NURS 6512N Week 4: Tina Jones Shadow Health History
Information Processing : 40 of 40 (100.0%)
Each relevant diagnosis is scored on a four-point scale:
Priority (1 point): the correct priority of the diagnosis was chosen
Evidence (up to 2 points): the strength of the patient cue(s) selected as evidence for the identified diagnosis
Required Evidence: selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points
Supporting Evidence: selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 point
Planning (1 point): the plan proposed to address the diagnosis includes at least one correct component
Relevant Diagnoses
1. Acute pain of the foot
4 of 4 points
Priority 1 / 1
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Student Response: High
Correct 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.
Evidence 2 / 2
Relevant
“I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.” Required Evidence
Irrelevant
(None provided)
Evidence Pro Tip: Tina reports intense pain and rates her pain on a numerical scale. She also reports characteristics of the pain, including its duration of one week; this timespan defines her pain as acute. NURS 6512N Week 4 – Health History, Tina Jones Shadow Health
Planning 1 / 1
Relevant
Intervene – Prescribe: Prescribe medications to treat pain.
Educate – Medication: Educate the patient on medications used for pain relief.
Educate – Medication: Educate the patient on non-pharmaceutical methods to reduce pain intensity.
Irrelevant
(None provided)
Planning Pro Tip: Intervene to reduce the pain by prescribing an appropriate analgesic and educating the patient on its effective use and potential side effects. Provide the patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation).
2. Local infection of skin and subcutaneous tissue of the foot
4 of 4 points
3. Uncontrolled type 2 diabetes mellitus
4 of 4 points
4. Asthma
4 of 4 points
Priority 1 / 1
Student Response: Low
Correct Priority: Low
Priority Pro Tip: Although Tina requires education to better manage her asthma, she does not report active respiratory complaints, making this a lower priority diagnosis.
Evidence 2 / 2
Relevant
“Um, the only things I know I’m diagnosed with are diabetes. And asthma.” Required Evidence
“It’s really rare for me to have an attack now. Three days ago I had some breathing problems, but I guess probably my last full attack was in high school.” Required Evidence
Irrelevant
(None provided)
Evidence Pro Tip: Tina reports a personal history of asthma, including past hospitalizations for asthma attacks, as well as her use of an albuterol inhaler. Her sibling’s asthma is of interest, given the strong genetic and environmental factors in the development of asthma.
Planning 1 / 1
Relevant
Assess – Respiratory: Assess lung sounds with auscultation.
Assess – Respiratory: Assess pulmonary function using spirometry.
Assess – Respiratory: Assess respirations (rate, rhythm, depth, quality).
Educate – Health Maintenance: Educate the patient on avoiding triggers of asthma.
Educate – Health Maintenance: Educate the patient on enacting her asthma action plan, including proper use of a rescue inhaler.
Irrelevant
(None provided)
Planning Pro Tip: Because Tina does not report treatment for maintenance of her asthma, instead relying on a rescue inhaler for sporadic attacks, educate her on developing and enacting a proactive plan to manage the disease. Though Tina does not report an active respiratory complaint, it is valuable to assess for abnormal findings that she may not report.
5. Dysmenorrhea
4 of 4 points
6. Hypertension
4 of 4 points
7. Menorrhagia
4 of 4 points
8. Obesity
4 of 4 points
9. Oligomenorrhea
4 of 4 points
Priority 1 / 1
Student Response: Low
Correct Priority: Low
Priority Pro Tip: Oligomenorrhea is a secondary issue caused by Tina’s endocrine and metabolic disorders and thus is a lower priority diagnosis.
Evidence 2 / 2
Relevant
“It’s not regular. Sometimes it’s every month, but sometimes it’s more like every two months. I don’t write it down or anything. I probably get…six periods a year.” Required Evidence
Irrelevant
(None provided)
Evidence Pro Tip: Tina reports having about 6 periods per year, meeting the criteria for oligomenorrhea, which are periods more than 35 days apart or 9 per year. Her periods occur fewer than 90 days apart, making oligomenorrhea the correct diagnosis rather than amenorrhea.
Planning 1 / 1
Relevant
Assess – Integumentary: Assess for the presence of axillary and pubic hair by inspection.
Assess – Integumentary: Assess the severity of hair growth at areas including the upper lip, chin, chest, thighs, upper arm, forearm, back, abdomen.
Intervene – Labs: Order a follicle-stimulating hormone test.
Intervene – Labs: Order a test of free androgen index.
Intervene – Labs: Order a test of free testosterone.
Intervene – Labs: Order a test of thyroid-stimulating hormone.
Educate – Health Maintenance: Educate the patient to keep a menstrual calendar to assist in assessing her pattern.
Irrelevant
(None provided)
Planning Pro Tip: Endocrine disorders are the cause of Tina’s irregular menstruation, so order labs to evaluate for polycystic ovarian syndrome and thyroid disease. Inspect for both hair growth indicative of excessive androgen production and that indicative of deficient production, and inspect for acanthosis nigricans. Educate your patient on keeping a menstrual calendar to more precisely identify irregularities in her cycle.
10. Polycystic ovarian syndrome
4 of 4 points
Other Diagnoses Identified
(No other diagnoses were identified)
Transcript
Started: Mar 19, 2023 | Total Time: 403 min
Weight: 90 kg
Exam Action 03/19/23 2:01 AM EDT
BMI: 31
Exam Action 03/19/23 2:01 AM EDT
Random blood glucose: 238
Exam Action 03/19/23 2:01 AM EDT
Blood pressure: 142/82
Exam Action 03/19/23 2:01 AM EDT
Respiratory rate: 19
Exam Action 03/19/23 2:01 AM EDT
O2 sat: 99%
Exam Action 03/19/23 2:01 AM EDT
Heart rate: 86
Exam Action 03/19/23 2:01 AM EDT
Height: 170.2 cm
Exam Action 03/19/23 2:01 AM EDT
Temperature: 38.4 °C
Exam Action 03/19/23 2:01 AM EDT
Hello. Am NURS 6512N Week 4 – Health History, Tina Jones Shadow Health, I will interview and examine you.
Greet 03/19/23 2:02 AM EDT
Hey.
What is your name?
Question 03/19/23 2:07 AM EDT
Tina Jones.
Why are you here today?
Question 03/19/23 2:07 AM EDT
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!
Am sorry to hear that
Empathize 03/19/23 2:07 AM EDT
I appreciate you telling me that.
When did you get the scrape?
Question 03/19/23 2:09 AM EDT
Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
How severe is the pain?
Question 03/19/23 2:10 AM EDT
It’s really bad.
Can you describe the pain?
Question 03/19/23 2:12 AM EDT
It’s throbbing and like, sharp if I try to put weight on it.
Did you hurt any other part? (Clarified to Did you hurt anything else during the fall?.)
Question 03/19/23 2:12 AM EDT
Well, at first, I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it, because the ankle felt pretty okay the next day and it wasn’t a problem all week. (Clarified to if I hurt anything else during the fall.)
How has the pain changed over time?
Question 03/19/23 2:13 AM EDT
At first, it seemed like it was healing up fine and it didn’t give me a lot of pain. But the last two days, the pain got way worse.
Does the pain radiate anywhere else?
Question 03/19/23 2:13 AM EDT
The pain’s worse in my foot, but I feel it moving up into my ankle, too.
How did you hurt your ankle?
Question 03/19/23 2:14 AM EDT
I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step.
Is it possible for you to stand on your foot?
Question 03/19/23 2:14 AM EDT
No, I can’t put weight on my foot without really sharp pain.
Can you rate your current pain level on a scale of 0 to 10?
Question 03/19/23 2:15 AM EDT
I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.
Can you tell me where the pain is located?
Question 03/19/23 2:19 AM EDT
It feels like the pain is just centered around the scrape, like around the ball of my foot. That’s where it hurts the most, but my whole foot feels some pain.
Which foot did you injure?
Question 03/19/23 2:19 AM EDT
My right foot.
Were you wearing shoes?
Question 03/19/23 2:20 AM EDT
No, I was barefoot.
Did you have any alcoholic drinks before the injury?
Question 03/19/23 2:20 AM EDT
No, I was stone-cold sober. It was the middle of the day.
Did you use home remedies for your foot?
Question 03/19/23 2:21 AM EDT
Yeah, I made sure to clean it and keep it bandaged.
What did you use to clean the er? (No matching questions found.)
Question 03/19/23 2:21 AM EDT
What did you use to clean it?
Question 03/19/23 2:22 AM EDT
Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
When did you go to the er?
Question 03/19/23 2:22 AM EDT
I went about an hour after I fell, I think.
Did you get any medication at the ER?
Question 03/19/23 2:23 AM EDT
Yes, they wrote me a prescription for some pain pills.
Do you know the name of the pain pills?
Tina Jones Comprehensive Assessment shadow health Transcript
Question 03/19/23 2:23 AM EDT
It’s called tramadol.
What dosage of tramadol?
Question 03/19/23 2:24 AM EDT
I’m not 100% sure, but I think they’re 50 milligrams.
How often were you taking the tramadol?
Question 03/19/23 2:24 AM EDT
I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
Did tramadol relieve pain?
Question 03/19/23 2:25 AM EDT
I’ve only been taking the pain pills the ER gave me and staying off it. . . and keeping the wound clean.
Has your foot bled since the injury?
Question 03/19/23 2:25 AM EDT
It’s not bleeding anymore. It only bled right after I scraped it.
What happened after you scraped your foot NURS 6512N Week 4 – Health History, Tina Jones Shadow Health
Question 03/19/23 2:26 AM EDT
I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
Its good to seek medical attention.
Educate 03/19/23 2:26 AM EDT
That makes sense.
Did the ER prescribe the pain pills?
Question 03/19/23 2:30 AM EDT
Yes, they wrote me a prescription for some pain pills.
Which pain pills were prescribed?
Question 03/19/23 2:31 AM EDT
It’s called tramadol.
How effective is the pain medication?
Question 03/19/23 2:32 AM EDT
They only help for a few hours at a time.
Am sorry to hear that.
Educate 03/19/23 2:32 AM EDT
Thanks for telling me.
How have you cared for the scrape?
Question 03/19/23 2:32 AM EDT
I made sure to clean it and just keep it bandaged. And I put Neosporin on it.
What happens after applying Neosporin?
Question 03/19/23 2:33 AM EDT
I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
How effective is neosporin? (Clarified to How effective was the neosporin?.)
Question
NURS 6512N Week 4: Tina Jones Shadow Health History
Information Processing : 40 of 40 (100.0%)
Each relevant diagnosis is scored on a four-point scale:
- Priority (1 point): the correct priority of the diagnosis was chosen
- Evidence (up to 2 points): the strength of the patient cue(s) selected as evidence for the identified diagnosis
- Required Evidence: selecting at least one cue that directly indicates the presence of a problem or risk is worth 2 points
- Supporting Evidence: selecting at least one cue that is a contributing factor or cause of a problem or risk, without the presence of Required Evidence, is worth 1 point
- Planning (1 point): the plan proposed to address the diagnosis includes at least one correct component
Relevant Diagnoses
Priority 1 / 1 |
|
|
Student Response: High Correct 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. |
Evidence 2 / 2 |
|
|
Relevant “I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.” Required Evidence Irrelevant (None provided) |
Evidence Pro Tip: Tina reports intense pain and rates her pain on a numerical scale. She also reports characteristics of the pain, including its duration of one week; this timespan defines her pain as acute. NURS 6512N Week 4 – Health History, Tina Jones Shadow Health |
Planning 1 / 1 |
|
|
Relevant Intervene – Prescribe: Prescribe medications to treat pain. Educate – Medication: Educate the patient on medications used for pain relief. Educate – Medication: Educate the patient on non-pharmaceutical methods to reduce pain intensity. Irrelevant (None provided) |
Planning Pro Tip: Intervene to reduce the pain by prescribing an appropriate analgesic and educating the patient on its effective use and potential side effects. Provide the patient with options for non-pharmacological pain relief, such as RICE (rest, ice, compression, elevation). |
Priority 1 / 1 |
|
|
Student Response: Low Correct Priority: Low |
Priority Pro Tip: Although Tina requires education to better manage her asthma, she does not report active respiratory complaints, making this a lower priority diagnosis. |
Evidence 2 / 2 |
|
|
Relevant “Um, the only things I know I’m diagnosed with are diabetes. And asthma.” Required Evidence “It’s really rare for me to have an attack now. Three days ago I had some breathing problems, but I guess probably my last full attack was in high school.” Required Evidence Irrelevant (None provided) |
Evidence Pro Tip: Tina reports a personal history of asthma, including past hospitalizations for asthma attacks, as well as her use of an albuterol inhaler. Her sibling’s asthma is of interest, given the strong genetic and environmental factors in the development of asthma. |
Planning 1 / 1 |
|
|
Relevant Assess – Respiratory: Assess lung sounds with auscultation. Assess – Respiratory: Assess pulmonary function using spirometry. Assess – Respiratory: Assess respirations (rate, rhythm, depth, quality). Educate – Health Maintenance: Educate the patient on avoiding triggers of asthma. Educate – Health Maintenance: Educate the patient on enacting her asthma action plan including proper use of rescue inhaler. Irrelevant (None provided) |
Planning Pro Tip: Because Tina does not report treatment for maintenance of her asthma, instead relying on a rescue inhaler for sporadic attacks, educate her on developing and enacting a proactive plan to manage the disease. Though Tina does not report an active respiratory complaint, it is valuable to assess for abnormal findings that she may not report. |
Priority 1 / 1 |
|
|
Student Response: Low Correct Priority: Low |
Priority Pro Tip: Oligomenorrhea is a secondary issue caused by Tina’s endocrine and metabolic disorders and thus is a lower priority diagnosis. |
Evidence 2 / 2 |
|
|
Relevant “It’s not regular. Sometimes it’s every month, but sometimes it’s more like every two months. I don’t write it down or anything. I probably get…six periods a year.” Required Evidence Irrelevant (None provided) |
Evidence Pro Tip: Tina reports having about 6 periods per year, meeting the criteria for oligomenorrhea, which are periods more than 35 days apart or 9 per year. Her periods occur fewer than 90 days apart, making oligomenorrhea the correct diagnosis rather than amenorrhea. |
Planning 1 / 1 |
|
|
Relevant Assess – Integumentary: Assess for presence of axillary and pubic hair by inspection. Assess – Integumentary: Assess severity of hair growth at areas including upper lip, chin, chest, thighs, upper arm, forearm, back, abdomen. Intervene – Labs: Order a follicle-stimulating hormone test. Intervene – Labs: Order a test of free androgen index. Intervene – Labs: Order a test of free testosterone. Intervene – Labs: Order a test of thyroid stimulating hormone. Educate – Health Maintenance: Educate the patient to keep a menstrual calendar to assist assessing her pattern. Irrelevant (None provided) |
Planning Pro Tip: Endocrine disorders are the cause of Tina’s irregular menstruation, so order labs to evaluate for poly-cystic ovarian syndrome and thyroid disease. Inspect for both hair growth indicative of excessive androgen production and that indicative of deficient production, and inspect for acanthosis nigricans. Educate your patient on keeping a menstrual calendar to more precisely identify irregularities in her cycle. |
Other Diagnoses Identified
(No other diagnoses were identified)
Transcript
 |
Weight: 90 kg
|
Exam Action |
|
BMI: 31
|
Exam Action |
|
Random blood glucose: 238
|
Exam Action |
|
Blood pressure: 142/82
|
Exam Action |
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Respiratory rate: 19
|
Exam Action |
|
O2 sat: 99%
|
Exam Action |
|
Heart rate: 86
|
Exam Action |
|
Height: 170.2 cm
|
Exam Action |
|
Temperature: 38.4 °C
|
Exam Action |
|
Hello. Am NURS 6512N Week 4 – Health History, Tina Jones Shadow Health , i will interview and examine you.
|
Greet |
 |
Hey.
|
|
|
What is your name?
|
Question |
|
Tina Jones.
|
|
|
why are you here today?
|
Question |
|
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!
|
|
|
Am sorry to hear that
|
Empathize |
|
I appreciate you telling me that.
|
|
|
When did you get the scrape?
|
Question |
|
Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days.
|
|
|
How severe is the pain?
|
Question |
|
It’s really bad.
|
|
|
Can you describe the pain?
|
Question |
|
It’s throbbing and like, sharp if I try to put weight on it.
|
|
|
Did you hurt any other part? (Clarified to Did you hurt anything else during the fall?.)
|
Question |
|
Well, at first I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it, because the ankle felt pretty okay the next day and it wasn’t a problem all week. (Clarified to if I hurt anything else during the fall.)
|
|
|
How has the pain changed over time?
|
Question |
|
At first, it seemed like it was healing up fine and it didn’t give me a lot of pain. But the last two days, the pain got way worse.
|
|
|
Does the pain radiate anywhere else?
|
Question |
|
The pain’s worse in my foot, but I feel it moving up into my ankle, too.
|
|
|
How did you hurt your ankle?
|
Question |
|
I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step.
|
|
|
Is it possible for you to stand on your foot?
|
Question |
|
No, I can’t put weight on my foot without really sharp pain.
|
|
|
Can you rate your current pain level on a scale of 0 to 10?
|
Question |
|
I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet.
|
|
|
Can you tell me where the pain is located?
|
Question |
|
It feels like the pain is just centered around the scrape, like around the ball of my foot. That’s where it hurts the most, but my whole foot feels some pain.
|
|
|
Which foot did you injure?
|
Question |
|
My right foot.
|
|
|
Were you wearing shoes?
|
Question |
|
No, I was barefoot.
|
|
|
Did you have any alcoholic drinks before the injury?
|
Question |
|
No, I was stone-cold sober. It was the middle of the day.
|
|
|
Did you use home remedies for your foot?
|
Question |
|
Yeah, I made sure to clean it and keep it bandaged.
|
|
|
What did you use to clean the er? (No matching questions found.)
|
Question |
|
What did you use to clean it?
|
Question |
|
Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
|
|
|
When did you go to the er?
|
Question |
|
I went about an hour after I fell, I think.
|
|
|
Did you get any medication at the ER?
|
Question |
|
Yes, they wrote me a prescription for some pain pills.
|
|
|
Do you know the name of the pain pills?
|
Question |
|
It’s called tramadol.
|
|
|
What dosage of tramadol?
|
Question |
|
I’m not 100% sure, but I think they’re 50 milligrams.
|
|
|
How often were you taking the tramadol?
|
Question |
|
I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON]
|
|
|
Did tramadol relieve pain?
|
Question |
|
I’ve only been taking the pain pills the ER gave me and staying off it. . . and keeping the wound clean.
|
|
|
Has your foot bled since the injury?
|
Question |
|
It’s not bleeding anymore. It only bled right after I scraped it.
|
|
|
What happened after you scraped your foot
NURS 6512N Week 4 – Health History, Tina Jones Shadow Health
|
Question |
|
I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
|
|
|
Its good to seek medical attention.
|
Educate |
|
That makes sense.
|
|
|
Did the ER prescribe the pain pills?
|
Question |
|
Yes, they wrote me a prescription for some pain pills.
|
|
|
Which pain pills were prescribed?
|
Question |
|
It’s called tramadol.
|
|
|
How effective is the pain medication?
|
Question |
|
They only help for a few hours at a time.
|
|
|
Am sorry to hear that.
|
Educate |
|
Thanks for telling me.
|
|
|
How have you cared for the scrape?
|
Question |
|
I made sure to clean it and just keep it bandaged. And I put Neosporin on it.
|
|
|
What happens after applying Neosporin?
|
Question |
|
I got the scrape to stop bleeding, and then I started to worry that I had sprained my ankle, so Mom and I decided better safe than sorry, and so we went to the ER.
|
|
|
How effective is neosporin? (Clarified to How effective was the neosporin?.)
|
Question |
|
Well, I had to come back to get my foot checked out even though I used the ointment. [AUDIO COMING SOON] (Clarified to how effective the neosporin was.)
|
|
|
How often have you been cleaning the scrape?
|
Question |
|
Since it happened, I’ve been washing it with soap and water, and if it seemed irritated, I would put some peroxide on there and then rinse it off.
|
|
|
Its good to keep it clean.
|
Educate |
|
Alright, thanks for letting me know.
|
|
|
Is the wound swollen? (Clarified to Is it swollen around the wound?.)
|
Question |
|
Yeah, it looks swollen around the scrape. (Clarified to if it is swollen around the wound.)
|
|
|
Does your scrape have an odor?
|
Question |
|
Um, no, not that I know of… That sounds gross.
|
|
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Does the scrape have pus?
|
Question |
|
Yeah, there’s definitely pus.
|
|
|
What color is the pus?
|
Question |
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It’s… white or maybe off-white.
|
|
|
Is the scrape red?
|
Question |
|
Yeah, it’s red all around the scrape.
|
|
|
Any temperature change around the scrape?
|
Question |
|
No.
|
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Are you having trouble getting around?
|
Question |
|
Yes! I mean, I literally can’t put weight on my foot, the pain is so sharp.
|
|
|
Am sorry to hear that.
|
Empathize |
|
Thanks for saying that.
|
|
|
Who has been helping you at home since you hurt your foot?
|
Question
|
Subjective Data Collection: 100 of 100 (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
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports pain
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
How severe is the pain?
Finding:
Reports foot wound
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
What’s causing your pain?
History of Present Illness
Finding:
Asked to rate current pain level on a scale
Finding:
Reports current pain is 7/10
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Can you rate the pain on a scale of 0 to 10?
Finding:
Asked for details about the pain
Finding:
Reports pain is throbbing
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Can you please describe the pain?
Finding:
Reports pain is sharp when she attempts to stand
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What is the pain like when you stand on your foot?
Finding:
Reports pain has increased in the past 2 days
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How has the pain changed over time?
Finding:
Reports feeling pain radiating into ankle
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does the pain radiate anywhere else?
Finding:
Reports pain prevents bearing weight on foot
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Can you bear weight on your foot?
Finding:
Asked location of wound
Finding:
Reports right foot is injured
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Which foot is in pain?
Finding:
Reports wound is on the plantar surface of her foot
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Where is the wound?
Finding:
Asked details of the injury
Finding:
Reports she scraped foot on a cement step
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How did your injury happen?
Finding:
Reports initial injury occurred 1 week ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did the pain start?
Finding:
Reports mild ankle injury
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you injure anything besides your foot?
Finding:
Reports being barefoot at the time of injury
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Were you wearing shoes when you fell?
Finding:
Asked about the assessment of the injury at the ER
Finding:
Reports going to the ER after sustaining the injury
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did you go to the ER?
Finding:
Reports going to the ER because she suspected an ankle sprain
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Why did you go to the ER?
Finding:
Reports receiving an X-ray at the ER NURS 6512N Week 4 – Health History, Tina Jones Shadow Health
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did they xray your foot at the ER?
Finding:
Reports X-ray showed no broken bones
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What did the x-ray show?
Finding:
Reports receiving a prescription for pain pills
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you receive any pain medications at the ER?
Finding:
Asked about drainage from the foot wound
Finding:
Reports that the wound bled a little after sustaining the injury
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did your foot bleed?
Finding:
Reports seeing pus draining from wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you notice any discharge from the wound?
Finding:
Reports noticing pus 2 days ago
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
When did you first notice the pus?
Finding:
Followed up on drainage
Finding:
Reports pus as white or yellow
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What color is the drainage from your wound?
Finding:
Denies odor from the wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does the wound have an odor?
Finding:
Asked about home treatment of foot wound
Finding:
Reports wound care regimen of bandaging
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How did you treat your foot at home?
Finding:
Reports cleaning wound twice a day
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How often did you clean the wound?
Finding:
Reports cleaning wound with hydrogen peroxide
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
What did you use to clean the wound?
Finding:
Reports applying bacitracin, neomycin and polymyxin B (Neosporin)
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you use any ointment on the wound?
Finding:
Asked about other foot wound symptoms
Finding:
Reports swelling around foot wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Is there swelling around the wound?
Finding:
Reports swelling worsened in the past 2 days
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
How long have you noticed swelling around the wound?
Finding:
Reports redness around the wound
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Did you notice any redness around the wound?
Finding:
Reports that the wound feels warm
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does the wound feel warm?
Finding:
Explored impact of patient’s foot injury on activities of daily living
Finding:
Reports pain affects ability to walk
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does your injury impact your ability to walk?
Finding:
Reports pain affects ability to stand at work for long periods of time
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(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:
Does your foot pain affect your work?
Finding:
Reports pain prevented her from being able to walk to class