NR 509 Comprehensive Health History

NR 509 Comprehensive Health History Assignment Completed Shadow Health Subjective Data. Comprehensive Health History Assignment Results | Turned In Advanced Health Assessment - Chamberlain - June 2019, NR509-June-2019 Return to Assignment Your Results Lab Pass Subjective 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