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Shadow Health - Health History Exam

Terms in this set (22)

Why is it important to obtain a patient's complete health history?
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Introduction to Tina
My name is Kayla and I am a nursing student at Wichita St. I will be completing your comprehensive health assessment today.
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Do you know what brings you to the hospital today?
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Ms. Jones is a pleasant 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and was admitted for IV antibiotics. She is a good historian. She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb. The injury occurred about one week ago. Her pain has worsened, and the swelling has persisted. She tried ibuprofen, but it didn't work well. The foot feels better when she rests, and it hurts more when she walks on it. Her pain is a 9 when she tries to ambulate. She took her temperature at home and reports it was 102. She has not been eating much and has been staying in bed the last few days, per patient report. The scrape is red and swollen with exudate and has no odor; she reports the swelling and exudate started two days ago. She reports diarrhea overnight. Pain improved with oxycodone. Stomach upset.
Onset - When did your foot first start to hurt?
Received scrape a week ago and the pain got a lot worse in last few days.
Location - Where is the scrape located? Which foot?
On the ball of R foot
How did you scrape your foot?
She hurt the ball of her right foot by scraping it on the edge of a metal step while changing a light bulb.
Duration -
Constant pain.
Characteristics
Pt describes pain as throbbing and sharp with ambulation. Foot is red and swollen, hot
Pain Now: 7/10, Best: 4/10 w/ Advil Worst: 9/10 Tolerable: 3/10
Reports no odor. White pus.
How to ask tolerable pain
What level of pain is acceptable to you?
Reaction to Treatment
Advil helps 4/10, but only for few hours. Pt couldn't stand on foot. Did not find ointment to be effective, pt states foot still caused pain and exudate.
Treatment
Bandaged and cleaned wound with Hydrogen Peroxide. Applied topical ointment Neosporin TID after cleaning.
A - Associated Symptoms
Do you experience any
N/V
N/T
F/F
Chest pain or shortness of breath
After old cart...
Ask do you have any preexisting medical conditions?
Tina's Chronic Illnesses Include
Asthma and Diabetes
After learning this ask about Acute/ Chronic asthma:
When were you diagnosed w/ Asthma & diabetes?
What do you use to treat it?
How often do you see a provider for this?
When were you diagnosed w/ diabetes?
Type 1 or 2?
Why did you stop your tx?
How do you monitor your blood glucose?
2.5 yrs - uses Proventil Inhaler
Haven't seen a provider for wellness check in 2 years.

age 24. Type 2 Diabetes. Watches diet and avoids sugar. Denies any medication for diabetes tx, didn't want to "deal with it".
What to add to nutrition?
- Any changes in appetite?
-any weight changes?
- what caused the weight loss?
- are you thirsty often?
- Do you urinate often?
Recent changes in appetite - increase in appetite
lost 10 pounds in a month, unintentional. Reports more frequent thirst and urination.
Questions about Asthma:
What triggers it?
What are your exacerbations like?
How mnay puffs do you take with your inhaler?
What is your allergy to cats like?
Are allergic to any medications?
What is your reaction to penicillin?
Do you have any latex allergies?
Any allergies to food?
Any allergies to dust?
Cats, dust, running up stairs
tightness and wheezing
2-3 puffs
sneezing, eyes water, asthma acts up
Penicillin
Reaction - Hives
no
no
Have you received all your immunizations?
Shots are current
Have you received all your childhood vacinations?
Yes, required for school
Do you get your annual flu vaccine?
No, pt believes flu shot not effective.
Are you up to date on tetanus vaccine?
Received tetanus booster a year ago
THIS SET IS OFTEN IN FOLDERS WITH...