Western Governors University - NRSG 652THealth History- Tina Jones Subjective Data. subjective Data Collection SCORE 98 of 100 (98.0%)

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Health History Results | Turned In NRSG652T-X-1904D-1 - November 2019, NRSG652T-X Return to Assignment (/assignments/283442/) Subjective Data Collection: 98 of 100 (98.0%) Chief Complaint History... of Present Illness Your Results Lab Pass (/assignment_attempts/5769172/lab_pass.p Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Self-Reflection Indicates an item that you found. 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 Not Scored A combination of open and closed questions will yiel better patient data. The following details are facts of patient's case. Established chief complaint pain foot wound Asked to rate current pain level on a scale current pain is 7/10 Asked for details about the pain pain is throbbing Asked location of wound right foot is injured wound is on the plantar surface of her foot Asked details of the injury she scraped foot on a cement step Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.Past Medical History Asked about the assessment of the injury at the ER an ankle sprain Asked about drainage from the foot wound that the wound bled a little after sustaining the injury Followed up on drainage pus as white or yellow odor from the wound Asked about home treatment of foot wound wound care regimen of bandaging polymyxin B (Neosporin) Asked about other foot wound symptoms swelling around foot wound Explored impact of patient's foot injury on activities of daily living pain affects ability to walk long periods of time walk to class Asked about preexisting medical conditions diabetes Followed up on diabetes diagnosis specific age of diagnosis was 24 Asked about diabetes management through lifestyle changes Asked about current diabetes medication use that she does not currently take medication for diabetes Asked about past diabetes medication use that she used to take diabetes medication metformin ER Asked about thirst increased thirst Asked about frequency of urination more frequent urination day Asked about change in appetite increased appetite Asked about weight change recent loss of 10 lbs Followed up on reason for weight change weight loss was unintentional Asked about history of asthma exacerbations last asthma attack was in high school Asked about asthma symptoms chest tightness during exacerbation Asked about prior hospitalizations past hospitalizations as a child and teen Asked about asthma diagnosis specific age of diagnosis is 2.5 years old Asked about asthma management using an inhaler week Asked about number of puffs when using asthma inhaler needed symptoms Asked about asthma triggers asthma triggered by cats seasonal triggersHome Medications Asked about general allergies allergy to cats Followed up on cat allergy symptoms sneezing, itchy eyes, and wheezing Asked about latex allergy latex allergy Asked about medication allergies penicillin allergy Asked about penicillin reaction that penicillin resulted in hives in childhood Asked about food allergies food allergies Asked if the patient has allergies to dust, mold, or pollen Asked about general immunizations received being up to date on shots Asked about childhood immunizations receiving all necessary childhood immunizations Asked if the patient has received a flu vaccine receiving annual flu vaccine Asked if the patient received a tetanus immunization Asked about use of pain medication taking prescription pain medication Followed up on efficacy of pain medication that pain pills provide partial relief pain returns in full every few hoursSocial Determinants of Health Social History Asked about other prescription medications a prescription inhaler Asked about use of OTC medication occasionally taking Advil (ibuprofen) for cramps Followed up on diabetes noncompliance that she got sick of the demands of medication compliance that cost of metformin was reason for discontinuing medication for not checking blood glucose Asked about patient's level of education currently working toward undergraduate degree Asked about patient's living situation living with mother and sister activities Asked about stressors she is currently under high stress Asked about diet last meal was dinner time the previou night mashed potatoes bread Asked about salt intake adding salt to food Asked about caffeine intake drinking coffee Asked about illicit drug use history of recreational marijuana smoking Followed up on drug use last use was at age 20 or 21 and waning interest Asked about alcohol intake last alcoholic drink was 3 weeks ago one sitting Asked about tobacco use smoking tobacco Asked about secondhand smoke exposure to secondhand smoke Asked about mother's health mother diagnosed with high blood pressure Asked about father's health father was diagnosed with Type 2 diabetes father was diagnosed with high blood pressure father was diagnosed with high past grief feeling at peace now Asked about paternal grandfather's health paternal grandfather diagnosed with Type 2 diabetes paternal grandfather diagnosed with high blood pressure paternal grandfather died of colon cancer Asked about paternal grandmother's health paternal grandmother diagnosed with high blood pressure paternal grandmother diagnosed with high cholesterol Asked about maternal grandfather's health maternal grandfather diagnosed with high blood pressure Asked about maternal grandmother's health maternal grandmother diagnosed with high blood pressure maternal grandmother diagnosed with high cholesterol Asked about brother's health brother having diagnosed health problems Asked about sister's health sister diagnosed with asthma Asked about family history of obesity that family members are overweight Asked about family history of thyroid issues family history of thyroid issues Asked about family history of substance abuse 1 uncle has alcoholism Asked about family history of headaches family history of headaches Asked about constitutional health occasional tiredness or fatigue night sweats Asked about review of systems for mental health depression suicidal ideation or attempts Asked about review of systems for head occasional headaches Asked about review of systems for ears change in hearing Asked about review of systems for eyes and vision periods of blurry vision discharge, crusting or wateriness last eye exam was in childhood Asked about review of systems for nose infrequent nose problems infrequent runny nose nosebleedsAsked about review of systems for mouth and jaw dental problems last dental visit was several years ago change in sense of taste dry mouth mouth pain mouth sores gum problems tongue problems jaw problems Asked about review of systems for neck, throat, and glands difficulty swallowing sore throat lymph node problems frequent sore throat swollen glands voice changes general neck problems Asked about breast health doing occasional breast exams general breast problems breast lumps breast pain nipple changes nipple discharge ever having a mammogram Asked about review of systems for respiratory current breathing problems current wheezing current chest tightness pain while breathing frequent coughing Asked about review of systems for cardiovascular chest pain or discomfort palpitations irregular heartbeat easy bruising edema circulation problems vascular diseases Asked review of systems for gastrointestinal nausea vomiting stomach pain change in bowel movements heartburn, GERD, or indigestion constipation diarrhea or loose stool flatulence or bloating bloody or tarry stool normal vaginal discharge Asked review of systems for reproductive last menstrual period was 3 weeks ago that periods are irregular menstruating every 6 weeks to 2 months typical period lasts 9 daysFollowed up on menstrual flow heavy periods heavy flow for 4 to 5 days changing tampon every 2 to 3 hours using super absorbency tampons anemia Followed up on menstrual symptoms heavy cramping cramps for the first 2 days of period Asked about treatment of menstrual symptoms using a heating pad at home to treat cramps taking ibuprofen for first 3 days of period ibuprofen effectively reduces pain from cramps Asked about sexual activity recent sexual activity past sexual activity that she prefers to sleep with men first sexual activity was at age 18 last sexual activity was 2 years ago total number of partners is 3 Asked about contraception no current use of any oral or hormonal birth control past use of oral contraception last taking oral contraception a couple of years ago she didn't see the point in taking contraception while single Asked about condom use past condom use past sexual encounters without condoms oral contraceptive use while sexually active Asked about STI testing last STI testing was 4 years ago STI symptoms uncertainty about past partners and STI testing Asked about history of pap smears last pap smear was 4 years ago no abnormal pap smears Asked about history of pregnancy current pregnancy past pregnancies Asked review of systems for musculoskeletal muscle pain joint pain muscle weakness joint swelling back pain history of fractures or breaks Asked review of systems for neurological dizziness or vertigo lightheadedness vision disturbances tingling loss of coordination loss of sensation history of seizures problems with balance or disequilibrium memory loss recent loss of consciousness or fainting Asked review of systems for skin, hair, and nails rarely using sunscreen acne excessive facial or body hair changes to neck skin moles no body sores (aside from foot wound) dandruff nail abnormalities occasional dry skin skin rashes Comments If your instructor provides individual feedback on this assignment, it will appear here. 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