Tina Jones: One person in the family, my dad's brother, has an alcohol problem, but we never see him. Example Question: Are you feeling feverish right now? Finding: Denies irregular heartbeat (Available)Pro Tip: Asking about heartbeat patterns is one possible component of a review of systems interview. If the patient reports a history of diarrhea, it could be a symptom of dietary or gastrointestinal problems. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as oral infection or recent trauma. ... Past Medical History. Student: So that you understand if there are any problems related to their chief complaint. I can't put any weight on it without like, shooting pain. Finding: Denies muscle weakness (Available)Pro Tip: Asking about muscle weakness is one possible component of a review of systems interview. NB: We have all the questions that you will ask Tina Jones plus the answers that she will provide already documented in the Subjective Data, Objective Data, Assessment, and Care Plan format. Finding: Reports large amount of urine (Found)Pro Tip: Polyuria is a common symptom of diabetes. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. Example Question: Tell me about your blood sugar monitoring. ", 3.Gaps in health literacy around diabetic diet Not Encountered, Description: Tina describes controlling her diabetes by avoiding "sweets." Finding: Asked about history of asthma exacerbations. ", 6. Finding: Denies current headache (Available)Pro Tip: Asking Tina is she currently has a headache is important because it might be contributing to her current discomfort and should be treated promptly. Example Question: Do you have joint pain? Finding: Reports that she used to take diabetes medication (Found)Pro Tip: Asking about Tina's medication history for asthma will provide a timeline of treatment. At the end of this prebrief, you will answer a short question about the upcoming assignment. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Finding: Reports father died at age 58 (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. A thorough rheumatologic assessment is performed within the context of a good general evaluation of the patient. Finding: Asked about childhood immunizations. Example Question: Did you injure anything besides your foot? Student: When did you realize you were allergic to cats? Finding: Reports infrequent itchy eyes (Available)Pro Tip: Asking about symptoms, such as itchy eyes, is one possible component of a review of systems interview. Student: Have you had any prior hospitalizations? Example Question: Do you have any throat problems? Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. Finding: Reports noticing pus 2 days ago (Available)Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began. Example Question: What prescription medications do you take? I didn't realize how sharp the edge was! Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. Finding: Denies depression (Available)Pro Tip: Asking about the patient's history with depression is one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. Example Question: Do you have any nose problems right now? "I have a monitor at home, but to be honest I don't really use it that often." You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. I get headaches sometimes, but that's all. Tina Jones: Grandpa Jones passed away when I was really little. All information is kept confidential. Example Question: What caused your father's death? Finding: Reports last use of medication was 3 years ago (Available)Pro Tip: It important to discover when Tina stopped taking any medications and what caused her to stop. Finding: Denies current birth control (Available)Pro Tip: A patient's use of birth control can impact the care plan, such as which medications are prescribed. Example Question: Tell me more about living at home. Example Question: What is your reaction to penicillin? Example Question: Do you have any swollen glands? Evidence - Relevant: "No, I don't take anything for my diabetes anymore." Past illnesses: e.g. Student: How effective was your pain medication at home? As a currently presenting symptom, it could impact the patient's care plan. Finding: Reports paternal grandfather diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Example Question: Have you noticed bruising more than usual? Finding: Asked about general immunizations received. Finding: Reports last tetanus vaccination was in the past year (Found)Pro Tip: For a patient with a recent scrape on a metal surface, confirming the last date of a tetanus shot is essential to prevent any diseases from contact. . Example Question: Have you had itchy eyes? With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance. Finding: Reports that family members are overweight (Found)Pro Tip: Asking about trends such as obesity can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. Finding: Reports being barefoot at the time of injury (Available)Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances. Finding: Denies chest pain or discomfort (Available)Pro Tip: Asking about chest pain is one possible component of a review of systems interview. Planning - Relevant: Planning Pro Tip: Interview the patient to determine her level of health literacy, and her attitudes and beliefs toward exercise. Example Question: When was your last tetanus booster? Example Question: Do you have any breast swelling? . Finding: Reports occasionally taking acetaminophen (Tylenol) for headaches (Available)Pro Tip: Finding out about your patient's use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills." Student: Do you have problems with your mouth? Finding: Denies current breathing problems (Available)Pro Tip: Asking about general breathing problems can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns. Finding: Reports mother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. ", 5. "I got this scrape on my foot a while ago, and it got really infected. Finding: Asked about review of systems for nose. he would sometimes get kind of mad at us when we did something wrong. Example Question: What did you eat for your last meal? Obesity is a long-term health concern that cannot be addressed in a single visit. Finding: Reports receiving polio shot (Available)Pro Tip: Discovering if a patient received a childhood polio vaccination reveals information about both her medical history and her susceptibility to infectious disease. Evidence Pro Tip: The strongest evidence of impaired walking is that Tina directly reports she can't bear weight or walk on her affected foot. Asking Tina if her father had diabetes can reveal generational patterns. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Note any significant change from previous state. Finding: Asked review of systems for reproductive. Finding: Reports last use was at age 20 or 21 (Found)Pro Tip: When a patient reports drug use, it's important to determine the reason for drug use, as well as the timeline. Tina Jones: I feel really stressed out right now! Finding: Reports maternal grandmother diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Brian foster chest pain shadow health assessment Transcript. Example Question: What pain medication have you been taking? PARCIAL 1 April 1 2020, questions and answers Exam for leadership Tina Jones Heent Interview Completed Shadow Health 1 Tina Jones Health History Care Plan Shadow Health.pdf Physical Assessment Final Notes Wk 1 to Wk 8 Physical Assessment Wk 1 to Wk 4 Past Medical History If possible find out how long current illnesses have been going on, and obtain dates for any events It may not be necessary to ask every question, if not pertinent Childhood illnesses Adult illnesses o Include any recent illnesses (i.e. Finding: Denies tingling (Available)Pro Tip: Asking about tingling sensations is one possible component of a review of systems interview. Student: Has your foot been draining any liquids? Asking Tina if her father had high cholesterol can reveal generational patterns. Finding: Denies brother having diagnosed health problems (Found)Pro Tip: Family histories might indicate a genetic predisposition. Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. Asking Tina if her maternal grandfather had high blood pressure can reveal generational patterns. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. but I don't do that anymore. – Education level (health literacy) – Access to health care Insurance/Financial status – Is the patient able to afford medications and health diet, and other out-of-pocket expenses? The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Past medical history. Finding: Denies swollen glands (Found)Pro Tip: Asking about a patient's glands in general could include lymph nodes or thyroid glands. Student: How effective was the Neosporin? Finding: Denies incontinence (Available)Pro Tip: As a currently presenting symptom, incontinence could result in a change to the patient's care plan. Student: How is your paternal grandmother's health? Finding: Reports recommended dose is 1-3 puffs as needed (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. Supporting evidence comes from her inability to incorporate meaningful dietary changes or increase her exercise. Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. Lumps have a range of severity, as they could be the result of breast injury or cancerous growths, but any abnormalities should be handled with the highest level of concern. Example Question: Do you take prescribed medication for your diabetes? Scheduled maintenance: Saturday, December 12 from 3–4 PM PST. Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Example Question: Are you ever exposed to secondhand smoke? Finding: Reports using an inhaler (Found)Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy. Tina Jones: Some of my friend's smoke when we go out drinking. Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patient's illness is an essential element of the illnesses history. Evidence - Relevant: "...Like a 7. Finding: Denies excessive flatulence or bloating (Available)Pro Tip: Asking about gas or bloating is one possible component of a review of systems interview. But my breathing definitely acts up. As a currently presenting symptom, it could indicate an asthma exacerbation or a new respiratory infection. Finding: Followed up on coping with father's death. While the patient is in your care, work with other healthcare professionals to keep the pain managed and improve the patient's mobility. ... Past Medical History. Indicates an item that is available to be found. She's still living on her own. Finding: Reports drinking diet coke instead of regular (Available)Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider. Student: We are going to take care of everything as quickly as possible. The patient's response to these questions may uncover additional problems, such as nerve damage. Determine age and health, or age and cause of death, of parents, sibling, and grandparents, noting the presence of specific illnesses in family (e.g. Provide an appropriate intervention (pharmaceutical or otherwise) and educate the patient. Even getting up and ready for church was too overwhelming. With a foot wound, it is imperative to discern if a patient can walk or not, as a lack of mobility can compromise quality of life. Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. Asking whether she's noticed ear discharge could indicate whether she has a ruptured eardrum. Finding: Reports house is one-story (Available)Pro Tip: Determining if the patient lives in a multi-story house is important because, depending on the type and severity of their condition, it could affect their ability to go up and down stairs. Student: What else will this exam involve? Evidence - Relevant: Evidence Pro Tip: Tina directly reports that she doesn't exercise, which is the primary evidence for a sedentary lifestyle. Finding: Reports infrequent sinus problems (Available)Pro Tip: Asking about symptoms, such as frequent sinus issues, is one possible component of a review of systems interview. Planning Pro Tip: To reduce the patient's pain, assess her current rating. Example Question: Have you ever been diagnosed with a sexually transmitted infection? Finding: Asked about diabetes management through lifestyle changes. Finding: Reports sister diagnosed with asthma (Found)Pro Tip: Family histories might indicate a genetic predisposition. Most people with diabetes feel better when they limit all starches, eat protein, and take regular medication. A history of hematuria could be a symptom of genitourinary problems. Example Question: How often do you change your bandage? Most importantly, ask about her goals and changes she may be willing to make. Finding: Reports right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patient's safety. Evaluate education level, family and household dynamics, spiritual practices, personal interests, sleep habits, and lifestyle (e.g. Finding: Reports currently working toward undergraduate degree (Found)Pro Tip: Finding out a patient's level of education can give you a baseline for her health literacy. Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. Finding: Reports changes to neck skin (Available)Pro Tip: Asking about changes in skin color is one possible component of a review of systems interview. I guess a little over a year ago. The patient is unable to bear weight on her affected leg, which prevents walking. Finding: Reports last penicillin reaction was in childhood (Available)Pro Tip: Determining a patient's last reaction to penicillin is part of gathering thorough information about her allergy. Finding: Denies hair loss (Available)Pro Tip: Asking about hair loss or balding is one possible component of a review of systems interview. Finding: Asked to rate current pain level on a scale. Finding: Denies sore throat (Available)Pro Tip: Asking if a patient has a sore throat is one possible component of a review of systems interview. A history of irregular periods could indicate hormonal or endocrine problems. Student: What made you stop taking medication for your diabetes? A history of pain during urination could be a symptom of genitourinary problems. Intervene - Hypoglycemia: Administer insulin and/or oral hypoglycemics, per physician orders. Finding: Asked review of systems for skin, hair and nails. Student: Have you used drugs other than marijuana? Tina Jones: Um, I have acne, if that counts. Start studying Week 5: HEENT: History and Physical Exam: Head, Ears, Eyes, Nose & Throat. Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Student: What medication allergies do you have? Student: Do you have a history of skin disease? Example Question: Have you had mouth pain? Other contributing factors are her family history of diabetes mellitus and a lack of physical exercise. Finding: Reports paternal grandfather diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Finding: Reports maternal grandfather diagnosed with high cholesterol (Available)Pro Tip: Family histories might indicate a genetic predisposition. Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. Example Question: What is the dose of the pain medication? Evidence Pro Tip: Tina expresses pain, which is the strongest evidence for this problem. but I don't do that anymore. I've been going to the same church since I was a kid, too, so the people at church are practically part of my family. Tina Jones: Mom has high cholesterol and blood pressure, I think. cancer, heart disease, hypertension, diabetes. cancer, heart disease, hypertension, diabetes. It's got all that going on." Finding: Denies nausea (Available)Pro Tip: Currently presenting nausea can be caused by changes in blood sugar, a reaction to medication, stress, or even spreading infection. For example, many starchy foods break down into glucose in the body, like pasta, and so you can eat those in moderation, too. Enquire about any raised blood pressure, heart problems, fainting fits, dizziness or collapses. As a currently presenting symptom, flank pain could result in a change to the patient's care plan. Example Question: Have you had night sweats? Tina Jones: No, I can't. Tina Jones: No, I don't take anything for my diabetes anymore. Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care. Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment. Student: What allergies do you have? Example Question: Does it hurt when you urinate? Tina Jones: Yeah, I've lost some weight recently. As a currently presenting symptom, it could indicate a change in patient status. Student: Did your father die from any disease? Finding: Denies joint pain (Available)Pro Tip: Asking about joint pain is one possible component of a review of systems interview. Finding: Reports occasional headaches (Available)Pro Tip: Asking about headache frequency is one possible component of a review of systems interview. Finding: Denies gum problems (Available)Pro Tip: Asking about symptoms, such as gum problems, is one possible component of a review of systems interview. The patient's response to these questions may uncover neurological problems. Finding: Reports chest tightness during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness. Prevent worsening infection by educating the patient about wound care and self-monitoring. ", 8. Every hour or two when I'm awake? Finding: Reports father was diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Student: Does your family have a history of obesity? You can pause and resume the assignment at any time; your work is always saved automatically. Finding: Asked about relevant medical history. A health history questionnaire consists of a set of survey questions that help either medical research, doctors or medical professional, hospitals or small clinics to understand the population they provide medical services to. Example Question: Have you ever taken medication for your diabetes? Finding: Denies change in sense of taste (Available)Pro Tip: Asking about symptoms, such as a change in taste, is one possible component of a review of systems interview. Finding: Denies change in hearing (Available)Pro Tip: Asking about changes in hearing is one possible component of a review of systems interview. Example Question: Have you noticed changes in your sleep? Example Question: Do you have any seasonal allergies? Tina Jones: Um...well, my dad died in a car accident, about a year ago. Example Question: How often did you clean the wound? Honestly, I didn't realize that I'd be admitted to the hospital for my foot. Student: How many puffs do you take when using your asthma inhaler? Asking Tina if her paternal grandfather had diabetes can reveal generational patterns. She describes being too busy to exercise and reports that her primary activity is being on her feet at work, a belief which demonstrates her misunderstanding of exercise. Uncovering the age of death can help you assess the patient's current risks. Example Question: Does your sister have health conditions? Finding: Reports past condom use (Available)Pro Tip: Asking about a patient's past condom use is one possible component of a review of systems interview. Tina Jones: I don't think I have any problems. Finding: Reports eating mac and cheese for lunch yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. Finding: Reports receiving measles-mumps-rubella shot (Available)Pro Tip: Discovering what childhood immunizations a patient has received reveals information about both her medical history and her susceptibility to infectious disease. I don't want to miss work or school but now it looks like I'll have to. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as vision loss. In Tina's case, it will help you better understand her asthma and create a timeline. Finding: Reports asthma (Found)Pro Tip: It is important to identify any existing medical conditions, such as Tina's asthma, because that information is an integral part of her health history. "I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. Finding: Denies voice changes (Available)Pro Tip: Asking about changes in a patient's voice is one possible component of a review of systems interview. Finding: Denies muscle pain (Found)Pro Tip: Asking about muscle pain is one possible component of a review of systems interview. Example Question: Have you had dry mouth? Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%. DON’T STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW. Finding: Denies ringing or tinnitus (Available)Pro Tip: Ringing in the ears can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing, or hearing loss. Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. Other supporting evidence is her recent injury caused by falling. Finding: Followed up on home pain medication. Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. Example Question: Does obesity run in your family? Tina Jones: I haven't smoked pot since I was twenty or twenty-one. Tina Jones: Whatever pain medication the ER gave me is helping. It is necessary to approach this subject with the utmost respect and sensitivity. Finding: Asked about constitutional health. If you would like, I can help you find a monitor that is as painless as possible. Finding: Reports penicillin allergy (Found)Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient's safety while she is in your care, as it affects what medications will be safe and appropriate. Asking Tina if her maternal grandmother had high cholesterol can reveal generational patterns. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data. And I put Neosporin on it. Finding: Asked about current diabetes medication use. Model Statement: "I understand how it can feel like a frustrating chore to check your sugar every day. Then educate the patient on risks of obesity, recommended dietary changes, and healthy exercise. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. First, gain a deep understanding of your patient's situation. ", 2.Impact of injury on daily life Followed Up, Description: Tina brings up her pain and frustration at how being unable to bear weight on her foot impacts her life. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. I know I need sleep, too. Example Question: How are you coping now? Tina Jones: Last year when Dad passed, he was only 58. Finding: Denies family history of headaches (Found)Pro Tip: Asking about trends such as headaches can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. Example Question: Have you ever had a seizure? Example Question: When was the last time you took your diabetes medication on a regular basis? Finding: Asked about prescription medications. Tina's diabetes diagnosis will have a large impact on her body's healing ability, which should be taken into consideration during your exam. 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