Example Question: Have you ever had a seizure? Finding: Asked about patient belief system. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. This numerical evidence is required to establish obesity. Example Question: How often do you check your blood sugar? Tina Jones: Yeah, there's definitely pus. Evidence Pro Tip: The strongest evidence of impaired walking is that Tina directly reports she can't bear weight or walk on her affected foot. Example Question: Do you have muscle weakness? Student: Have you had any musculoskeletal problems? Finding: Denies latex allergy (Available)Pro Tip: Confirming absence or presence of a latex allergy is essential in a hospital setting, where some instruments have latex parts. 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: Denies nosebleeds (Available)Pro Tip: Asking about symptoms, such as frequent nosebleeds, is one possible component of a review of systems interview. Evidence Pro Tip: Tina directly reports ineffective diabetes management when discussing her lack of treatment. I guess a little over a year ago. Finding: Reports increased thirst (Found)Pro Tip: Your patient's thirst can offer insight into underlying medical conditions. Danny Rivera reports a history of frequent rhinorrhea and cough. Finding: Reports living in a house (Available)Pro Tip: Learning about your patient's living situation helps develop rapport and gives you a broad picture of her lifestyle. 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 vision loss. Sometimes it runs, but not very often. This record provides necessary information for healthcare professionals who will continue patient care. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. Asking Tina if her asthma can help you develop a sense of health patterns within her family. As a currently presenting symptom, it could impact the patient's care plan. I don't want to miss work or school but now it looks like I'll have to. Supporting evidence comes from her inability to incorporate meaningful dietary changes or increase her exercise. SUBSTANCE ABUSE HISTORY Have any of your family members had problems with alcohol and/or drug abuse?_____ Please describe who, their relationship to you, and the substances they abused._____ _____ _____ Please describe your alcohol and/or drug use, past … I can also walk through some pain management exercises with you that don't involve medication, if you are interested. Example Question: Are you drinking more water than normal? You can pause and resume the assignment at any time; your work is always saved automatically. Finding: Denies lymph node problems (Available)Pro Tip: Asking about a patient's lymph nodes is one possible component of a review of systems interview. Student: Do you have problems with your mouth? Example Question: Has your injury prevented you from going to class? Student: Do you have a family history of psychiatric illness? 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 allergic reactions or infection. Finding: Reports change in appetite began a month ago (Available)Pro Tip: Determining the onset of appetite change can reveal important details about underlying health conditions. And keeping your sugar down will help your foot wound heal quickly, too. Tina Jones: Well, I used to smoke pot. 7/22/2020 Health History | Completed | Shadow Health 2/9 Past Medical History Reports seeing pus draining from wound Reports noticing pus 2 days ago Followed up on drainage Reports pus as white or yellow Denies odor from the wound Asked about home treatment of foot wound Reports wound care regimen of bandaging Reports cleaning wound twice a day Reports applying bacitracin, neomycin … If a patient reports atypical discharge, it could indicate a yeast or sexually transmitted infection. I can give you some more information on what a balanced diet looks like for someone with diabetes. Contributing factors are a past history of hospitalization and asthma attacks, as well as sedentary lifestyle and obesity. They're crazy, but nobody's diagnosed with anything. ", 3.Gaps in health literacy around diabetic diet Not Encountered, Description: Tina describes controlling her diabetes by avoiding "sweets." Finding: Denies pain while breathing (Available)Pro Tip: Asking about pain during breathing is one possible component of a review of systems interview. Model Statement: "I understand how it can feel like a frustrating chore to check your sugar every day. Finding: Denies night sweats (Available)Pro Tip: Asking about additional symptoms, such as night sweats, is one possible component of a review of systems interview. Tina Jones: Well, Poppa died about five years ago. Finding: Reports maternal grandmother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Educate - Medication: Educate the patient on medications used for pain relief. Max twice a week. Example Question: How many puffs of your inhaler are you prescribed? Example Question: Do you have any environmental allergies? Example Question: Did you injure anything besides your foot? Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. Kind of big like me. Finding: Denies joint pain (Available)Pro Tip: Asking about joint pain is one possible component of a review of systems interview. Finding: Denies current chest tightness (Available)Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. Model Statement: "I'm sorry to hear about your father's passing. Finding: Reports pain affects ability to stand at work for long periods of time (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. You also want to identify any potential issues with substance abuse. Asking Tina if her paternal grandfather had diabetes can reveal generational patterns. Your questioning should cover a broad array of the symptoms' characteristics. The patient's response to these questions may uncover neurological problems. Your role in this simulation is that of a healthcare provider who will conduct a focused history and physical examination of Mr. Foster in order to assess his condition and transfer his care. Finding: Reports paternal grandfather diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Evidence - Relevant: Evidence Pro Tip: Tina directly reports that she doesn't exercise, which is the primary evidence for a sedentary lifestyle. Example Question: What is the pain like when you stand on your foot? Example Question: Do you remember what you were prescribed for diabetes? Student: Do you currently take medicine for your diabetes? Student: Have you had any prior hospitalizations? As a currently presenting symptom, flank pain could result in a change to the patient's care plan. Example Question: Tell me more about any sugars you consume. 11/30/2017 Health History | Completed | Shadow Health 1/9 Health History Results | Turned In Nurs 347 Health Assessment - Fall '17, NURS 347 Return to Assignment Your Results Lab Pass Indicates an item that you found. Intervene - Mobility: Provide assistive devices to facilitate mobility (crutches, therapeutic boot to minimize pressure on plantar surface, wheelchair). . Counseling around past drug use Not Followed Up, Description: Tina discusses her past history of marijuana smoking. Asking whether she's noticed ear discharge could indicate whether she has a ruptured eardrum. Finding: Denies current headache (Available)Pro Tip: Asking Tina is she currently has a headache is important because it might be contributing to her current discomfort and should be treated promptly. Finding: Reports allergy to cats (Found)Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies. Tina Jones: No, my heart's always been fine. Finding: Denies chills (Available)Pro Tip: Asking about additional symptoms, such as chills, is one possible component of a review of systems interview. Evidence - Relevant: "BMI: 31" Evidence Pro Tip: Tina's BMI is 31, which is in the obese range. Any recent or abrupt changes could impact the patient's care plan, such as administering treatment for constipation or diarrhea. Student: Can you walk with your foot being injured? Finding: Denies jaw problems (Available)Pro Tip: Asking about symptoms, such as jaw problems, is one possible component of a review of systems interview. 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. Finding: Denies lumps (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as lumps, is one way of assessing overall breast health. As a currently presenting symptom, it could indicate a change in patient status. Student: Hello, my name is Catlain, I am your nurse today. 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. Example Question: How long did it take you to lose 10 pounds? Move from open questions to closed questions (shaped like a cone), "cast a wide net" - allow patients to communicate more generally, and allow them to emphasize their own concerns and priorities, "Describe", "Tell me about", "How", "Why", - Ask the patient to elaborate or describe, "zoom in" on particulars and refine their understanding of an aspect of patient health, "How many", "How Often", "Can you, do you, will you, are you", "is it, has it, have you, etc", "Which", "Who". 3 Sometimes, very severe abdominal pain is described as acute, which is appropriate only if the pain is a new problem. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. Previous levels of lipids if ever checked or known. Student: Have you ever smoked cigarettes? Evidence - Relevant: Evidence Pro Tip: The strongest evidence of Tina's fall risk is reports of being unable to bear weight or walk on her foot. I definitely don't anymore, though. Tina Jones: He died last year, so I was 27. I think she had high blood pressure and cholesterol, too. . Evidence - Relevant: "Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent blood glucose monitoring and a general lack of diabetes management, which increases her risk for fluctuating blood glucose levels. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. Example Question: Does your maternal grandmother have health conditions? This can be achieved by asking for a 24-hour diet recall. Provide assistance with activities such as toileting and ensure that the patient can access and use assistive devices. Diana Shadow: Hi. Student: We are going to take care of everything as quickly as possible. Example Question: What is your reaction to penicillin? And hit a tree. Example Question: Do you have any existing conditions? Finding: Reports occasionally taking acetaminophen (Tylenol) for headaches (Available)Pro Tip: Finding out about your patient's use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions. There was about a month where it was hard for us to get to church. Student: Can you walk with your foot being injured? The presence of a physical injury supports her susceptibility to acute pain. Example Question: Does the pain radiate anywhere else? Priority - High Priority Pro Tip: Uncontrolled blood glucose levels delay or prevent wound healing, and must be addressed to resolve the infection. Example Question: Do you have a family history of thyroid problems? . Example Question: Can you please describe the pain? Example Question: Do you ever have ringing in your ears? As a currently presenting symptom, nocturia could result in a change to the patient's care plan. Different sources include different questions to be asked while conducting a PMH, but in general, they include the following: General state of health: e.g. Also, to help treat their current condition. Evidence - Relevant: "No, I don't take anything for my diabetes anymore." Questions to Instructor Forum: This is a great place to ask course content or assignment questions. Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Assess - Musculoskeletal: Assess the patient's mobility. Example Question: Have you ever smoked cigarettes? Finding: Reports she stopped because of health reasons and waning interest (Available)Pro Tip: Communicating about why a patient stopped or started drug use gives insight into their attitudes and dependencies on a substance. Example Question: What prescription medications do you take? Example Question: Have you had ear discharge? but I don't do that anymore. 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