Tina Comprehensive Assessment Shadow Health Subjective Questions| score 50 of 50 (100.0%)

1/29/2020 Blackboard Learn


Subjective Data Collection: 50 of 50 (100.0%)

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below to reveal important th
information, including Pro
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Categ Scored Items Patient Data hoso
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ory Experts selected these topics as essential components A combination of open and closed questions will yield
cial
of a strong, thorough interview with this patient. better patient data. The following details are facts of the Hist
patient's case.
ory
Confirmed reason for visit Reports needing a pre-employment physical
Reports no current acute health problems Soci
al
Asked about last visit to a healthcare provider Last visit to a healthcare provider was 4 months
ago
Dete
Reason for last visit was annual gynecological rmin
exam
Last general physical examination was 5 months ants
ago when she was prescribed metformin and daily
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Asked about current prescription medications Reports taking diabetes medication th
Reports using a daily inhaler
Reports taking prescription birth control pills
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Followed up about diabetes medication Medication is metformin al
Started taking metformin 5 months ago
Reports that eating probiotic yogurt helps with side
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effects and they have abated over time
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Followed up on metformin frequency and dose Reports taking metformin twice daily
Metformin dose is 850 mg Revi
ew
Asked about asthma medication Reports using Flovent inhaler twice daily of
Has a Proventil rescue inhaler
Last use of Proventil inhaler was three months ago Syst
Has used Proventil inhaler twice in the last year ems
Followed up about birth control prescription Started taking birth control 4 months ago
Reason for birth control was to manage PCOS
symptoms
Birth control type is Yaz (drospirenone and ethinyl
estradiol)
Takes birth control pill daily
Takes birth control pill at the same time every day
Reports no skipped days


Asked about current non-prescription Reports rare Advil use for cramps
medications Reports no OTC herbal products
Reports no OTC vitamins
Reports no OTC supplements

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, 1/29/2020 Blackboard Learn
Asked about allergies Confirms allergies
Reports no new allergies


Followed up on seasonal allergies Reports no recent seasonal allergy symptoms
Reports no current medication for allergies


Asked about diabetes Reports managing diabetes with diet and exercise
in addition to medication


Asked about blood glucose monitoring Reports checking blood sugar once a day
Checks sugar in the morning
Blood sugar number is usually around 90
Reports having adequate supplies


Asked about asthma symptoms Reports no current asthma symptoms
Reports no recent asthma exacerbations
Reports last asthma exacerbation was three
months ago


Asked about headache symptoms Reports no recent headache


Asked about vision Reports optometrist visit
Optometrist visit 3 months ago
Reports prescription eyeglasses
Reports that glasses improve overall vision
Reports reduction in blurry vision


Asked about palpitations Reports no current palpitations
Reports no recent palpitations


Asked about hypertension treatment Reports that blood pressure responded to diet and
exercise changes


Asked about GERD Reports no recent GERD symptoms
Reports no current GERD symptoms
Reports no current medication for GERD


Asked about back pain Reports no current back pain
Reports no recent back pain


Asked date of last menstrual period Last menstrual period was 2 weeks ago


Asked about menstrual patterns Reports a period every 4 weeks
Reports that period lasts 5 days
Reports some cramping
Reports a medium flow


Asked about weight changes Reports recent weight loss
Reports weight loss of about 10 pounds
Reports that weight loss was result of change in
diet and increased exercise


Asked about diet Typical breakfast is fruit smoothie with probiotic
yogurt or egg on wheat toast with probiotic yogurt
Typical lunch is dinner leftovers or tuna or chicken
sandwich on wheat bread
Typical dinner is vegetables with a protein and
brown rice or quinoa
Typical snack is carrot sticks or an apple


Asked about caffeine intake Reports limiting caffeine since heart and sleep
This study source was downloaded by 100000832411349 from CourseHero.com on 10-20-2022 problems
01:39:53 GMT -05:00

https://class.waldenu.edu/webapps/blackboard/content/contentWrapper.jsp?course_id=_16633159_1&displayName=Shadow+Health+NURS6512&hr… 2/5
https://www.coursehero.com/file/54061240/Tina-Comprehensive-Assessment-Shadow-Health-Subjective-Questionspdf/