Tina Jones Comprehensive Assessment/Comprehensive Assessment Tina Jones Shadow Health Tran, Exams of Nursing

Download Tina Jones Comprehensive Assessment/Comprehensive Assessment Tina Jones Shadow Health Tran and more Exams Nursing in PDF only on Docsity! Tina Jones Comprehensive Assessment/Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentatio Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Transcript All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394) Greet Hello, my name is Tammy. I will be conducting an interview and a physical exam. Hey. What is your name? Tina Jones. What is your date of birth? February 17th. How old are you? I’m 28. 07/22/20 5:37 PM EDT Question 07/22/20 5:37 PM EDT Question 07/22/20 5:37 PM EDT Question 07/22/20 5:43 PM EDT That is great. I am glad you are having your period every month. Thanks. How long have you had asthma? I’ve had asthma a long time. . . since I was really little. What age were you diagnosed with asthma? 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. I am sorry about the experience. Thanks. How do you manage your asthma? Empathize 07/22/20 5:50 PM EDT Question 07/22/20 5:51 PM EDT Question 07/22/20 5:51 PM EDT Empathize 07/22/20 5:52 PM EDT Question 07/22/20 5:52 PM EDT 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? 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. It is important to stay away from triggers. Thanks for telling me. What happens when you are around dust? 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. What inhaler do you use? The daily inhaler is Flovent, and the rescue inhaler is Proventil. Question 07/22/20 5:53 PM EDT Educate 07/22/20 5:54 PM EDT Question 07/22/20 5:54 PM EDT Question 07/22/20 5:59 PM EDT How often do you use Flovent? Twice a day. When did you most recently use the Flovent inhaler? I use my Flovent inhaler two times a day. When did you last use your inhaler? I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too. Question 07/22/20 6:00 PM EDT Question 07/22/20 6:01 PM EDT Question 07/22/20 6:03 PM EDT How much Albuterol do you use? Question 07 I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church. What is your relationship like with your family? Question 07/22/20 7:39 PM EDT I’m sleeping a lot better now, which is a relief. Good to hear. Thanks. How many hours are you sleeping a night? I’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night. That is great. Thanks. Have you ever smoked tobacco? No. I think it’s gross. Empathize 07/22/20 7:42 PM EDT Question 07/22/20 7:42 PM EDT Empathize 07/22/20 7:42 PM EDT Question 07/22/20 7:43 PM EDT Question Have you ever used cocaine? No way, I have no interest in that. That stuff can mess you up. Have you ever used heroin? Uh, no. Have you ever used illegal drugs? Well, I used to smoke pot. . . but I don’t do that anymore. What was the last time you smoked pot? I haven’t smoked pot since I was twenty or twenty-one. Do you have any family history of mental illness? 07/22/20 7:43 PM EDT Question 07/22/20 7:49 PM EDT Question 07/23/20 3:17 PM EDT Question 07/23/20 3:17 PM EDT Question 07/23/20 3:18 PM EDT No. They’re crazy, but nobody’s diagnosed with anything. Have you had suicidal thoughts? No, I’ve never done that. Any new family medical history report? My mom has some issues, and I think some of my grandparents did, too. How old is your mom? Mom is 50. What medical problems does your mum have? Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. Question 07/23/20 3:19 PM EDT Question 07/23/20 3:20 PM EDT Question 07/23/20 3:21 PM EDT Question 07/23/20 3:21 PM EDT Any fever? I haven’t had a fever. Any chills? Nope, no chills. Any acne? I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything special. But my zits have gotten better, and I think it’s because I’m on birth control now. Has your body hair improved? I think I have a little less body hair than I used to. Do your eyes feel itchy? Question 07/23/20 3:32 PM EDT Question 07/23/20 3:32 PM EDT Question 07/23/20 3:32 PM EDT Question 07/23/20 3:32 PM EDT Question 07/23/20 3:33 PM EDT They haven’t been itchy lately at all. Are you having any redness in your eyes? My eyes haven’t been red lately. . . not since I came in with those allergies a while ago. Are your eyes dry? My eyes don’t feel dry. Do you have any pain in your eyes? I haven’t had any eye problems lately–I went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good. Are you having any ear problems? My ears feel fine. Any changes in your hearing? Question 07/23/20 3:33 PM EDT Question 07/23/20 3:34 PM EDT Question 07/23/20 3:34 PM EDT Question 07/23/20 3:34 PM EDT Question 07/23/20 3:36 PM EDT My hearing is good. Any ear pain? My ears feel fine. Ear drainage? (Clarified to Do you have drainage from your ears?.) Nothing is coming out of my ears. (Clarified to if I have ear drainage.) Any changes in your sense of smell? No. Any nose bleeds? Nope, my nose isn’t bleeding at all. Any sinus pressures? Question 07/23/20 3:36 PM EDT Question 07/23/20 3:36 PM EDT Question 07/23/20 3:46 PM EDT Question 07/23/20 3:47 PM EDT Question 07/23/20 3:47 PM EDT My voice has been fine. Any swollen lymph nodes? My lymph nodes seem fine. Are you having any nausea? No, I haven’t been nauseous at all. Any vomiting? No. ANY pain in the abdomen? I haven’t really had any stomach problems since I came in with them a while ago. Question 07/23/20 3:52 PM EDT Question 07/23/20 3:52 PM EDT Question 07/23/20 3:53 PM EDT Question 07/23/20 3:53 PM EDT Question Any constipation? I don’t have that problem. Any diarrhea? I haven’t had any problems with diarrhea. Excessive flatulence? I haven’t been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. flatulence is one of the side effect of metformin Thanks for telling me. Any food intolerance I can eat just about anything. 07/23/20 3:53 PM EDT Question 07/23/20 3:54 PM EDT Question 07/23/20 3:54 PM EDT Educate 07/23/20 3:55 PM EDT Question 07/23/20 3:56 PM EDT Question Any burning sensation when you urinate? No, it doesn’t burn when I pee. Any blood in your urine? No! That doesn’t sound like it would be good. Are you having any pain right now? I don’t have any pain anywhere. Any vaginal discharge? My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish. Any vaginal itching? 07/23/20 3:56 PM EDT Question 07/23/20 3:57 PM EDT Question 07/23/20 3:57 PM EDT Question 07/23/20 3:58 PM EDT Question 07/23/20 3:58 PM EDT I think my memory has been fine. Any muscle pain? My muscles have felt great, especially since I started exercising more. Joint pain? My joints always seem fine. Any muscle weakness? No, I haven’t felt weak at all. Any swelling? Nothing is swollen. Question 07/23/20 4:01 PM EDT Question 07/23/20 4:02 PM EDT Question 07/23/20 4:02 PM EDT Question 07/23/20 4:03 PM EDT Performed pulse oximetry Performed spirometry Inspected scalp Inspected scalp Inspected hair on scalp Inspected scalp Inspected right eyebrow and orbital area Inspected left eyebrow and orbital area Inspected mouth: Oral mucosa moist. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Exam Action 07/24/20 10:01 AM EDT Exam Action 07/24/20 10:01 AM EDT Exam Action 07/24/20 10:01 AM EDT Exam Action 07/24/20 10:01 AM EDT Exam Action 07/24/20 10:01 AM EDT Exam Action 07/24/20 10:01 AM EDT Exam Action 07/24/20 10:02 AM EDT Exam Action 07/24/20 10:02 AM EDT Exam Action 07/24/20 10:02 AM EDT Subjective Data Collection: 50 of 50 (100.0%) Hover To Reveal… Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions. • Found: Indicates an item that you found. • Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Current Health Status Finding: Confirmed reason for visit Finding: Reports needing a pre-employment physical Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Example Question: Can I confirm that you are here for a physical? Finding: Reports no current acute health problems Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Example Question: Do you have any current health problems? Finding: Asked about last visit to a healthcare provider Finding: Last visit to a healthcare provider was 4 months ago Finding: Has a Proventil rescue inhaler Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. Example Question: Do you have a rescue inhaler? Finding: Last use of Proventil inhaler was three months ago Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Example Question: When did you last use your rescue inhaler? Finding: Has used Proventil inhaler twice in the last year Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation. Example Question: How often do you use your rescue inhaler? Finding: Followed up about birth control prescription Finding: Started taking birth control 4 months ago Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Example Question: How long ago did you start taking birth control? Finding: Reason for birth control was to manage PCOS symptoms Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Example Question: Why did you decide to start taking birth control? Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Example Question: What type of birth control do you use? Finding: Takes birth control pill daily Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: How often do you take your birth control pill? Finding: Takes birth control pill at the same time every day Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: Do you take your pill at the same time every day? Finding: Reports no skipped days Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: Have you missed any days of your birth control pill? Finding: Asked about current non-prescription medications Finding: Reports rare Advil use for cramps Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan. Example Question: Do you take Advil? Finding: Reports no OTC herbal products Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan. Example Question: Do you use any herbal products? Finding: Reports no OTC vitamins Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan. Example Question: Do you take any vitamins? Finding: Reports no OTC supplements Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan. Example Question: Do you take any supplements? Finding: Asked about allergies Finding: Confirms allergies Pro Tip: Discerning what is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina’s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina’s health literacy. Example Question: Can you confirm your allergies? Finding: Reports no new allergies Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing. Example Question: Have you noticed any new allergies? Finding: Followed up on seasonal allergies Finding: Reports no recent seasonal allergy symptoms Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing. Example Question: Have you been having seasonal allergies? Finding: Reports no current medication for allergies Pro Tip: Tina’s response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: Are you taking any medication for your allergies? Finding: Asked about diabetes Finding: Reports managing diabetes with diet and exercise in addition to medication Finding: No masses Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses. Finding: Palpated sinuses Finding: No frontal sinus tenderness Pro Tip: Palpating the frontal sinuses checks for sinusitis. Finding: No maxillary sinus tenderness Pro Tip: Palpating the maxillary sinuses checks for sinusitis. Finding: Palpated jaw Finding: No clicks, full ROM Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Finding: Palpated lymph nodes Finding: No axillary lymphadenopathy Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Finding: No supraclavicular lymphadenopathy Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Palpated thyroid Finding: Thyroid smooth without nodules, no goiter Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder. Finding: Inspected eyelids and conjunctiva Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Finding: Left fundus with sharp disc margins, no hemorrhages Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition. Finding: Tested PERRL with penlight Finding: Right pupil: equal, round, reactive to light Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Finding: Left pupil: equal, round, reactive to light Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems. Finding: Tested eye movements Finding: Normal convergence Pro Tip: This test accommodation assesses the eye’s ability to focus on close objects. Finding: EOMs intact bilaterally, no nystagmus Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions. Finding: Tested peripheral vision Finding: Peripheral vision intact in both eyes, all fields Finding: Inspected interior eyes with ophthalmoscope Finding: Mild retinopathic changes on right Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. By visualizing the fundus, you can look for any retinopathic changes. Finding: Palpated abdomen – deep Finding: Right upper quadrant: no masses, guarding or rebound Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Finding: Right lower quadrant: no masses, guarding or rebound Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Left upper quadrant: no masses, guarding or rebound Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Finding: Left lower quadrant: no masses, guarding or rebound Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Finding: Palpated organs Finding: Liver: palpable 1 cm below right costal margin Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems. Finding: Spleen: not palpable Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions. Finding: Right kidney: not palpable, no masses Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness. Finding: Left kidney: not palpable, no masses Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness. Musculoskeletal Finding: Inspected neck Finding: Neck without swelling, masses, or deformity Pro Tip: The inspection of your patient’s unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall. Finding: Left foot without swelling, masses, or deformity Pro Tip: Your patient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy. Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Finding: Tested ROM for upper extremities Finding: Right and left shoulders: full ROM Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides. Finding: Right and left elbows: full ROM Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides. Finding: Right and left wrists: full ROM Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides. Finding: Tested ROM for spine Finding: Rotate left: full ROM Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides. Finding: Rotate right: full ROM Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides. Finding: Extension: full ROM Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Finding: Flexion: full ROM Documentation / Electronic Health Record Vitals Student Documentation Model Documentation 128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs Health History • Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F Student Documentation Model Documentation Identifying Data & Reliability The patient is a 28-year-old female who presented for a pre-employment physical exam. She provided the health information freely during the interview. Ms. Jones’ speech is clear and coherent General Survey Ms. Jones appears alert and oriented She is Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre- employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent appropriately dressed She appears to be in good distress. She is well-nourished, well-developed, health Reason for Visit Ms. Jones visited to have a physical exam for the health insurance at her new workplace History of Present Illness and dressed appropriately with good hygiene. “I came in because I’m required to have a recent physical exam for the health insurance at my new job.” Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver Ms. Jones reported that she recently got a job at & Company. She needs to obtain a pre- a new place and she is required to obtain a physical examination. She does not have any employment physical prior to initiating employment. Today she denies any acute Student Documentation Model Documentation concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian acute concerns She was diagnosed with PCOS syndrome and prescribed oral contraceptives at and oral contraceptives were prescribed She had that visit, which she is tolerating well. She has type 2 diabetes and asthma She reports positive lifestyle modifications Medications Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD Allergies Allergic to cats and dust Allergic to penicillin Denies any food or latex allergy Medical History Diagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects currently. She states that she feels healthy, is taking better care of herself than in the past and is looking forward to beginning the new job. • Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago) • Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. with PCOS four months ago and take Yaz Has a Never intubated. Type 2 diabetes diagnosed at history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual