dressed appropriately.
N/A
Chief Complaint
Patint presents for an initial primary care visit complaining of an
infected wound.
N/A
History Of Present Illness
Tina Jones is a 28 year old African American female who
presents today with an infected foot wound. The injury occured a
week ago as she was going down the back steps and tripped. She
caught the railing but turned her right ankle and scraped up
around the ball of her right foot on the edge of the step. She was
barefoot when the injury occurred. She was seen in the ED,
wound care provided, x-ray and received a prescription for pain.
N/A
Student Documentation Model Documentation
She reports the scrape and pain getting progressively worse and
constant in the last few days. She reports the area as red, puffy,
and has pus with off white discharge. The pain is centered around
the scrape but her whole right foot feels some pain. The pain is
described as throbbing and sharp when bearing weight. The pain
worsens when she bears weight on her right foot and alleviates
with Tramadol. She rated her pain symptoms as 7 out of 10 upon
evaluation. She reports fever up to 102 degrees last night and did
not take any medication for the fever. She has been doing wound
care in the morning and night and uses Neosporin and bandage to
protect the wound. She is concerned about the wound and the
pain affects her attendance at work.
Medications
1. Tramadol 50 mg TID, Last dose 2 tablets priorto arrival. 2.
Proventil inhaler 90 micrograms, 2-3 puffs, 2-3 times a week and
as needed. Last dose was 3 days ago when she was at cousin’s
house who had cats. 3. Tylenol 500mg for headache, usually 1-2
tablets at night before bed. Last dose 2 tabs prior to arrival. 4.
Advil 200 mg for cramps takes up to three times a day. Last dose
was 3 weeks ago. 5. Metformin, unknown dosage and frequency,
last taken 3 years ago. Stopped taking because she felt sick and
gassy.
N/A
Allergies
1. Cats – difficulty breathings, sneezing itchy eyes 2. Penicillinas a child, rash, hives 3. Dust- asthma attack
N/A
Medical History
1. Asthma, diagnosed as a child at about 2.5 years old. 2.
Diabetes, type 2, diagnosed 4 years ago. Uncontrolled. She took
metformin when first diagnosed but stopped 3 years ago and just
watches her diet and avoids sweets. Last lab test for diabetes was
6 months after diagnosed. Denies any surgical history.
N/A
Health Maintenance
Miss Jones’ last visit to her primary doctor for a physical exam
was about two years ago. Her last dental check up was a few
years ago. Her vision was last tested when she was a kid. Her last
pap smear was 4 years ago. Denies exercising, She denies going
to the gym. She states she is up on her feet all the time at work
and considers that her exercise. Her typical diet consists of
N/A
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Student Documentation Model Documentation
muffin, pumpkin bread for breakfast, a sandwhich for lunch, and
some kind of meat with vegetable for dinner.Her favorite food
consist of pizza and mac and cheese. Miss Jones drinks diet coke.
Denines adding salt to food. Immunizaton: She received her last
influenza vaccine 5 or 6 years ago. Pneumococcal vaccine,
unable to recall. She received a tetanus booster about a year ago.
She received all childhood immunization. She had chicken pox
when she was a kid. Sleeps adequately but have not been
sleeping well in the past 2 days because of the foot pain.
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Family History
1. Mother has high cholesterol and hypertension. 2. Father had
high blood pressure, cholesterol, and diabetes was diagnosed in
his 30’s. Died of a car accident at age 58. 3. Brother, overweight
but denies any medical condition. 4. Sister has a history of
asthma but well controlled. 5. Paternal grandfather died of colon
cancer in his mid 60’s. 6. Maternal grandfather died of heart
attack at age 80. History of hypertension and high cholesterol.
7.Maternal grandmother died of stroke 5 years ago. History of
asthma but almost never had attacks. She had a history of
hypertension and high cholesterol 8. Paternal grandmother is 82
now. She has hypertension and high cholesterol.. 9. Paternal
uncle was an alcoholic.
N/A
Social History
Drinks alcohol occassionally, no more than once or twice a week,
sometimes less. Started drinking at age 15 or 16. Last drink was
3 weeks ago. Denies smoking cigaretttes or tobacco. Denies
vaping. She is exposed to second hand smoke when out with
friends. Used to smoke marijuana, last use was 6 or 7 years ago
She lives in a one-story house with her mom and sister. Reports
she lives in a safe neighborhood. Works as a full time supervisor
at a mid-American Copy & Ship company. Works 32 hours a
week, sometimes more. Has access to health insurance. Her
ability to walk was impaired due to the wound and affected her
attendance to work. She is working on her bachelor’s degree in
accounting. She denies use of contraceptives. She used to take
contraceptives when she was sexually active. She is not sexually
active currently. Heterosexual. She has had 3 sexual patners in
the past. She has never been pregnant. Volunteers with her church
group for Habitat for Humanity doing painting or serving food
and drinks for other volunteers. Lives with her mom and sister.
Lives in a safe community. Good support from family. Her
N/A
Student Documentation Model Documentation
religious affiliation is Baptist. She enjoys going to the bible study
with friends, going to friends’ houses to watch shows and hang
out. She enjoys weekends going out to bar or go dancing, She
considers people at church as part of her family.
Objective
Review of Systems: General: Feels exhausted at the end of the
day after work. + Fever, reports 102 degrees last night, reports
chills last night but denies night sweats. Reports unintentional
weight loss, 10 lbs over a month. Denies weakness. Head:
Reports headaches that lasts for a few hours. Describes
headaches as tight, throbbing behind eyes that started a few years
ago and is relieved by Telenol and sleep. Headache occurs
weekly with reading and studying for school. Denies migraine,
seizures, dizziness, and head injury. Eyes: Reports vision getting
worse in the past years. States vision is blurry when reading or
studying. Denies wearing contacts nor eyeglasses. Denies eye
pain. Denies abnormal eye discharges unless around cats. They
get a little watery. Denies diplopia, and floaters. Her last visit to
an ophalmologist was when she was a kid. Denies history of
glaucoma or cataracts. Ears; Denies changes in hearing, ringing,
discharges and balance problems. Denies any recent ear
infection. Denies ear pain. Denies any ear surgery. Nose: Denies
changes to nose.Denies nasal polyps, nose bleeds, sinus infection
nor difficulty smelling. Mouth/Throat: Denies chewing nor
swallowing difficulties. Denies changes to teeth or gums. Denies
changes to voice and taste. No report of dry mouth. She has no
dental appliances. Last dental check up was a few years ago.
Neck: Denies neck injury. reports a “crick” on her neck when
reading but states nothing serious. No report of swollen glands.
Cardiovascular: Denies chest pain, palpitations or heart murmurs.
Denies swelling to legs. States other than her right foot, there is
no pain in her lower extremities. Dyspnea on exertion reported
occasionally when walking up the stairs or when having to walk
a long way. Denies history of hypertension or heart attack. Never
had EKG done. Respiratory: Reports breathing is fine in the last
few days. Denies cough. Reports she gets short of breath
sometimes because of her asthma. Rare asthma attacks. Last full
attack was in high school. Asthma triggered by cats and dust.
During asthma attacks, she describes her symptoms as chest and
throat tightness with wheezing. Denies history of
pneumonia. Denies hemoptysis. Last PPD was 2 years ago.
Gastrointestinal: No nausea, vomiting, or abdominal pain.
Reports normal bowel pattern. Denies hematemesis nor blood in
N/A
Student Documentation Model Documentation
stool. Unexplained and unintentional weight loss, about 10 lbs
over a month. Reports increase in appetite that started about a
month ago and drinks a lot more water than normal. Denies
gastric reflux, constipation or diarrhea. Denies hemorrhoids or
jaundice. Genitourinary: Reports polyuria and nocturia, Denies
dysuria or hematuria. Reports irregular menstrual period. She
reports getting 6 periods every year. Reports abdominal cramps
during period, with lots of bleeding for more than a week. Takes
Advil for cramps and helps with her symptoms.. She also applies
heating pad which only helps a little. Last pap smear was 4 years
ago. Denies any history of STDs. Heterosexual. She has not been
sexually active in the past 2 years. She used to be on
contraceptive pills when she was sexually active. Has never been
pregnant. No report of berast changes. Denies lumps nor nipple
discharges. Reports soreness to breasts which she said is typical
before her period. Does not perform breast self exam. Never had
mammogram. Denies breast cancer history in the family.
Muskuloskeletal: No muscle weakness Denies history of arthritis
or gout. Denies any history of trauma or fracture. Reports
difficulty in bearing weight due to wound on right foot. Denies
any problems with range of motion other than her right foot due
to the foot wound. Integumentary: Reports scrape around the ball
of her right foot, described as red and puffy with off white pus.
Denies foul odor to wound. Reports dry skin to arms and legs and
uses lotion to prevent dryness. Reports skin discoloration to her
neck, described as getting darker and skin’s breaking out that
started in the last few months. Denies other skin changes. Denies
changes to hair and nail. Denies rashes nor abnormal bruising.
Denies changes to moles. Neurology: Denies dizziness, syncopal
episodes and numbness. Reports headache as reported above.
Denies memory changes, muscle tremors, and seizures. Denies a
history of stroke. Psychiatry: Denies history of anxiety nor
depression. Reports feeling depressed when father died suddenly
due to a car accident but lasted about a month and realized it was
part of the grieving process. Sleeps at least 8 hours a day. Denies
suicidal or homicidal history. Reports recently stressed with
schedule and foot pain. Denies any psychiatric history.
Endocrine: Reports polyuria, polydipsia, polyhagia and
temperature intolerance. History of type 2 diabetes diagnosed
two years ago, Does not monitor blood sugar. She was prescribed
metformin but stopped taking 3 years ago. Manages diabetes by
watching her diet and staying away from sugar. Drinks diet coke.
Hematologic/lymphatic: Denies easy bruising, bleeding tendency,
anemia, blood transfusion, and clotting disorders.
Student Documentation Model Documentation
Allergic/immunologic: History of asthma. Allergic to cats, dust,
and penicillin. Denies food allergies, immunotherapy, frequent or
chronic infections. Denies history of HIV.
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