Week 4 – Assignment 2 – Tina Jones Health Assessment

Week 4 – Assignment 2 – Tina Jones Health Assessment
Name:

Section:

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

Neck:

Breasts:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

Neurological:

Skin:

Hematologic:

Endocrine:

© 2021 Walden University Page 1 of 1

© 20

21

Walden University

Page

1

of

2

Name:

Section:

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA:

Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness

(HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (

Include history of parents,

maternal/p

aternal

Grandparents, siblings,

and children):

Review of Systems:

From head

to

toe, include each system that covers the Chief Complaint,

History of Present Illness, and History).

Remember that the information you include in this

section is based on what t

he patient tells you. To ensure that you include all essentials in your

case, refer to Chapter 2 of the Sullivan text.

General:

Include any recent weight changes, weakness, fatigue, or fever, but

do not

restate HPI data here

.

HEENT:

Neck:

© 2021 Walden University Page 1 of 2

Name:

Section:

Week 4

Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Immunization History:

Health Maintenance:

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings,

and children):

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,

History of Present Illness, and History). Remember that the information you include in this

section is based on what the patient tells you. To ensure that you include all essentials in your

case, refer to Chapter 2 of the Sullivan text.

General: Include any recent weight changes, weakness, fatigue, or fever, but do not

restate HPI data here.

HEENT:

Neck:

Assignment 2: Digital Clinical Experience (DCE): Health History Assessment

In Week 3, you began your DCE: Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool, Shadow Health and finalize for submission.

To Prepare

· Review Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment. (See attachment)

· Review the DCE (Shadow Health) Documentation Template for Health History (Attached)

· Use the template (Attached) to complete your Documentation Notes for this DCE Assignment.

Assignment Instructions :

Complete the Health History of Tina Jones (see below information and attached transcript “Tina Jones Transcript”) – To complete the assignment, please use the attached template.

Identifying Data & Reliability

Ms. Jones who is 28 yrs. old, obese African American single woman who presents to establish care and with a right foot injury.

She is the primary source of the history. Without contradiction, she freely provides specific details of her injury and of her visit. Her speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Patient is 28 yr. Old single African American, alert, awake, and oriented x 3. She is pleasant; her speech is clear and coherent. Appears healthy, well-developed and well nourished. obese.

VS obtained BP 142/82, HR 86, RR 19, T 101.1, SPO2 99%, blood sugar 235. Weighs 90kg and BMI is 31.

Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.

Chief Complaint

“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!”

Symptoms: Right foot pain accompanied by drainage. Pain affects ability to walk or put weight on it. Also, affects sleep. Pain 7 out of 10.

Diagnosis: infected right foot wound.

History Of Present Illness

Tina fell going down the back steps of her house. Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot and scraped the sole of her right foot. Her wound bled and she was able to stop the bleeding. She cleaned the wound and went to the ER fearing that she sprained her ankle. ER X-rayed her foot and reported no fracture seen. They gave her a prescription for a 5-day supply of Tramadol 50 mg. She cleaned her wound twice daily with soap and water or hydrogen peroxide, let it dry, and then she has been applying antibiotic on the scrape and covered with a dressing. The wound wasn’t getting worse, but it wasn’t getting any better. Two days ago, she noticed pus was in the wound, and that there was swelling and redness and a warm feeling in her foot. She had a fever last night and didn’t take any medication for it.

She said tramadol doesn’t seem to work too well.

She reports that ankle swelling, and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 7 out of 10

after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night.

She denies recent illness.

Reports a 10- pound, unintentional weight loss over the month and increased appetite. Denies change in diet or level of activity.

Medications

Tylenol 500-1000 mg PO prn (DX: headaches),

Tramadaol 50 mg PO – 2 tabs PO TID (ED dispensed 30 pills) (DX: R foot pain),

Ibuprofen 600 mg PO TID (DX: menstrual cramps)

Albuterol 90 mcg/spray MDI- 2 puffs Q4H prn (DX: wheezing); last time pt used was a month ago)

Acetaminophen 500-1000 mg PO prn (headaches)

Allergies

· Penicillin (rash)

· Allergic to cats and dust (sneezing, itchy eyes; asthma acts up);

denies food and latex allergies

· When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.

Medical History

· Diagnosed with Type 2 diabetes at age 24, but is not taking any medication for diabetes and does not monitor blood sugar She previously took metformin, but she stopped three years ago, stating that the pills made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn’t monitor her blood sugar. Last blood glucose was elevated last week in the emergency room.

· Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats and dust.

She uses her inhaler 2 to 3 times per week. She was exposed to cats three days ago and had to use her inhaler once with positive relief of symptoms. She was last hospitalized for asthma “in high school”. Never intubated.

· Has irregular menstrual cycles with heavy menstrual flow and painful cramping (6 menstrual cycles/ year);

· Recent 10 pounds weight loss (not knowing how);

· Increased thirst and frequent urination.

· Sometimes has headaches.

· Vaccination is current, except for flu

· No surgeries.

· OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs four years ago.

· Hematologic: Denies bleeding, bruising, blood transfusions and history of blood clots.

· Skin: Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes.

Health Maintenance

· Recommend to have annual check-up with OBGYN and to keep a log of menstrual cycle.

· Take blood pressure and pulse reading twice daily and keep a log of it.

· Continue to eat a daily balanced meal three times a day.

· Clean right foot wound with normal saline and cover with dry sterile dressing daily and change as needed.

· Return to clinic within a week to assess on wound and to see if an antibiotic is needed.

· Last Pap smear 4 years ago. Last eye exam in childhood.

· Last dental exam “a few years ago.”

· PPD (negative) ~2 years ago.

· No exercise.

· 24- hour Diet Recall: States that she skipped breakfast

yesterday, and would typically have a baked good for breakfast, a sandwich for lunch, and a meatloaf or chicken for dinner. Her snacks consist of pretzels or French fries.

· Immunizations: Tetanus booster was received within the past year,

influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine in college.

· Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike, Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.

Family History

· Father deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes

· Mother age 50, has high cholesterol and blood pressure, denies diabetes, occasionally drinks alcohol.

· Brother (Michael, 25): overweight

· Sister (Britney, 14): asthma but is controlled.

· Close-knit family of mother, sister, and brother.

· Both sets of grandparents have high blood pressure.

· Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol

· Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol

· Paternal grandmother: still living, age 82, hypertension

· Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes

· Paternal uncle: alcoholism

· Negative for mental illness, kidney disease, sickle cell anemia, thyroid problems

Social History

· Eats a balanced diet of carbs, protein, and fat;

· She drinks 4 caffeinated drinks per day (diet coke).

· Denied nicotine and tobacco use.

· Alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode.

· She has a good support system with her close-knit family of mother, sister, and brother.

· Never married, no children.

· Lived independently since age 20, currently lives with mother and sister

in a single-family home to support family after death of father one year ago.

· Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift supervisor.

· She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company.

· She has a car, cell phone, and computer.

· She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs.

· She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system.

· She reports stressors relating to the death of her father and balancing work and school demands, and finances. She states that family and church help her cope with stress.

· Occasional cannabis uses from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin.

· No foreign travel.

· No pets.

· Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago.

· She plans on getting married and having children someday.

Objective

Right foot wound measures 2 cm x 1.5 cm x 2.5 cm, drainage/pus present.

VS obtained BP 142/82, HR 86, T 101.1, RR 86.

Right foot wound with evidence of infection. Wound: 2 cm x 1.5 cm, 2.5 mm deep wound, red wound edges, right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema.

Assignment 2: Digital Clinical Experience

(DCE): Health History Assessment

In Week 3, you began your DCE: Health History Assessment. For this week, you will

complete this Health History Assessment in your simulation tool

, Shadow Health and

finalize for submission.

To Prepare

·

Review

Student Checklist: Health History Guide and the History Subjective Data

Checklist, provided in this week’s Learning Resources, to guide you through the

necessary components of the assessment.

(See

attac

hment)

·

R

eview the DCE (Shadow Health) Documentation Template for Health

History

(

Attached

)

·

U

se

the

t

emplate

(

Attached)

to

complete your Documentation Notes for this DCE

Assignment.

Assignment

Instructions

:

Complete the

Health History of Tina Jones

(

see

below

information a

nd attached

transcript

Tina Jones Tr

anscript

”)

To

complete

the

assignment

, please use the

attached

template.

Identifying Data & Reliability

Ms. Jones who is 28 yrs. old, obese African

American single woman who presents to

establish

care and with

a right foot injury.

She is the primary

source

of the history. Without

contradiction

, she freely

provides

specific details of her injury and of her

visit. Her

s

peech is clear and coherent. She

maintains eye

contact throughout the interview.

General Survey

Patient is 28

yr. Old

single African

American,

alert,

awake, and oriented x 3. She is

pleasant; her

speech is clear and coherent. Appears healthy,

well

developed

and well

nourished. obese.

VS

obtained BP 142/

82, HR 86, RR 19, T 101.1,

SPO2 99%, blood sugar 235. Weighs

90kg and

BMI is 31.

Ms. Jones is alert and oriented, seated upright on

the examination table, and is in no

apparent

distress. She is well

nourished, well

developed,

and dressed appropriately

with

good hygiene.

Assignment 2: Digital Clinical Experience

(DCE): Health History Assessment

In Week 3, you began your DCE: Health History Assessment. For this week, you will

complete this Health History Assessment in your simulation tool, Shadow Health and

finalize for submission.

To Prepare

 Review Student Checklist: Health History Guide and the History Subjective Data

Checklist, provided in this week’s Learning Resources, to guide you through the

necessary components of the assessment. (See attachment)

 Review the DCE (Shadow Health) Documentation Template for Health History

(Attached)

 Use the template (Attached) to complete your Documentation Notes for this DCE

Assignment.

Assignment Instructions:

Complete the Health History of Tina Jones (see below information and attached

transcript “Tina Jones Transcript”) – To complete the assignment, please use the

attached template.

Identifying Data & Reliability

Ms. Jones who is 28 yrs. old, obese African American single woman who presents to

establish care and with a right foot injury.

She is the primary source of the history. Without contradiction, she freely provides

specific details of her injury and of her visit. Her speech is clear and coherent. She

maintains eye contact throughout the interview.

General Survey

Patient is 28 yr. Old single African American, alert, awake, and oriented x 3. She is

pleasant; her speech is clear and coherent. Appears healthy, well-developed and well

nourished. obese.

VS obtained BP 142/82, HR 86, RR 19, T 101.1, SPO2 99%, blood sugar 235. Weighs

90kg and BMI is 31.

Ms. Jones is alert and oriented, seated upright on the examination table, and is in no

apparent distress. She is well-nourished, well-developed, and dressed appropriately

with good hygiene.

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