Shadow Health Assessment Assignment | Health History Results | Turned In

Health History Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-April-2024
Return to Assignment




Your Results Lab Pass




Overview
Transcript
Transcript
Started: May 05, 2018 | Patient Exam Time: 181 min
Subjective Data Collection
All Lines (233) Interview Questions (204) Statements (14) Exam Actions (15)
Objective Data Collection
Exam Action
Education & Empathy
Height: 170 cm 05/05/18 11:43
AM CDT
Documentation

Information Processing Exam Action
Weight: 90 kg 05/05/18 11:43
Health History Tips and Tricks AM CDT

Self-Reflection
Exam Action
BMI: 31 05/05/18 11:43
AM CDT


Exam Action
Random blood glucose: 238 05/05/18 11:43
AM CDT


Exam Action
Temperature: 101.1 F 05/05/18 11:43
AM CDT


Exam Action
Blood pressure: 142/82 05/05/18 11:43
AM CDT


Exam Action
Respiratory rate: 19 05/05/18 11:43
AM CDT


O2 sat: 99%

, Exam Action
05/05/18 11:43
AM CDT


Exam Action
Heart rate: 86 05/05/18 11:43
AM CDT


Greet
Hello, Tina Jones my name is Sara an FNP student here to
05/05/18 11:43
interview you today. AM CDT



Hey.


Question
What brings you here today? 05/05/18 11:44
AM CDT


I got this scrape on my foot a while ago, and I thought it would
heal up on its own, but now it's looking pretty nasty. And the pain
is killing me!


Question
Where is the pain on your foot? 05/05/18 11:46
AM CDT


It feels like the pain is just centered around the scrape, like around
the ball of my foot. That's where it hurts the most, but my whole
foot feels some pain.


Question
Can you tell me what foot this is please 05/05/18 11:47
AM CDT


It's . . . [Ms. Jones reports the correct year.] [AUDIO COMING
SOON]


Question
Which foot is the pain located? 05/05/18 11:47
AM CDT



My right foot.


Question
How severe is the pain in your right foot? 05/05/18 11:48
AM CDT



It's really bad.

,Can you rate the pain on a scale of 0 to 10. 10 being the worst Question
pain you have ever had in your life 05/05/18 11:48
AM CDT



... I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet.


Question
what are you taking for pain? 05/05/18 11:49
AM CDT



It's called tramadol.


Question
Where did you get this medication? 05/05/18 11:50
AM CDT


The ER doctor prescribed them for me when I was in there a week
ago.


Question
So the pain started a week ago? (Clarified to did your wound have
05/05/18 11:50
pus in it all week.) AM CDT



No, I started seeing it two days ago.


Question
What caused you to have this pain? 05/05/18 11:50
AM CDT


Being around cats is the worst, but dust and running up stairs can
make my breathing bad, too.


Question
Why are you having right foot pain? (No matching questions
05/05/18 11:51
found.) AM CDT


Question
how did your injury happen? 05/05/18 11:51
AM CDT


I was going down the back steps, and I tripped. . . I caught the
railing, but I guess I kind of turned my ankle a little bit. And I
scraped up my foot on the edge of the step.


Question
can you please describe the pain? 05/05/18 11:52
AM CDT


It's throbbing and like, sharp if I try to put weight on it.

, Question
what is the pain like when you stand on your foot? 05/05/18 11:52
AM CDT


Yes! I mean, I literally can't put weight on my foot, the pain is so
sharp.


Question
when did the pain start? 05/05/18 11:52
AM CDT


Well, I got the scrape a week ago, but the scrape and the pain got
a lot worse in the last few days.


Question
Has the pain changed over time? 05/05/18 11:52
AM CDT


At first, it seemed like it was healing up fine and it didn't give me a
lot of pain. But the last two days, the pain got way worse.


Question
Does your pain radiate? 05/05/18 11:53
AM CDT


The pain's worse in my foot, but I feel it moving up into my ankle,
too.


Question
Can you bear weight on your foot? 05/05/18 11:54
AM CDT



No, I can't. I can't put any weight on it without like, shooting pain.


Empathize
I am sorry I understand how you feel. 05/05/18 11:54
AM CDT



I appreciate you telling me that.


Question
Did you injure anything else beside your foot? 05/05/18 11:55
AM CDT