Exam (elaborations) NR 509 Advanced Health Assessment Chamberlain Tina Jones Completed Shadow Health

Exam (elaborations) NR 509 Advanced Health Assessment Chamberlain Tina Jones Completed Shadow Health Subjective Data Collection Objective Data Collection Education & Empathy Documentation Information Processing Health History Tips and Tricks Self-Reflection IInntteerrvviieeww QQuueessttiioonnss (()) SSttaatteemmeennttss ((1144)) EExxaamm AAccttiioonnss ((1155)) Height: 170 cm Weight: 90 kg BMI: 31 Random blood glucose: 238 Temperature: 101.1 F Blood pressure: 142/82 Respiratory rate: 19 O2 sat: 99% AAllll LLiinneess (()) 5/5/2018 Health History | Completed | Shadow Health Exam Action 05/05/18 11:43 AM CDT Exam Action 05/05/18 11:43 AM CDT Greet 05/05/18 11:43 AM CDT Question 05/05/18 11:44 AM CDT Question 05/05/18 11:46 AM CDT Question 05/05/18 11:47 AM CDT Question 05/05/18 11:47 AM CDT Question 05/05/18 11:48 AM CDT Heart rate: 86 Hello, Tina Jones my name is Sara an FNP student here to interview you today. Hey. What brings you here today? 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! Where is the pain on your foot? 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. Can you tell me what foot this is please It's . . . [Ms. Jones reports the correct year.] [AUDIO COMING SOON] Which foot is the pain located? My right foot. How severe is the pain in your right foot? It's really bad. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 11:48 AM CDT Question 05/05/18 11:49 AM CDT Question 05/05/18 11:50 AM CDT Question 05/05/18 11:50 AM CDT Question 05/05/18 11:50 AM CDT Question 05/05/18 11:51 AM CDT Question 05/05/18 11:51 AM CDT Question 05/05/18 11:52 AM CDT Can you rate the pain on a scale of 0 to 10. 10 being the worst pain you have ever had in your life ... I'd say a 7. It hurts a lot, and the pain pills haven't kicked in yet. what are you taking for pain? It's called tramadol. Where did you get this medication? The ER doctor prescribed them for me when I was in there a week ago. So the pain started a week ago? (Clarified to did your wound have pus in it all week.) No, I started seeing it two days ago. What caused you to have this pain? Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Why are you having right foot pain? (No matching questions found.) how did your injury happen? 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. can you please describe the pain? It's throbbing and like, sharp if I try to put weight on it. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 11:52 AM CDT Question 05/05/18 11:52 AM CDT Question 05/05/18 11:52 AM CDT Question 05/05/18 11:53 AM CDT Question 05/05/18 11:54 AM CDT Empathize 05/05/18 11:54 AM CDT Question 05/05/18 11:55 AM CDT what is the pain like when you stand on your foot? Yes! I mean, I literally can't put weight on my foot, the pain is so sharp. when did the pain start? Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. Has the pain changed over time? 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 your pain radiate? The pain's worse in my foot, but I feel it moving up into my ankle, too. Can you bear weight on your foot? No, I can't. I can't put any weight on it without like, shooting pain. I am sorry I understand how you feel. I appreciate you telling me that. Did you injure anything else beside your foot? 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 11:55 AM CDT Question 05/05/18 11:56 AM CDT Educate 05/05/18 11:56 AM CDT Question 05/05/18 11:57 AM CDT Question 05/05/18 11:57 AM CDT Question 05/05/18 11:57 AM CDT Question 05/05/18 11:57 AM CDT 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. Did you have any alcoholic drinks before injury? No, I was stone-cold sober. It was the middle of the day. Where you wearing shoes when you fell? No, I was barefoot. Always make sure to wear shoes when outside. OK, I understand. You went to the ER for your injury? Yeah, right after it happened, I worried I might've sprained my ankle so mom drove me to the ER. Did your foot bleed? Yeah, right when I hurt it. Did you notice any discharge from the wound? Yeah, there's definitely pus. When did you first notice pus? Two days ago. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 11:57 AM CDT Question 05/05/18 11:58 AM CDT Empathize 05/05/18 11:59 AM CDT Question 05/05/18 11:59 AM CDT Question 05/05/18 11:59 AM CDT Question 05/05/18 12:00 PM CDT Question 05/05/18 12:00 PM CDT What color is the drainage from your wound? It's... white or maybe off-white. Does the wound have an odor? Um, no, not that I know of... That sounds gross. I understand it sounds gross but in order to find out what is going on with your foot. I must ask this question. Thanks for saying that. How did you treat your foot at home? I made sure to clean it and just keep it bandaged. And I put Neosporin on it. How often did you clean the wound? Twice a day -- every morning and every night. How often did you change the bandage? Every morning and night. I was keeping an eye on it. Is there swelling around the wound? Yeah, it looks swollen around the scrape. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 12:01 PM CDT Question 05/05/18 12:02 PM CDT Question 05/05/18 12:04 PM CDT Question 05/05/18 12:04 PM CDT Exam Action 05/05/18 12:05 PM CDT Exam Action 05/05/18 12:09 PM CDT Exam Action 05/05/18 12:09 PM CDT Exam Action 05/05/18 12:09 PM CDT Exam Action 05/05/18 12:10 PM CDT Does the wound feel warm? Yeah, it feels pretty warm. Does your foot pain affect your work? Well, I tried to go in two days ago but I couldn't walk well enough, so I just went home after a couple hours. And I didn't go in yesterday. My boss was understanding, but I need to be able to work! Has your injury prevented you from going to class? I had a class two days ago, and I skipped it. I haven't missed any classes before this, and I emailed my professor, so I should be okay. I don't want to get behind, so I need to get back to it! Are you feeling feverish right now? I don't feel feverish right now, but last night I had a high temperature. Measured wound: 2 cm x 1.5 cm, 2.5 mm deep Swabbed wound and sent to lab for C & S Cleansed and irrigated wound with normal saline and applied dry sterile dressing. Measured wound: 2 cm x 1.5 cm, 2.5 mm deep Swabbed wound and sent to lab for C & S 5/5/2018 Health History | Completed | Shadow Health Exam Action 05/05/18 12:10 PM CDT Educate 05/05/18 12:10 PM CDT Educate 05/05/18 12:11 PM CDT Question 05/05/18 12:14 PM CDT Question 05/05/18 12:16 PM CDT Question 05/05/18 12:16 PM CDT Question 05/05/18 12:17 PM CDT Question 05/05/18 12:17 PM CDT Cleansed and irrigated wound with normal saline and applied dry sterile dressing. a culture was taken of your foot and sent to the lab to find out what is going on with the drainage That makes sense. the wound was also cleaned and placed a sterile dressing Alright, thanks for letting me know. Do you have any medical conditions? Yeah. . . I have asthma and diabetes. When were you diagnosed with diabetes? I was diagnosed when I was 24. At age 24 you were diagnosed with diabetes? (Clarified to how old were you when you were diagnosed with diabetes.) I was diagnosed when I was 24. Do you know what type of diabetes you have? It's Type 2. Do you follow a diabetic diet? I really try not to worry about what I eat, other than watching my sugar and trying to make healthy choices. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 12:17 PM CDT Question 05/05/18 12:17 PM CDT Question 05/05/18 12:18 PM CDT Question 05/05/18 12:19 PM CDT Question 05/05/18 12:19 PM CDT Question 05/05/18 12:20 PM CDT Question 05/05/18 12:20 PM CDT Empathize 05/05/18 12:20 PM CDT Tell me more about any sugars you consume. Once I found out I had diabetes, I started watching my sugar and staying away from regular soda. Do you drink sugary drinks? No. I drink a lot of soda, but only Diet Coke. Do you take any prescribed medication for diabetes? (Clarified to Do you have a prescription for diabetes medication?.) I don't take medicine for it anymore. have you taken medication for diabetes? Yeah, when I was diagnosed they gave me a medicine to try. Do you remember what you were prescribed? It was Metformin. When was the last time you took your diabetes medication? I haven't taken it in about three years, honestly. Why aren't you taking your diabetes medication? I just got sick of dealing with it! I understand but medication is very important for your diabetes. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 12:21 PM CDT Question 05/05/18 12:22 PM CDT Question 05/05/18 12:22 PM CDT Educate 05/05/18 12:24 PM CDT Question 05/05/18 12:25 PM CDT Question 05/05/18 12:25 PM CDT Question 05/05/18 12:26 PM CDT Thanks. Tell me about your blood sugar monitoring. I don't check it very often, honestly. . . I think the last time was about a month ago. How often do you check your blood sugar? I don't check it very often, honestly. . . I think the last time was about a month ago. What are your usual blood sugar levels? I guess sometimes it's probably high, but I don't know the numbers. I almost never check it. I don't really get what the numbers mean. It is important to check your blood sugars on a regular basis. A diabetic educator will help you with this information in detail if you are interested. Thanks for telling me. Have you been thirsty lately? You know, I did notice lately that I've been really thirsty. Are you drinking more water than normal? I've definitely been drinking more water lately. Have you been urinating more often than usual? Yeah, but I've been drinking more water. 5/5/2018 Health History | Completed | Shadow Health Question 05/05/18 12:27 PM CDT Question 05/05/18 12:27 PM CDT Question 05/05/18 12:28 PM CDT Question 05/05/18 12:28 PM CDT Question 05/05/18 12:29 PM CDT Question 05/05/18 12:29 PM CDT Question 05/05/18 12:30 PM CDT How often do you urinate during the day? I don't know. Every hour or two when I'm awake? How often do you wake up at night to urinate? I probably have to get up two or three times a night. With your last meal? I had leftover chicken and mashed potatoes last night. what is your Typical breakfast? I'll usually have a muffin or pumpkin bread from the cafe near my house. what Is your typical lunch