NR 509 Shadow Health Focused Exam Case : Comprehensive Transcript : Chamberlain College Of Nursing

6/12/2019 Comprehensive Assessment | Completed | Shadow Health


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Advanced Health Assessment - Chamberlain, NR509-April-2019
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Overview
Transcrip
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Transcript
Started: Jun 10, 2019 | Patient Exam Time: 448 min
Subjective Data
All Lines Interview Questions Statements Exam Actions
(734) (256) (33) (445)
Collection Objective Data

Collection Documentation Greet
Hello my name is Sara and FNP student I will be conducting your
06/10/19 3:17 PM
interview today
Plan My Exam CDT

Self-Reflection
Hey.


Question
What is your name 06/10/19 3:17 PM
CDT



Tina Jones.


Question
Your date of birth? 06/10/19 3:17 PM
CDT



February 17th.


Question
And how old are you? 06/10/19 3:18 PM
CDT



I'm 28.




https://chamberlain.shadowhealth.com/assignment_attempts/3569767 1/36

, What brought you into the clinic today?
Question
06/10/19 3:23 PM
CDT

I came in because I'm required to have a recent physical exam for the health insurance at my new job.



Question
Do you have any current health problems?
06/10/19 3:23 PM
CDT

I don't have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I'm taking good care of my health



Question
Where is your new job? (Clarified to what is your new job.)
06/10/19 3:26 PM
CDT

Smith, Stevens, Stewart, Silver & Company. I'll be helping a more experienced accountant with her clients, and then eventually I'll get more responsibility, and build



Empathize
That is great that you are excited
06/10/19 3:27 PM
CDT


Thanks.



Question
When was your last physical?
06/10/19 3:28 PM
CDT

doctor's appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks la



Question
And what did your kind of gynecologist say?
06/10/19 3:28 PM
CDT

She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be he



How much birth control are you taking? (Clarified to How often do you take birth control.) Question
06/10/19 3:29 PM
CDT

, I take it every morning, with breakfast.



What is the name of your birth control? (Clarified to what was the name of the birth control pill you took.) Question
06/10/19 3:29 PM
CDT


They're called Yaz.



Question
Has your menstrual cycle improved since TAKING YAZ?
06/10/19 3:30 PM
CDT


Now that I'm on the pill I'm getting my period every month.



That's great I am really glad that you are having your period every month Empathize
06/10/19 3:32 PM
CDT


Thanks.



Question
How long have you had asthma?
06/10/19 3:32 PM
CDT


I've had asthma a long time. . . since I was really little.



Question
What age were you diagnosed with asthma?
06/10/19 3:32 PM
CDT

My doctor told me when I was pretty little... I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.



Empathize
That sounds frightening
06/10/19 3:33 PM
CDT


Thanks.



Question
How do you manage your asthma?
06/10/19 3:33 PM
CDT

I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

, What are your triggers for asthma?
Question
06/10/19 3:33 PM
CDT

Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven't had a full asthma attack in years, though



Question
What happens when you're around DUST?
06/10/19 3:34 PM
CDT

I used to have a reaction when I was in a dusty house for a long time.
. . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn't happened since I got my daily inhaler.


Question
What daily inhaler do you use?
06/10/19 3:34 PM
CDT


It's Flovent.



How much fLOVENT do you use a day (No matching questions found.) Question
06/10/19 3:34 PM
CDT


Question
How much flovent do you use? (No matching questions found.)
06/10/19 3:35 PM
CDT


Question
How often do you use flovent?
06/10/19 3:35 PM
CDT

Twice a day. [Nurse confirmed: fluticasone propionate 88 mcg b.i.d./spray MDI]



Question
When was your last dose of flovent?
06/10/19 3:37 PM
CDT

Probably. . . well, not for my last period. Maybe for the one before? So six weeks ago?



when you last use flovent? (Clarified to when did you last use your inhaler.) Question
06/10/19 3:38 PM
CDT