The Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Example Question: Do you have muscle weakness? Student: Have you had any neurological problems? But I don't smoke, and nobody at home smokes. Finding: Reports infrequent runny nose (Found)Pro Tip: Asking about symptoms, such as runny nose, is one possible component of a review of systems interview. Example Question: Do you know what type of diabetes you have? Example Question: What is your religious affiliation? Asking Tina if she has dry eyes solicits information about one particular symptom. Finding: Reports last hospitalization was age 16 (Available)Pro Tip: Finding out the date of Tina's last hospitalization is important for understanding the timeline of her medical issues, asthma in particular. Evidence - Relevant: Evidence Pro Tip: As Tina discusses symptoms of her wound, including symptoms such as discharge, redness, warmth, and swelling, she reports strong evidence of impaired skin integrity. Finding: Asked if the patient has received a flu vaccine. Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care. Example Question: How are your lymph nodes? Neurological shadow health assessment Transcript. I’ve never had it tested. Student: So that you understand if there are any problems related to their chief complaint. . As a currently presenting symptom, it could impact the patient's care plan. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Finding: Denies odor from the wound (Available)Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics. Finding: Reports receiving polio shot (Available)Pro Tip: Discovering if a patient received a childhood polio vaccination reveals information about both her medical history and her susceptibility to infectious disease. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. HPI: Ms. Jones is a 28 yo AA female who presented to the clinic with complaints of difficulty sleeping started a month ago. Student: How is your maternal grandfather's health? Example Question: What is the dose of the pain medication? Finding: Denies tongue problems (Available)Pro Tip: Asking about symptoms, such as tongue pain, is one possible component of a review of systems interview. Example Question: How many stories is your house? Browse. Example Question: Are your immunizations current? Finding: Asked about prior hospitalizations. Finding: Denies corrective lenses (Available)Pro Tip: Asking about the patient's use of corrective lenses is one possible component of a review of systems interview. Finding: Denies palpitations (Available)Pro Tip: Asking about palpitations is one possible component of a review of systems interview. Exam 1. Finding: Asked about constitutional health. Finding: Reports pus as white or yellow (Found)Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics. Example Question: What caused your father's death? And diabetes -- we have diabetes in common. Tina Jones: I feel really stressed out right now! Finding: Denies ear discharge (Available)Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer's ear. Finding: Denies family history of thyroid issues (Found)Pro Tip: Asking about trends such as thyroid issues can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family. Example Question: Do you ever get heartburn? The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Finding: Reports past hospitalizations (Found)Pro Tip: Finding out if the patient has any past hospitalizations is the first step in understanding any past serious medical issues. Planning Pro Tip: To gain a deep understanding of your patient's situation, determine her level of health literacy, her feelings and beliefs about the disease, and the motivation behind her choices. Example Question: Do you have any environmental allergies? Do you have anything that stresses you out (Clarified to Are you stressed out?. Example Question: Have you ever had a seizure? Example Question: Do you have any reaction to dust? My mom said I should make an appointment. Tina Jones: No, my heart's always been fine. Finding: Asked if the patient has allergies to dust, mold, or pollen. Example Question: When was your last penicillin reaction? Finding: Followed up on home pain medication. You also want to identify any potential issues with substance abuse. Example Question: When did you last have issues with asthma? You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. Loss of a family member Not Followed Up, Description: Tina shares information about her father dying. Tina Jones: Granny's doing good. Finding: Explored impact of patient's foot injury on activities of daily living. Granny, Mom, and Dad had it…and honestly I think my other three grandparents might’ve had issues with that, too. NR 509 Week 1 Assignment: Shadow Health History Assignment. To be honest, though, I’m not exactly sure what it covers. Student: Can you rate your current pain level on a scale of 0 to 10? The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Plus, he had high blood pressure, and...I'm pretty sure he had diabetes. It makes me anxious and uncomfortable. Example Question: Have you had problems with your sinuses? Diana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre-existing conditions. Finding: Reports moles (Available)Pro Tip: Monitoring moles is key in preventing cancerous growths. Model Statement: "I understand that it can be challenging to keep up with daily medication. Finding: Reports penicillin allergy (Found)Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient's safety while she is in your care, as it affects what medications will be safe and appropriate. Most importantly, ask about her goals and changes she may be willing to make. Finding: Denies stomach pain (Available)Pro Tip: Asking about stomach pain is one possible component of a review of systems interview. Example Question: Does the wound feel warm? Finding: Followed up on cat allergy symptoms. . Tina Jones: Well, he passed away. Student: What are some things that trigger your asthma? Example Question: Does your mother have health conditions? As a currently presenting symptom, it could indicate a change in patient status. Search. OTHER SETS BY THIS CREATOR. She describes being too busy to exercise and reports that her primary activity is being on her feet at work, a belief which demonstrates her misunderstanding of exercise. Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. You can document your findings, including vital signs, in the Electronic Health Record. Student: Do you have problems with your mouth? Finding: Denies tingling (Available)Pro Tip: Asking about tingling sensations is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint, such as oral infection or recent trauma. Example Question: Do you have a loss of sensation anywhere? When I'm reading or studying I'll notice that things start to get kind of blurry. Student: We are going to take care of everything as quickly as possible. Finding: Denies dry eyes (Available)Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. As a currently presenting symptom, nocturia could result in a change to the patient's care plan. Example Question: Do you take any herbal supplements? Intervene - Hypoglycemia: Administer insulin and/or oral hypoglycemics, per physician orders. Example Question: Have you seen a healthcare provider for this injury? Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient's chief complaint. Priority: High Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain. 26 terms. Planning - Relevant: Planning Pro Tip: Take a general survey of the patient for changes in skin color, and assess respiratory rate, rhythm, depth, and quality to confirm there are no acute breathing issues. For example, many starchy foods break down into glucose in the body, like pasta, and so you can eat those in moderation, too. Intervene - Diet: Provide the patient a diet without concentrated sweets. Finding: Reports injury occurred 1 week ago (Available)Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute. Example Question: What's the most puffs you ever take? Some mornings lately I’ve had two, though. Planning - Relevant: Assess - Health Literacy and Patterns: Assess the patient's knowledge related to diabetic disease process, assess personal/social supports. Student: Hello, my name is Catlain, I am your nurse today. . Example Question: What medication allergies do you have? Example Question: Do you have trouble breathing? I’m pretty exhausted by the end of the day, so I don’t have the energy to do any extra exercise. Student: What is your level of education? Contributing factors are a past history of hospitalization and asthma attacks, as well as sedentary lifestyle and obesity. Finding: Denies difficulty swallowing (Available)Pro Tip: Asking if a patient has difficulty swallowing is one possible component of a review of systems interview. Example Question: When was the last time you took your diabetes medication on a regular basis? If the patient reports a history of nausea, it could be a symptom of a recurring gastrointestinal problem. Priority: High Priority Pro Tip: This is a high priority. It is important to ask your patient about the flu vaccine. Tina Jones: My chest and throat get tight, and I start to wheeze. I haven’t had thrown up, or even had an upset stomach, in a long time. Intervene - Pain: Administer non-pharmacologic interventions to reduce pain. Finding: Denies loss of coordination (Available)Pro Tip: Asking if the patient has experienced loss of coordination is one possible component of a review of systems interview. Finding: Denies smoking tobacco (Found)Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health, and is a potential factor in delayed wound healing. Example Question: Do you have any breast swelling? Student: Why don't you have your dad's income? Finding: Reports living with mother and sister (Available)Pro Tip: Learning about your patient's living situation helps develop rapport and gives you a broad picture of her lifestyle. Finding: Asked about review of systems for head. Student: What do you do to manage your asthma? Finding: Reports pain is sharp when she attempts to stand (Found)Pro Tip: Determining what physical activities and movements exacerbate the patient's pain can help you better understand the problems and assess treatment needs. Asking your patient about this can inform your care plan. 9. . Finding: Denies history of STIs (Available)Pro Tip: Asking about a patient's history of STIs is one possible component of a review of systems interview. The most common causes of muscle pain are overuse, and conditions such as arthritis. Example Question: How are you coping now? Educate the patient about what risks are, and what good diabetes care looks like. Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Example Question: Was your weight loss intentional? The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. It wasn’t the cost that was a problem. 8. Finding: Denies history of breast cancer (Available)Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. For the other kinds, I got all the required ones when I was a kid, and for college...I'm sure I have a record somewhere at home. Finding: Reports occasional dry skin (Available)Pro Tip: Chronic or severe dry skin might require a patient to be seen by a dermatologist. Example Question: Have you ever smoked cigarettes? Finding: Reports paternal grandmother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. View Tina.Jones_Cardiovascular.Objective Data.Shadow Health.pdf from NURSING 305 at California State University, Long Beach. Finding: Denies chest pain or discomfort (Available)Pro Tip: Asking about chest pain is one possible component of a review of systems interview. Tina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. Finding: Denies current wheezing (Available)Pro Tip: Patients who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Example Question: What is the pain like when you stand on your foot? The patient's response to these questions may uncover additional problems, such as nerve damage. The daily inhaler is Flovent, and the rescue inhaler is Proventil. Honestly, I didn't realize that I'd be admitted to the hospital for my foot. Tina Jones: Um...I've smoked pot before. However, for a patient with no active respiratory complaints, this problem does not need to be addressed immediately. Student: What medications did you take for your diabetes? Student: Do you have a history of cardiovascular problems? Example Question: Does dust trigger your asthma? The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. But I think it can be on the high side sometimes. Student: Are you allergic to dust, mold, or pollen? Example Question: Have you had a mammogram? Tina Jones: It's... white or maybe off-white. My foot slid off the bottom step and it got all scraped up. Student: What type of drugs did you use? Student: Have you had any musculoskeletal problems? Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. Example Question: Did you injure anything besides your foot? 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