Knowing that Mom needed me kind of helped me get through day by day. Tina Jones: She's pretty healthy. Tina Jones: No. 7. Finding: Asked about current diabetes medication use. Empower the patient to take part in her own care by educating her on controlled breathing techniques. After an appropriate time interval, assess pain levels again to see how the intervention affected the pain. Finding: Denies nail abnormalities (Available)Pro Tip: Nail fungus might cause discoloration and disfigurement of the nails. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. My faith is a big part of my life--when things get hard like they've been this past year, I know I can trust that God's looking out for me. Finding: Reports specific age of diagnosis is 2.5 years old (Available)Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the patient's history of the condition, including the age of diagnosis. Gaps in health literacy around asthma control Not Followed Up, Description: Tina describes increased inhaler use and decreased effectiveness, indicating that her asthma is uncontrolled. Finding: Reports receiving meningococcal shot (Available)Pro Tip: Discovering if a patient has received a childhood meningococcal vaccination reveals information about both her medical history and her susceptibility to infectious disease. Finding: Reports infrequent blood glucose monitoring (Found)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. Tina Jones: I don't know what caused it, I just lost weight. Tina Jones: I don't think I have any problems. Finding: Reports taking ibuprofen (Advil) at home (Found)Pro Tip: Discovering how a patient has been medicating for pain is a crucial element of understanding and treating her condition or injury. Finding: Denies stomach pain (Available)Pro Tip: Asking about stomach pain is one possible component of a review of systems interview. Previous levels of lipids if ever checked or known. Finding: Reports using inhaler no more than 2 times per week (Available)Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. Tina Jones: No, I can't. Screening/Risk Assessment – Identified health concerns based on screening assessments and demographic information Nutrition/Activity Finding: Reports pain affects ability to stand at work for long periods of time (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. Example Question: Tell me more about any sugars you consume. I'm not a huge health nut or anything. However, for a patient with no active respiratory complaints, this problem does not need to be addressed immediately. At the end of this prebrief, you will answer a short question about the upcoming assignment. I can't put any weight on it without like, shooting pain." 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. Tina Jones: It's throbbing and like, sharp if I try to put weight on it. Student: What allergies do you have? Planning - Relevant: Planning Pro Tip: Interview the patient to determine her level of health literacy, and her attitudes and beliefs toward exercise. Example Question: Do you have a family history of headaches? Finding: Denies lymph node problems (Available)Pro Tip: Asking about a patient's lymph nodes is one possible component of a review of systems interview. Educate - Medication: Educate the patient on medications used for pain relief. Finding: Reports paternal grandfather died of colon cancer (Found)Pro Tip: Family histories might indicate a genetic predisposition. MEDICAL HISTORY QUESTIONNAIRE TODAY'S DATE: _____ ***Since this is your medical history and it will be used in evaluating your health, it is extremely important that the questions be answered as accurately and completely as possible. Student: Do you have a family history of psychiatric illness? So, I guess at first I just focused on getting things done--groceries, laundry, insurance papers and stuff. Tina Jones: My chest and throat get tight, and I start to wheeze. Mom was having such a hard time, crying a lot, everything made her sad, she was kind of depressed. Example Question: Have you noticed any hair loss? Example Question: Do you have any swollen glands? Asking Tina if her mother had high blood pressure can reveal generational patterns. 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. When I'm reading or studying I'll notice that things start to get kind of blurry. Example Question: What did you eat for breakfast yesterday? Finding: Denies edema (Available)Pro Tip: Asking about edema is one possible component of a review of systems interview. It is important to ask your patient about the flu vaccine. Finding: Denies ever having a mammogram (Available)Pro Tip: Inquiring into what breast screenings Tina has had can lead to a discussion about any test results and their implications for her cardiovascular health. Most people with diabetes feel better when they limit all starches, eat protein, and take regular medication. Example Question: Have you had mouth sores? 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. Finding: Denies chest pain or discomfort (Available)Pro Tip: Asking about chest pain is one possible component of a review of systems interview. Student: Can you walk with your foot being injured? Student: How effective was your pain medication at home? Provide an appropriate intervention (pharmaceutical or otherwise) and educate the patient. Example Question: Do you have a history of suicidal thinking? Tina Jones: No. Example Question: Does your maternal grandfather have health conditions? As a currently presenting symptom, it could impact the patient's care plan. Example Question: Do you ever have chest pain? Knowing your extended family history can provide important clues for your ongoing health. She also reports sometimes needing more puffs to resolve symptoms. Learning about the patient's religious beliefs will allow you to provide the appropriate support and resources. 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. Example Question: Do you have any seasonal allergies? Student: Does your family have a history of substance abuse? Example Question: Did you receive the meningitis vaccine? Example Question: How old was your father when he died? Example Question: When did you last have issues with asthma? ", 3.Gaps in health literacy around diabetic diet Not Encountered, Description: Tina describes controlling her diabetes by avoiding "sweets." Tina Jones: He died last year, so I was 27. Example Question: What is your highest level of education? Student: When did you last use drugs? Finding: Denies chills (Available)Pro Tip: Asking about additional symptoms, such as chills, is one possible component of a review of systems interview. Intervene - Pain: Administer non-pharmacologic interventions to reduce pain. Example Question: Have you ever smoked marijuana? 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. Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are significantly higher than her baseline. Finding: Reports infrequent eye redness (Available)Pro Tip: Asking about symptoms, such as eye redness, is one possible component of a review of systems interview. But it is important to keeping your diabetes under control. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. Tina Jones: No, I can't. Example Question: How much weight have you lost? The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. 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. Asking Tina if her mother had high cholesterol can reveal generational patterns. Educate - Pain: Educate the patient on non-pharmaceutical methods to reduce pain intensity. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Diana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre-existing conditions. 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. 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. Example Question: Do you have any food allergies? It's important to learn about any past pregnancies, live births, or miscarriages. Tina Jones: Well, Poppa died about five years ago. 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. It's good to hear that you no longer smoke pot. Tina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. Example Question: Have you seen a healthcare provider for this injury? Learn vocabulary, terms, and more with flashcards, games, and other study tools. Student: Did your father die from any disease? Finding: Denies muscle pain (Found)Pro Tip: Asking about muscle pain is one possible component of a review of systems interview. 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. Your questioning should cover a broad array of the symptoms' characteristics. Example Question: Does dust trigger your asthma? As a currently presenting symptom, it could indicate a change in patient status. Finding: Denies past pregnancies (Available)Pro Tip: A patient's history of pregnancy can shed light on other health conditions, body systems, or risk factors. Example Question: Does anyone live at home with you? Questions to Instructor Forum: This is a great place to ask course content or assignment questions. Finding: Reports asthma triggered by dust (Found)Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. Example Question: Can you bear weight on your foot? Educate - Exercise: Educate the patient about the benefits of exercise. Diana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre-existing conditions. Planning - Relevant: Assess - Health Literacy and Patterns: Assess the patient's knowledge related to diabetic disease process, assess personal/social supports. Example Question: How many pain pills do you take at a time? Existing conditions can also inform your treatment and understanding of the patient's current health issues. Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression. Finding: Reports cause of death was a car accident (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. Example Question: How many days have you needed pain medication? Plus, he had high blood pressure, and...I'm pretty sure he had diabetes. Evidence - Relevant: "BMI: 31" Evidence Pro Tip: Tina's BMI is 31, which is in the obese range. Intervene - Pain: Administer prescribed analgesics to provide optimal pain relief. Finding: Asked review of systems for reproductive. Finding: Asked if the patient has received a flu vaccine. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. 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. Example Question: What is the dose of the pain medication? Finding: Asked about review of systems for mouth and jaw. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. ", 5. That sounds like a difficult situation. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Finding: Reports increased appetite (Found)Pro Tip: Identifying if a patient has recently experienced a change in appetite is important, as it could indicate an underlying endocrine or psychiatric condition. Finding: Reports last hospitalization was for asthma (Available)Pro Tip: Finding out if Tina has any past hospitalizations is the first step in understanding any past serious medical issues. Finding: Reports past grief (Found)Pro Tip: Asking about Tina's reaction to her father's death is a vital part of patient-centered care. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Example Question: Do you have joint pain? A history of incontinence could be a symptom of genitourinary or pelvic problems. Example Question: When was your last alcoholic drink? 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. Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: Have you used drugs other than marijuana? Finding: Asked about review of systems for neck, throat and glands. It's killing me. Risk factors include second-hand smoke from father, history of pneumonia in the past year, and being overweight for his age. Tina Jones: He had high blood pressure and cholesterol. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. Finding: Reports pain is throbbing (Found)Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain. Finding: Reports last hospitalization was age 16 (Available)Pro Tip: Finding out the date of Tina's last hospitalization is important for understanding the timeline of her medical issues, asthma in particular. Finding: Asked about review of systems for cardiovascular. Example Question: What is your reaction to penicillin? ", 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. Finding: Reports father was diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. 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. Example Question: Has your sense of smell changed? 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've never really had stomach or bowel problems. Family History Checklist: Questions for Relatives Learn your family's health history. He would just get really calm and quiet and tell us to go to our rooms without supper, or that we were grounded when we were older. Finding: Denies muscle weakness (Available)Pro Tip: Asking about muscle weakness is one possible component of a review of systems interview. I guess a little over a year ago. 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 allergic reactions, infection, or physical trauma. Tina Jones: Um...well, my dad died in a car accident, about a year ago. Prevent worsening infection by educating the patient about wound care and self-monitoring. Finding: Asked about history of asthma exacerbations. Past Medical History Schizophrenia, since age 23 Past Surgical History No previous surgeries Medication History Risperdal 2 mg P.O. Finding: Reports paternal grandfather diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Tina Jones: Um...I've smoked pot before. Example Question: Do you have any nose problems right now? The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Finding: Asked about relevant medical history. Example Question: Have you noticed an increase in appetite? Finding: Asked about review of systems for mental health. Finding: Reports that penicillin resulted in hives (Available)Pro Tip: Determining a patient's reaction to an allergen is essential to gauge if the allergy is life-threatening. Example Question: Have you been more thirsty lately? Example Question: Do you have nail fungus? Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound. Example Question: Have you had a mammogram? A history of pain during urination could be a symptom of genitourinary problems. It's scary to think about. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. 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. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Example Question: Do you know what type of diabetes you have? Even regional rheumatic problems require a thorough examination of the patient. Student: Have you had any musculoskeletal problems? Finding: Reports that she does not currently take medication for diabetes (Found)Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control. Finding: Reports moles (Available)Pro Tip: Monitoring moles is key in preventing cancerous growths. As a currently presenting symptom, it could result in a change to the patient's care plan. Finding: Explored impact of patient's foot injury on activities of daily living. My foot slid off the bottom step and it got all scraped up. Tina Jones: I got this scrape on my foot a while ago, and it got really infected. Tina Jones: I haven't had a full attack in years. As a currently presenting symptom, it could indicate a change in patient status. Finding: Asked about childhood immunizations. Example Question: Do you take any supplements? ... Past Medical History. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient's most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient's condition and effectiveness of any treatments. Example Question: Have you experienced nipple discharge? Example Question: How are you coping now? Tina Jones: I feel really stressed out right now! Finding: Asked about patient's level of education. I know I need sleep, too. Example Question: Is there swelling around the wound? Example Question: Do you live in a house? Finding: Asked about the effectiveness of pain medication at home. Example Question: Did you notice any redness around the wound? Tina Jones: Granny's doing good. Evidence Pro Tip: Tina expresses pain, which is the strongest evidence for this problem. Student: What are some things that trigger your asthma? Question These assessments together will give you a comprehensive picture of Ms. Jones' overall health. History of Present Illness. She reports intense pain on a numerical scale and describes pain characteristics. Finding: Reports pus as white or yellow (Found)Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics. Example Question: What did you eat for your last meal? So, it was really sudden. Example Question: Can you please describe the pain? Finding: Denies dizziness or vertigo (Available)Pro Tip: Asking about dizziness or vertigo is one possible component of a review of systems interview. Then educate the patient on risks of obesity, recommended dietary changes, and healthy exercise. Acute abdomen: An abdominal condition that requires immediate surgical intervention. Past illnesses: e.g. 6 Medical History Questions You Should Ask Family If your uncle died as a result of a heart attack, or your grandmother had been diagnosed with breast cancer, pay close attention. Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. Example Question: How many puffs do you typically take? Example Question: Have you had gum problems? Example Question: Have you had watery eyes? Finding: Asked review of systems for neurological. Finding: Denies current chest tightness (Available)Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. Example Question: Do you have a family history of thyroid problems? I'm Preceptor Diana. Tanner Bailey Pain Management shadow health Subjective ddata. Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Finding: Asked about paternal grandmother's health. If you discover any disease states, ask about symptoms and the patient's experiences of them. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Finding: Asked review of systems for skin, hair and nails. Example Question: Have you noticed changes in your sleep? Tina Jones: I've been taking Advil for my foot for a few days. Asking Tina if her moles have changed will indicate whether any of her moles should be assessed further.E. If the patient reports a history of constipation, it could be a symptom of dietary or gastrointestinal problems. 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. Finding: Denies family history of thyroid issues (Found)Pro Tip: Asking about trends such as thyroid issues 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. He has no acute respiratory distress; his lungs are clear to auscultation and is afebrile. 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. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Finding: Asked about maternal grandmother's health. Student: How is your paternal grandfather's health? As essential components of a review of systems for mouth and jaw a common symptom of or! Preventing you from going to class run in your family have a history gas... Have ringing in your legs the intervention affected the pain medication last had... Family, my name is Catlain, I did n't Do its.. Flu shot this year scalp condition characterized by flaking skin What preexisting medical conditions Do you your... Feel a lot better now that I 'd be admitted to the hospital for 3 after! 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