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Exam (elaborations)

Shadow Health Tine Jones Health History Subjective Data

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Shadow Health Tine Jones Health History Subjective Data Shadow Health Assignments for virtual clinical hours

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Adv Hlth Assess/Diagnostic Rea
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Adv Hlth Assess/Diagnostic Rea
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Adv Hlth Assess/Diagnostic Rea

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October 11, 2023
Number of pages
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Written in
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10/11/23, 10:55 AM Shadow Health Tine Jones Health History Subjective Data


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Health History Results | Turned In
Advanced Health Assessment - Summer 2021, NUR 703
Return to Assignment (/assignments/486483/)




Your Results Lab Pass (/assignment_attempts/9873101/lab_pass.pdf)




Overview
Subjective Data Collection: 95 of 100 (95.0%)
Transcript

Subjective Data Collection
Hover To Reveal... Indicates an item that you
Objective Data Collection found.
Hover over the Patient Data items Indicates an item that is
Education & Empathy below to reveal important available to be found.
information, including Pro Tips and
Documentation
Example Questions.

Information Processing

Program Competency Progress
Category Scored Items Patient Data
Health History Tips and Tricks
Not Scored

Self-Reflection Experts selected these topics as essential components A combination of open and closed questions will yield
of a strong, thorough interview with this patient. better patient data. The following details are facts of
Student Survey
the patient's case.



Chief Complaint


Established chief complaint Reports pain
Reports foot wound



History of Present Illness


Asked to rate current pain level on a scale Reports current pain is 7/10



Asked for details about the pain Reports pain is throbbing
Reports pain is sharp when she attempts to
stand
Reports pain has increased in the past 2 days
Reports feeling pain radiating into ankle
Reports pain prevents bearing weight on foot



Asked location of wound Reports right foot is injured
Support
foot
Reports wound is on the planta



Asked details of the injury Reports she scraped foot on a cement step
Reports initial injury occurred 1 week ago
Reports mild ankle injury
Reports being barefoot at the time of injury



Asked about the assessment of the injury at the Reports going to the ER after sustaining the
ER injury
Reports going to the ER because she suspected
an ankle sprain
Reports receiving an X-ray at the ER
Reports X-ray showed no broken bones
Reports receiving a prescription for pain pills

about:blank 1/11

, 10/11/23, 10:55 AM Shadow Health Tine Jones Health History Subjective Data
Asked location of wound Reports right foot is injured
Support
foot
Reports wound is on the planta



Asked details of the injury Reports she scraped foot on a cement step
Reports initial injury occurred 1 week ago
Reports mild ankle injury
Reports being barefoot at the time of injury



Asked about the assessment of the injury at the Reports going to the ER after sustaining the
ER injury
Reports going to the ER because she suspected
an ankle sprain
Reports receiving an X-ray at the ER
Reports X-ray showed no broken bones
Reports receiving 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
Reports noticing pus 2 days ago



Followed up on drainage Reports pus as white or yellow
Denies odor from the wound



Asked about home treatment of foot wound Reports wound care regimen of bandaging
Reports cleaning wound twice a day
Reports cleaning wound with hydrogen peroxide
Reports applying bacitracin, neomycin and
polymyxin B (Neosporin)



Asked about other foot wound symptoms Reports swelling around foot wound
Reports swelling worsened in the past 2 days
Reports redness around the wound
Reports that the wound feels warm



Explored impact of patient's foot injury on Reports pain affects ability to walk
activities of daily living Reports pain affects ability to stand at work for
long periods of time
Reports pain prevented her from being able to
walk to class




Past Medical History


Asked about preexisting medical conditions Reports diabetes
Reports asthma



Followed up on diabetes diagnosis Reports specific age of diagnosis was 24
Reports that her diabetes is Type 2



Asked about diabetes management through Reports staying away from sweets
lifestyle changes Reports drinking diet soda instead of regular



Asked about current diabetes medication use Reports that she does not currently take
medication for diabetes
Asked about past diabetes medication use Reports that she used to take diabetes
medication
Reports previous medication was prescription
metformin
Reports last use of medication was 3 years ago



Asked about blood glucose monitoring Reports infrequent blood glucose monitoring
Reports last glucose check was a week ago at
the ER
Reports confusion about what the numbers
mean



Asked about thirst Reports increased thirst
R i d i k

about:blank 2/11

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