Comprehensive Health History Assignment _ Completed _ Shadow Health Subjective Data | SCORE 101 OUT OF 104 (97.1%)

Comprehensive Health History Assignment Results | Turned In Advanced Health Assessment - Chamberlain - June 2019, NR509-June-2019 Return to Assignment Your Results Lab Pass Subje ctive Data Collection: 101 of 104 (97.1%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Indicates an item that you found. Indicates an item that is available to be found. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint Established chief complaint Reports pain Reports open foot wound History of Present Illness Asked for details about the pain Describes the pain as throbbing Describes the pain as sharp when she attempts to stand Initial injury occurred 1 week ago Pain has increased in the past 2 days Reports feeling pain radiating into ankle Pain prevents bearing weight on foot Asked to rate pain on a scale Rates present pain at a 7 out of 10 Clarified location of wound Confirmed that right foot is injured Confirmed that wound is on the plantar surface of her foot Determined details of the injury Scraped foot on a cement step Reports mild ankle injury Was not drinking at the time of the injury Was not wearing shoes at the time of injury Asked about the assessment of the injury at the ER Went to the ER after sustaining the injury Decided to go because she suspected an ankle sprain Received an x-ray X-ray showed no broken bones Received a prescription for pain pills Asked about drainage from the foot wound Reports that the wound bled a little after sustaining the injury Reports seeing pus draining from wound Began noticing pus 2 days ago Followed up about character of drainage from the foot wound Describes pus as white or yellow in color Reports no odor from the wound Asked about home treatment of foot wound Describes wound care regimen of cleaning and bandaging Cleaned wound twice a day Cleaned wound with hydrogen peroxide Changed bandage twice a day Applied neosporin Asked about other foot wound symptoms Reports swelling around foot wound Noticed swelling getting worse in the past 2 days Reports redness around the wound Reports that the wound feels warm Explored impact of patient's foot injury on activities of daily living Pain affects ability to walk Pain affects job performance Pain prevented her from attending class Asked about recent fever Reports a fever last night Medical History: Medication Asked about use of pain medication Has been taking prescription pain medication Medication is Tramadol Asked about pain medication frequency Has been taking pain medication for 2 days Takes dose 3 times a day Last dose was this morning Asked about pain medication dose Dosage is 50 milligrams Takes 2 pills each time Asked about the efficacy of pain medication Reports that pain pills provide partial relief Pain returns in full every few hours Asked about other prescription medications Uses a prescription inhaler Asked about use of OTC medication Occasionally takes Advil (ibuprofen) for cramps Occasionally takes Tylenol (acetaminophen) for headaches Does not take vitamin supplements Does not take herbal supplements Medical History: Allergies Asked about general allergies Reports allergy to cats Asked follow up on cat allergy reaction Reports sneezing, itchy eyes, and wheezing Asked if the patient is allergic to latex Denies latex allergy Asked if the patient is allergic to any medications Reports a penicillin allergy Asked about penicillin reaction Reports that penicillin resulted in hives in childhood Asked if the patient has any food allergies Denies food allergies Asked if the patient has allergies to dust, mold, or pollen Reports reaction to dust Dust causes sneezing, itchy eyes, and wheezing Denies seasonal allergies Medical History: Immunizations Asked about general immunizations received Reports being "up to date on shots" Asked about childhood immunizations Reports receiving all necessary childhood immunizations Asked if the patient has received a flu vaccine Has not received annual flu vaccine Asked if the patient received a tetanus immunization Last tetanus vaccination was in the past year Medical History: Diabetes Asked details about diabetes diagnosis Diagnosed as an adult Specific age of diagnosis is 24 years old Reports that her diabetes is Type 2 Asked about diabetes management Reports that she tries to manage diabetes with diet Reports "staying away from sweets" Reports drinking diet soda instead of regular Asked about current diabetes medication use Does not currently take medication for diabetes Asked about past diabetes medication use Used to take diabetes medication Previous medication was prescription metformin Last use of medication was 3 years ago Explored the reasons the patient stopped her diabetes regimen it" Reports that she "got sick of dealing with Reports disliking metformin side effects Describes that she didn't like checking sugar and taking daily pills Asked about patient's blood sugar monitoring Does not monitor blood glucose Last glucose check was a week ago at the ER Reports confusion about "what the numbers mean" Asked about increased thirst Reports increased thirst Reports increased water intake Asked about frequency of urination Reports more frequent urination Reports urinating "every hour or so" during the day Reports urinating 2 to 3 times during the night Asked about change in appetite Reports an increase in appetite Reports increase in appetite began a month ago Asked about weight loss Reports recent weight loss Lost 10 lbs Weight loss occurred over the past month Followed up on weight loss by asking if it was intentional Weight loss was not caused by intent or lifestyle changes Medical History: Asthma Asked details about asthma and breathing problems Last breathing problem was 3 days ago Describes asthma symptoms as chest tightness and inability to "take in air" Describes wheezing as an asthma symptom Reports last asthma attack was in high school Asked about prior hospitalizations Reports past hospitalizations Last hospitalization was for asthma Last hospitalization was age 16 Estimates 5 total hospitalizations for asthma as a child and teen Reports that she has never been intubated during a hospitalization Asked about asthma diagnosis Diagnosed with asthma in childhood Specific age of diagnosis is 2.5 years old Asked about asthma inhaler drug Uses an inhaler Inhaler is Proventil (albuterol) Asked about frequency of asthma inhaler use Last use of inhaler was 3 days ago Uses inhaler 2 or 3 times per week Asked about number of puffs when using asthma inhaler Prescribed usage is 2 puffs Sometimes needs more than 2 puffs to control symptoms Asked about asthma triggers Asthma triggered by cats Asthma triggered by dust Asthma triggered by running up stairs Reports no seasonal triggers Medical History: Hypertension Asked about personal history of hypertension Denies past diagnosis of hypertension Reports that last BP reading was 140 over 80 or 90 Does not check BP regularly Last check was a few months ago Is aware of family history of hypertension Is aware of own increased risk Medical History: Gynecological and Sexual History Asked about menstrual frequency and duration Last menstrual period "about 3 weeks ago" Reports irregular periods Reports menstruating every 6 weeks to 2 months Typical period lasts 9 days Asked about menstrual flow Reports heavy periods Reports heavy flow for 4 to 5 days Reports changing tampon every 2 to 3 hours Uses super absorbency tampons Denies any known anemia Asked about menstrual symptoms Reports heavy cramping Reports cramps for the first 2 days of period Asked about treatment of menstrual symptoms Uses a heating pad at home to treat cramps Takes Advil for first 3 days of period Reports that Advil effectively reduces pain from cramps Asked about sexual activity Reports no recent sexual activity Reports past sexual activity Reports that she prefers to sleep with men First sexual activity was at age 18 Last sexual activity was "about 2 years ago" Total number of partners is 3 Asked about contraception Reports no current use of any oral or hormonal birth control Reports past use of oral contraception Last took oral contraception "a couple of years" ago Describes the reasons why she stopped use: "didn't see the point" while single Asked about condom use Reports past condom use Reports past sexual encounters without condoms Reports oral contraceptive use while sexually active Asked about STI testing Last STI testing was 4 years ago Reports no known STI symptoms Expresses a gap in knowledge of STI symptoms and prevention Expresses uncertainty about past partners and STI testing Asked about history of pap smears Last pap smear was 4 years ago Reports no abnormal pap smears Asked about history of pregnancy Reports that she is not currently pregnant Reports no previous pregnancies Social History: Daily Life Asked about patient's level of education Currently working toward undergraduate degree Asked what subject the patient is studying in college Majoring in accounting Discussed the patient's stress level Reports stress related to injury, missing work and school, and cost of care Asked about patient's living situation Lives at home with mother and sister Reports that family members will be able to help with activities Social History: Diet and Nutrition Asked about food intake Last meal was dinner time the previous night Last meal consisted of baked chicken and mashed potatoes Breakfast is usually a muffin or pumpkin bread Lunch is usually a sandwich Dinner is usually a home-cooked meat dish and side of vegetables Snacks are pretzels or French fries Asked about salt intake Is uncertain about salt intake, describes "not adding a lot of salt to my food" Asked about caffeine intake Does not drink coffee Reports habitual diet soda drinking Drinks up to 4 diet sodas per day Social History: Substance Use Asked about illicit drug use Reports past history of marijuana smoking Followed up on patient's marijuana use Last use was at age 20 or 21 Stopped because of health reasons and lost interest Asked about the quantity of alcoholic drinks consumed Last alcoholic drink was 3 weeks ago Reports no more than 2 or 3 alcoholic drinks in one sitting Reports no more than 1 or 2 nights a week drinking alcohol Reports no more than 6 to 10 alcoholic drinks per month Asked about tobacco use Denies smoking tobacco Asked about secondhand smoke Denies exposure to secondhand smoke Review of Systems Asked about general symptoms Denies recent or frequent illnesses Reports occasional tiredness or fatigue Reports some recent fever-related chills Denies night sweats Describes typical sleep patterns Asked about review of systems for mental health Denies history of depression Denies history of suicidal ideation or attempts Denies past diagnosis of mental health conditions Asked about review of systems for head Reports occasional headaches Denies current headache Denies head injury Asked about review of systems for ears Denies general ear problems Denies change in hearing Denies ear pain Denies ear discharge Denies ringing or tinnitus Asked about review of systems for eyes and vision Denies double vision Reports changes in vision Denies eye pain Reports infrequent itchy eyes Denies eye redness Denies dry eyes Denies discharge, crusting or wateriness Does not have corrective lenses Reports last eye exam was in childhood Reports occasional blurry vision Asked about review of systems for nose Reports infrequent nose problems Denies change in sense of smell Reports occasional sneezing around cats and dust Denies nosebleeds Denies frequent sinus problems Reports infrequent runny nose Asked about review of systems for mouth and jaw Reports last dental visit was several years ago Denies general mouth problems Denies change in sense of taste Denies dry mouth Denies mouth pain Denies mouth sores Denies gum problems Denies tongue problems Denies jaw problems Reports no known dental problems Asked about review of systems for neck, throat and glands Denies difficulty swallowing Denies sore throat Denies history of frequent throat problems Denies voice changes Denies general neck problems Denies history of lymph node problems Denies swollen glands Asked about review of systems for respiratory Denies current breathing problems Denies current wheezing Denies current chest tightness Denies pain while breathing Denies coughing Asked about review of systems for cardiovascular Denies chest pain or discomfort Denies palpitations Denies irregular heartbeat Denies easy bruising Reports no edema (other than foot swelling due to infection) Denies circulation problems Denies vascular diseases (varicose veins, peripheral vascular disease) Asked review of systems for gastrointestinal Denies nausea Denies vomiting Denies stomach pain Denies heartburn, GERD, or indigestion Denies constipation Denies changes in bowel movements Denies diarrhea or loose stool Denies flatulence or bloating Denies bloody or tarry stool Asked review of systems for genitourinary Denies dysuria Reports nocturia Reports polyuria Denies hematuria Denies flank pain Denies incontinence Denies history of urinary tract or bladder infection Reports normal vaginal discharge Asked review of systems for breasts Denies general breast problems Denies breast lumps Denies breast pain Denies nipple changes Denies nipple discharge Reports no past mammograms Reports doing self-breast exams Asked review of systems for musculoskeletal Denies muscle pain Denies joint pain Denies muscle weakness Denies joint swelling Denies back pain Denies history of fractures or breaks Asked review of systems for neurological Denies dizziness, lightheadedness, or vertigo Denies vision disturbances Denies numbness or tingling Denies loss of coordination Denies loss of sensation Denies past history of seizures Denies problems with balance or disequilibrium Denies memory loss Denies recent loss of consciousness or fainting Asked review of systems for skin, hair and nails Reports rarely using sunscreen Reports acne Reports changes to neck skin Reports excessive facial or body hair Reports moles Reports no body sores (aside from foot wound) Denies dandruff Denies nail abnormalities Reports occasional dry skin Denies rashes Family History: 3 Generations Asked about mother's health Mother diagnosed with hypertension Mother diagnosed with high cholesterol Asked about father's health Father diagnosed with Type 2 diabetes Father diagnosed with hypertension Father diagnosed with high cholesterol Followed up to ask about coping after father's death Reports grief at the time but feeling "at peace" with it now Asked father's age at death Died at age 58 Asked cause of father's death Cause of death: car accident Asked about paternal grandfather's health Paternal grandfather diagnosed with Type 2 diabetes Paternal grandfather diagnosed with hypertension Paternal grandfather diagnosed with high cholesterol Asked about paternal grandmother's health Paternal grandmother diagnosed with hypertension Paternal grandmother diagnosed with high cholesterol Asked about maternal grandfather's health Maternal grandfather diagnosed with hypertension Maternal grandfather diagnosed with high cholesterol Asked about maternal grandmother's health Maternal grandmother diagnosed with hypertension Maternal grandmother diagnosed with high cholesterol Asked about brother's health Reports no diagnosed health problems Asked about sister's health Sister diagnosed with asthma © Shadow Health® Show Less