Tina Jones Comprehensive Assessment Results

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Shadow Health Comprehensive Assessment Results

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Comprehensive Assessment Results |

NUR 3065

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Overview

Transcript

Subjective Data Collection

Transcript

All Lines (485) Interview Questions (148) Statements (15) Exam Actions (322)

Started: Dec 07, 2015 | Patient Exam Time: 199 min

Objective Data Collection

Documentation

hello mrs jones my name is ashley i will be your nurse today

Greet

10:26 AM EST

Plan My Exam

Hey.

I am going to do a physical exam on you and ask you some questions along the way

Educate

10:27 AM EST

Thanks for telling me.

let me know if any thing feels uncomfortable for you and i will do my best to be gentle

Empathize

10:28 AM EST

Thanks.

can you tell me your name and date of birth

Question

10:28 AM EST

My name’s Tina Jones, and my birthday’s February 17th.

do you have any medication allergies

Question

10:29 AM EST

Yeah, I’m allergic to penicillin.

what happens if you take penicillin

Question

10:29 AM EST

I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that.

do you have any environmental allergies

Question

10:30 AM EST

The only allergies I know of are cats and penicillin. . . and I think I’m allergic to dust, too. But I’ve been really good about avoiding asthma triggers lately.

what happens when you are around cats

Question

10:30 AM EST

I’ve been trying really hard to stay away from cats, but I have been around them a couple times without meaning to. I still get allergic around them, and my asthma acts up, but not as bad as when I had to come in a while ago.

what do you do when your asthma acts up (Clarified to what treatment did you use when your asthma acted up.)

Question

10:31 AM EST

My breathing has been great lately. . . I got a new inhaler that I use every day, and now I barely ever use my rescue inhaler.

ok great i am going to take your vitals now

Educate

10:32 AM EST

Thanks for telling me.

are you experiencing any pain

Question

10:32 AM EST

I don’t have any pain anywhere.

do you have a family history of cancer

Question

10:33 AM EST

Um, Grandpa Jones died of colon cancer.

i am sorry to hear that

Empathize

10:33 AM EST

Thanks.

do you have a family history of stroke

Question

10:34 AM EST



Yeah, that’s how my Nana died.

do you have a family history of heart disease

Question

10:34 AM EST

Well. . . only Poppa. He died of a heart attack.

do you have a family history of skin cancer

Question

10:35 AM EST

The only cancer that I know of in our family is colon cancer–Grandpa Jones died of that.

do you have a family history of diabetes

Question

10:35 AM EST

Dad had sugar diabetes, and I think my Grandpa Jones did too.

do you have a history of hypertension

Question

10:36 AM EST

Yeah, I had high blood pressure when I had it checked here a while ago, but then the gynecologist checked it recently and said it was normal, so I think it improved.

do you have diabetes

Question

10:37 AM EST

Yeah, I was diagnosed a few years ago.

can you tell me what a typical diet would be for you

Question

10:38 AM EST

Well. . . for breakfast, a smoothie made with frozen fruit and yogurt or an egg on wheat toast with yogurt on the side. For lunch, I eat leftovers from dinner the night before, or I’ll have a sandwich on wheat bread.

Then for dinner, I’ll have chicken or fish, usually, with vegetables and brown rice or quinoa on the side.

what medications do you use at home

Question

10:48 AM EST

I’m taking metformin now, that’s every day. And I take Yaz, the birth control pill. I’m on a daily inhaler, Flovent, and a rescue inhaler, Proventil, when I need it.

do you have asthma

Question

10:49 AM EST

Yeah, I do.



how often do you use your rescue inhaler

Question

10:49 AM EST

Only once every few months.

does the rescue inhaler work for you (Clarified to does the inhaler work.)

Question

10:50 AM EST

Yeah, it’s always really helped me.

do you have any problems caring for yourself at home

Question

10:51 AM EST

Of course I do. I try to make healthy decisions, but sometimes my busy work and school schedule get in the way.

do you need any assistance walking

Question

10:52 AM EST

I don’t need help with that, no.

whats your name and date of birth

Question

10:53 AM EST

My name is Tina Jones, and I was born on February 17th.

Discovered orientation to person

Exam Action

10:53 AM EST

what building are you in now

Question

10:53 AM EST

I’m at the doctor’s office. . . it’s Shadow Health General Clinic.

Discovered orientation to place

Exam Action

10:53 AM EST

what is the date and year

Question

10:53 AM EST

It’s [Tina says correct date and year].

Confirmed situation orientation

Discovered orientation to time

Exam Action

10:53 AM EST

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Performed pulse oximetry

Performed spirometry

Exam Action

10:53 AM EST

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10:53 AM EST

do you have any open wounds on you

Question

10:56 AM EST

I think I’d notice if I hurt myself.

i am going to start your physical exam

Educate

10:56 AM EST

Thanks for telling me.

Inspected scalp

Inspected hair on scalp

Inspected facial skin

Exam Action

10:56 AM EST

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10:56 AM EST

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10:56 AM EST

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10:57 AM EST

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10:57 AM EST

i noticed you have discoloration on your neck. when did that start

Question

10:57 AM EST

I think it’s been a couple years at this point.

does that area around your neck cause you any discomfort (Clarified to has the skin on your neck been painful.)

Question

10:58 AM EST

The skin on my neck feels normal to me.

do you have any skin issues

Question

10:58 AM EST

Well, I still get zits but my acne is better than it used to be. I think the birth control is helping. And the skin on my neck… I don’t think it’s getting any darker.

thats great that you are seeing an improvement in your skin. a lot of times acne is brought on by changes in hormones birth control is a big help for a lot of people

Empathize

11:00 AM EST

Thanks.

Inspected left arm

Inspected right arm

Inspected right shoulder

Inspected right elbow

Inspected right shoulder

Inspected left shoulder

Inspected left elbow

Inspected left hand

Inspected right hand

Exam Action

11:00 AM EST

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11:01 AM EST

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11:01 AM EST

do you suffer from dry skin

Question

11:01 AM EST

It’s always been pretty dry, since I was a teenager at least. I just moisturize, and that seems to take care of it. [AUDIO COMING SOON]

have you noticed any scraps or tears in your skin

Question

11:01 AM EST



Well, I still get zits but my acne is better than it used to be. I think the birth control is helping. And the skin on my neck… I don’t think it’s getting any darker.

Inspected fingernails: no ridges or abnormalities

Inspected toenails: no ridges or abnormalities

Inspected scalp

Inspected hair on scalp

Palpated scalp: no masses

Inspected upper eyelids

Inspected lower eyelids

Exam Action

11:01 AM EST

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11:03 AM EST

what do you use glasses for (Clarified to Why do you wear glasses.)

Question

11:03 AM EST

I went in to the eye doctor about three months ago, and she said I was near sighted and prescribed these glasses.

Inspected right eyebrow and orbital area

Inspected left eyebrow and orbital area

Exam Action

11:04 AM EST

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11:04 AM EST

have you noticed any discharge from your eyes

Question

11:05 AM EST

Nothing’s been coming out of my eyes.

have you had any redness or itching from your eyes

Question

11:05 AM EST

My eyes haven’t been red lately.

have you noticed any vision changes

Question

11:05 AM EST



I don’t have problems now that I got these glasses.

when was the last time you had an eye exam

Question

11:06 AM EST

I hadn’t gone in a long while, but I went three months ago. She tested my vision and prescribed these glasses. I’m supposed to go back next year.

Tested right pupillary light reflex

Tested left pupillary light reflex

Exam Action

11:06 AM EST

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11:06 AM EST

are you having any problems hearing

Question

11:07 AM EST

My hearing is good.

Examined fundus of right eye

Examined fundus of left eye

Exam Action

11:07 AM EST

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11:08 AM EST

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11:08 AM EST

can you follow my finger with your eyes

Question

11:09 AM EST

Ok.

Tested convergence

Tested extraocular movement

Exam Action

11:09 AM EST

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tell me when you can no longer see my fingers

Question

11:10 AM EST

Ok, I will.

Tested peripheral vision

Exam Action

11:10 AM EST



Now.

F P

T O Z

L P E D

P E C F D

E D F C Z P

F E L O P Z D

have you noticed any drainage from your ears

Question

11:12 AM EST

I haven’t noticed anything like that.

are you having any trouble hearing

Question

11:12 AM EST

My hearing is good.

any earaches

Question

11:12 AM EST

My ears feel fine.

noticed any ringing in your ears

Question

11:13 AM EST

My ears have been normal. . .

have you noticed any dizziness

Question

11:13 AM EST

I haven’t been getting dizzy at all.



any recent headaches

Question

11:13 AM EST

I haven’t had any headaches lately, actually.

ever head injury (Clarified to have you ever had a head injury.)

Question

11:14 AM EST

No, I’ve still never had that kind of injury.

how do you clean your ears

Question

11:15 AM EST

I use Q tips maybe once a week.

qtips can rupture your ear drum if they are inserted to far we recommend only using a washcloth

Educate

11:16 AM EST

Thanks for telling me.

Inspect ears

Inspected right naris

Inspected left naris

Performed otoscopic exam of right ear

Performed otoscopic exam of left ear

Exam Action

11:16 AM EST

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have you noticed any discharge from your nose

Question

11:18 AM EST

No, my nose hasn’t been running at all.

any nasal stuffiness

Question

11:19 AM EST

My nose has been fine, other than around cats. I’ve been really careful to avoid them lately, though.

do you get frequent colds

Question

11:19 AM EST

No, I don’t get colds at all really.

any nosebleeds

Question

11:19 AM EST

Nope.

Four

Question

11:19 AM EST

Four.

Question

R. 11:20 AM EST

R.

Nine.

Question

11:20 AM EST

Nine.

Performed whisper test on left ear

Exam Action

11:20 AM EST

Question

F. 11:20 AM EST

F.

Eight

Question

11:20 AM EST

Eight.

Question

W. 11:20 AM EST

W.

Performed whisper test on right ear