ASSIGNMENT: NURS 6512 DIGITAL CLINICAL EXPERIENCE (DCE): HEALTH HISTORY ASSESSMENT

NURS 6512 DIGITAL

ASSIGNMENT: NURS 6512 DIGITAL CLINICAL EXPERIENCE (DCE): HEALTH HISTORY ASSESSMENT

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): “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!”

History of Present Illness (HPI): T.J is a twenty-eight-year-old patient who comes to the clinic complaining of pain in the foot with a scrape that has failed to health up on its own. She injured her right ankle and scraped the ball of her foot. She indicates that she visited a local emergency room where an x-ray was performed and turned out negative with no fractures. The emergency room staff prescribed tramadol for pain after the x-ray. The patient has been cleaning the foot with soap and water and has been using Neosporin ointment, too, after the wound is dry. The patient also noticed that the foot started swelling and becoming red around the scrape some two days ago. The wound also feels warm. The patient’s foot sole has become more painful, with a pain score of 7 out of 10 after the painkiller medication. The pain increases to a 9 out of 10 with weight bearing. The patient also indicated that she saw a fluid with an off-white color seeping from the wound yesterday. However, she indicates that the fluid is odorless. The pain is affecting her normal operation as she tried going to work but couldn’t walk well and had to go back home after a few hours since the boss was understanding.

ORDER A CUSTOMIZED, PLAGIARISM-FREE ASSIGNMENT: NURS 6512 DIGITAL CLINICAL EXPERIENCE (DCE): HEALTH HISTORY ASSESSMENT HERE

Medications: albuterol inhaler, advil 200 mg, Tylenol and tramadol

Allergies:  penicillin, dust, and cats

Past Medical History (PMH): The patient indicates that she had been diagnosed with type 2 diabetes at the age of 24, which she controlled with metformin and lifestyle changes such as reducing sugar intake. She stopped taking metformin three years ago but has been monitoring her blood sugar. The patient was also diagnosed with asthma and uses a Proventil inhaler and two puffs of albuterol which she uses every two to three days. The patient was last hospitalized for an asthma attack while in high school.

Past Surgical History (PSH):  the patient has no past surgical history

Sexual/Reproductive History: the patient has regular menses. No history of STI and no records of a boyfriend.

Personal/Social History: the patient lives with her mother and sister, and their relationship is great. She is working on a bachelor’s degree in accounting. They have a church family who showed them love and compassion when their father died. The patient drinks two to three glasses of alcohol every week, especially during weekends. The denies smoking

Immunization History: The patient’s influenza immunization is not up to date; she received a tetanus booster about one year ago

Health Maintenance: the patient consumes some food in excess, like diet coke, which is not good for her health. she also takes two to three glasses of alcohol, which may not be good for her health.

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

The patient’s mother has high cholesterol and high blood pressure. The father died in a car accident at fifty-eight and had type 2 diabetes, high blood pressure, and high cholesterol. The paternal grandpa died at the age of sixty-five of colon cancer, and he also had type 2 diabetes. The paternal grandmother is living with hypertension and is currently eighty-two. The patient’s uncle has an alcohol-drinking problem, and they never see him.

Review of Systems: From head to toe, including 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: The patient recently lost ten pounds unintentionally and reports fatigue when the day ends. Reports fever experienced the previous night.

            HEENT: The patient reports headaches occurring weekly, especially with reading, in the past year. Denies any neck and head trauma. She denies any ear discharges, ear pain, tinnitus, or difficulty in hearing. She reports blurred vision, which comes with reading and studying, and the problem has worsened over the years. She reports no visual testing since her childhood and does not put on any corrective glasses. The patient reports eye itches when exposed to cats. Denies any eye discharges or pain. She reports congestion and rhinitis connected to cat allergy. She denies sinus complications, change in smell, epistaxis, frequent infections, or colds. She denies any changes in taste, dry mouth, oral lesions, dental problems, or pain. She denies changes in her voice, denies dysphagia, and sore throat. She denies hypothyroidism or hyperthyroidism.

Neck: denies any neck trauma or pain

            Breasts: the breast is normal with no lumps noted

            Respiratory: The patent denies recent cough, hemoptysis, current wheezing, dyspnea, or cough.

            Cardiovascular/Peripheral Vascular: she denies any pain in the lower extremities, varicosities, peripheral edema, orthopnea paroxysmal nocturnal dyspnea, exertion, or palpitations.

            Gastrointestinal: The patient denies liver and gallbladder disease, bloody stools, abdominal pain, jaundice, changes in bowel habits, constipation, diarrhea, vomiting, nausea, dysphagia, reflux, or digestive problem. The patient reports polyuria, nocturia, polydipsia, and polyphagia.

            Genitourinary: The patient denies kidney stones and a history of recurrent urinary tract infections. She also denies cloudy urine, dysuria, or flank pain.

            Musculoskeletal: The patient denies any generalized weakness, denies neck trauma and pain, denies back pain. She also denies a history of arthritis, gout, or fractures. Denies arthralgias and myalgias

            Psychiatric: The patient denies suicidal thoughts or ideas. Denies depression

            Neurological: The patient denies paralysis, seizures, tremors, tingling, numbness, syncope, weakness, vertigo, dizziness, and fainting.

            Skin: The skin is warm with no lesions, itchiness noted, has a wound on the foot

            Hematologic: The patient denies anemia or bleeding

            Endocrine: Denies intolerance to cold or heat. She also reports sweating.

ORDER A CUSTOMIZED, PLAGIARISM-FREE ASSIGNMENT: NURS 6512 DIGITAL CLINICAL EXPERIENCE (DCE): HEALTH HISTORY ASSESSMENT HERE

DIGITAL CLINICAL EXPERIENCE (DCE): HEALTH HISTORY ASSESSMENT

A comprehensive health history is essential to providing quality care for patients across the lifespan, as it helps to properly identify health risks, diagnose patients, and develop individualized treatment plans. To effectively collect these heath histories, you must not only have strong communication skills, but also the ability to quickly establish trust and confidence with your patients. For this DCE Assignment, you begin building your communication and assessment skills as you collect a health history from a volunteer “patient.”

RESOURCES

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE

• Review this week’s Learning Resources as well as the Taking a Health History media program, and consider how you might incorporate these strategies. Download and review the 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.
• Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Shadow Health Student Orientation media program and the Useful Tips and Tricks document provided in the week’s Learning Resources to guide you through Shadow Health.
• Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.

DCE Health History Assessment:

Complete the following in Shadow Health:

Orientation (Required, you will not be able to access the Health History without completing the requirements). 

• DCE Orientation (15 minutes)
• Conversation Concept Lab (50 minutes, Required)

Health History

• Health History of Tina Jones (180 minutes)

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve total score of 80% or better(includes BOTH DCE and Documentation), but you must take all attempts by the Week 4 Day 7 deadline.

SUBMISSION INFORMATION

No Assignment submission due this week but will be due Day 7, Week 4.