NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children Case
NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children Case Example Solution Included
NURS 6512 Week 3: Assessment of Nutrition in Children
Many experts predict that genetic testing for disease susceptibility is well on its way to becoming a routine part of clinical care. Yet many of the genetic tests currently being developed are, in the words of the World Health Organization (WHO), of “questionable prognostic value.
—Leslie Pray, PhD
Obesity remains one of the most common chronic diseases in the United States. As a leading cause of United States mortality, morbidity, disability, healthcare utilization and healthcare costs, the high prevalence of obesity continues to strain the United States healthcare system (Obesity Society, 2016).
More than one-third (39.8%) of U.S. adults have obesity (CDC, 2018). The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; the medical costs for people who are obese were $1,429 higher than those of normal weight (CDC, 2018).
According to the Centers for Disease Control and Prevention (CDC), the rate of childhood obesity has tripled in the past 30 years, with an estimated 13.7 million children and adolescents considered obese (CDC, 2018). When seeking insights about a patient’s overall health and nutritional state, body measurements can provide a valuable perspective. This is particularly important with pediatric patients.
Measurements such as height and weight can provide clues to potential health problems and help predict how children will respond to illness. Nurses need to be proficient at using assessment tools, such as the Body Mass Index (BMI) and growth charts, in order to assess nutrition-related health risks and pediatric development while being sensitive to other factors that may affect these measures. Body Mass Index is also used as a predictor for measurement of adult weight and health.
Assessments are constantly being conducted on patients, but they may not provide useful information. In order to ensure that health assessments provide relevant data, nurses should familiarize themselves with test-specific factors that may affect the validity, reliability, and value of these tools.
This week, you will explore various assessment tools and diagnostic tests that are used to gather information about patients’ conditions. You will examine the validity and reliability of these tests and tools. You will also examine assessment techniques, health risks and concerns, and recommendations for care related to patient growth, weight, and nutrition.
Learning Objectives
Students will:
- Evaluate validity and reliability of assessment tools and diagnostic tests
- Analyze diversity considerations in health assessments
- Apply concepts, theories, and principles related to examination techniques, functional assessments, and cultural and diversity awareness in health assessment
- Apply assessment skills to collect patient health histories
Week 3: Assignment 1 – Case Study Assignment: Assessment of Nutrition in Children
When seeking to identify a patient’s health condition, advanced practice nurses can use a diverse selection of diagnostic tests and assessment tools; however, different factors affect the validity and reliability of the results produced by these tests or tools. Nurses must be aware of these factors in order to select the most appropriate test or tool and to accurately interpret the results.
Not only do these diagnostic tests affect adults, body measurements can provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture—among other factors—are also relevant. That said, gathering and communicating this information can be a delicate process.
For this Assignment, you will consider examples of children with various weight issues. You will explore how you could effectively gather information and encourage parents and caregivers to be proactive about their children’s health and weight.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
TO PREPARE
- Review this week’s Learning Resources and consider factors that impact the validity and reliability of various assessment tools and diagnostic tests. You also will review examples of pediatric patients and their families as it relates to BMI.
- Based on the risks you might identify consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
- Consider how you could encourage parents or caregivers to be proactive toward the child’s health.
THE ASSIGNMENT
Assignment (3–4 pages, not including title and reference pages):
Assignment: Child Health Case:
Include the following:
- An explanation of the health issues and risks that are relevant to the child you were assigned.
- Describe additional information you would need in order to further assess his or her weight-related health.
- Identify and describe any risks and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
- Taking into account the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information.
- Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight.
Case 1: Acklin, Alvarez, Amama, Basco, Black, Bolivard, Brown & Colyer
4-year-old overweight female with normal weight parents who are living with elderly grandparents in their home
Case 2: Curry, Fobanjong, Garcia, Green, Hutcheson, Iskander, Jean & Johnson
10-year-old severely underweight male in 3rd grade who lives with her normal weight mom on the weekends and her underweight father during the week.
Case 3: Jordan, Moore, Parfait, Pina, Queija, Raymond & Russell
5-year-old severely underweight male who lives with his normal weight adopted mother and father.
LEARNING RESOURCES
- Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 3, “Examination Techniques and Equipment”
This chapter explains the physical examination techniques of inspection, palpation, percussion, and auscultation. This chapter also explores special issues and equipment relevant to the physical exam process.
o Chapter 8, “Growth and Nutrition”
In this chapter, the authors explain examinations for growth, gestational age, and pubertal development. The authors also differentiate growth among the organ systems.
- Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Student checklist: Health history guide Download Student checklist: Health history guide. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
- Centers for Disease Control and Prevention. (2021, April 9). Childhood overweight & obesity. http://www.cdc.gov/obesity/childhood/
This website provides information about overweight and obese children. Additionally, the website provides basic facts about obesity and strategies to counteracting obesity. - Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
o Chapter 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom Analysis”
This chapter introduces the diagnostic process, which includes performing an analysis of the symptoms and then formulating and testing a hypothesis. The authors discuss how becoming an expert clinician takes time and practice in developing clinical judgment.
- Nyante, S. J., Benefield, T. S., Kuzmiak, C. M., Earnhardt, K., Pritchard, M., & Henderson, L. M. (2021). Population‐level impact of coronavirus disease 2019 on breast cancer screening and diagnostic procedures. Cancer, 127(12), 2111–2121. https://doi.org/10.1002/cncr.33460
- Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). History subjective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.
- Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Week 1)
o Chapter 5, “Pediatric Preventative Care Visits” (pp. 91 101)
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
- Shadow Health. (2021). Welcome to your introduction to Shadow Health. https://link.shadowhealth.com/Student-Orientation-Video
- Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us
- Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. Download Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
- Document: Shadow Health Nursing Documentation Tutorial Download Shadow Health Nursing Documentation Tutorial(Word document)
Required Media
Taking a Health History
How do nurses gather information and assess a patient’s health? Consider the importance of conducting an in-depth health assessment interview and the strategies you might use as you watch. (16m)
Optional Resources
- LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.
o Chapter 3, “The Screening Physical Examination”
o Chapter 17, “Principles of Diagnostic Testing”
o Chapter 18, “Common Laboratory Tests”
NURS_6512_Week_3_Assignment_1_Rubric
| NURS_6512_Week_3_Assignment_1_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning Outcome In 3–4 pages, address the following: An explanation of the health issues and risks that are relevant to the child you were assigned. |
|
25 pts | ||||
| This criterion is linked to a Learning Outcome Describe additional information you would need in order to further assess his or her weight-related health. |
|
25 pts | ||||
| This criterion is linked to a Learning Outcome Identify and describe any risks, and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Taking into account the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information. |
|
10 pts | ||||
| This criterion is linked to a Learning Outcome Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight. |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. |
|
5 pts | ||||
| Total Points: 100 | ||||||
NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children Case Example Solution 1
Assessment of Nutrition in Children Example Approach
Nutrition, among other things, influences children’s growth and development. The nutritional need is especially important before a child reaches the age of five, owing to the robust physical and physiological development. At this stage of development, any dietary deficiency has both short- and long-term health repercussions. The case study is about a five-year-old severely underweight child who lives with his normal-weight adopted mother and father. His weight predisposes him to several health issues and hazards, as detailed below.
An Explanation of the Health Issues and Risks Relevant to the Child
Given the consequences of malnutrition, especially during the first five years of life, adequate nutrition is paramount. Low weight for age is one of the signs of malnutrition, as demonstrated in the 5-year-old child’s case scenario. Concerning health issues and risks, the child will undergo immunological, cardiovascular, gastrointestinal, endocrine, genitourinary, and circulatory changes.
The immune system of malnourished children is significantly compromised due to decreased immunoglobin levels, reduced complement system, and low phagocytic activity, putting the child at risk of infections (Dipasquale et al., 2020). In the cardiovascular system, the patient is in danger of diminished cardiac output and low blood pressure, which may lead to hypoperfusion of the body’s vital organs (Dipasquale et al., 2020).
Because of the gut’s diminished absorptive capacity, nutritional absorption is substantially reduced, exacerbating undernutrition. Furthermore, in the genitourinary system, the kidney’s capacity to excrete excess acid and water is severely diminished, and the patient is vulnerable to urinary tract infections due to inadequate immunity (Dipasquale et al., 2020). The many biochemical and physiological changes are a response to the body’s already low energy levels.
Additional Information
Obtaining a medical history from children may be challenging; consequently, in most circumstances, proxy reporting by parents is helpful. It is critical to gather information on the various causes of the child’s malnutrition, as well as vital data for the child’s diagnosis.
Data on the child’s dietary intake may tell if child abuse is a likely cause of malnutrition. According to Burford et al. (2020), the underprivileged, such as adopted children, may encounter medical neglect in a variety of ways, one of which is a deprivation of adequate nutritious food. Asking the parents about the child’s dietary schedule, components, and capacity to acquire food is vital
Malnutrition may be caused by nutritional deprivation, but it can also be associated with other medical conditions. I would have to determine whether the child has any medical condition that causes significant wasting, such as HIV, tuberculosis, malignancies, or any other chronic disease. Laboratory testing would also provide further information to aid in determining the cause of malnutrition.
Among the valuable laboratory data that would be required are a complete blood count or blood culture, which may indicate an infection as a cause or a consequence of malnutrition, HIV testing, and Xpert MTB/RIF for tuberculosis (Keller, 2019). Because the child is adopted, obtaining information from the parents may be challenging because they are more likely to conceal any history of the child’s mistreatment.
As a result, emphasizing the significance of the medical history to the parents, explaining to them in clear, precise, and unadorned language, and acknowledging or speaking to them in their local language are critical in acquiring the information.
NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children Case References
Burford, A., Alexander, R., & Lilly, C. (2020). Malnutrition and medical neglect. Journal of Child & Adolescent Trauma, 13(3), 305–316. https://doi.org/10.1007/s40653-019-00282-0
Dipasquale, V., Cucinotta, U., & Romano, C. (2020). Acute malnutrition in children: Pathophysiology, clinical effects and treatment. Nutrients, 12(8), 2413. https://doi.org/10.3390/nu12082413
Keller, U. (2019). Nutritional laboratory markers in malnutrition. Journal of Clinical Medicine, 8(6), 775. https://doi.org/10.3390/jcm8060775
NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children Case Example Solution 2
Malnutrition in children is a weight and nutrition-related condition that has caused a significant morbidity and mortality both in the developing and developed countries. Underweight condition is defined by the body mass index (BMI) or body fat percentage that is too low for general sustainable health. According to the World Health Organization, weight is charted against the age of the child. The child is then considered underweight when their weight for age falls below negative two standard deviations (WHO, 2010).
Health Issues and Risks of being Underweight
Severe underweight in children is associated with nutritional and immunity deficiencies that place the individuals at risks of growth impairment presenting with stunting, osteoporosis, and recurrent infections. The body requires minerals and nutrients for growth, sustenance and immune system development.
Underweight individuals are also at risks of developing cardiovascular diseases. However, their risk of developing cardiovascular disease is less than that of the obese and overweight individuals (Park et al., 2017). In comparison, the risk in overweight individuals depends on coexisting comorbidities while that in underweight individual does not.
Being underweight has been recently associated with higher mortality than normal. The impact is worse in older populations than younger age groups (Lorem et al., 2017). Underweight individuals are also at risk of developing acute recurrent infections. Common infections include the upper respiratory tract infections (URTIs) and skin infections (Harpsøe et al., 2016). For this reason, comprehensive interventions are necessary to mitigate the effects of being underweight on long-term health outcomes.
Additional Information to Further Assess her Weight-related Health
The patient for this week’s case study is a twelve-year old Hispanic girl who is severely underweight. Her parents are underweight as well. She recently experienced bullying in school, probably due to her condition. Weight below the normal for age can be acute or chronic depending on the duration and onset of decline in weight.
Additional information required to assess her health would further include the family nutrition, health conditions during the pregnancy, birth, and postnatal life (Kumar et al., 2019); and presence of chronic familial illnesses (Tatsumi et al., 2016). The information acquired would determine the type of under-nutrition and the most appropriate management approach.
Since the girl’s parents are also underweight, it would be prudent to examine the history of genetic or familial chronic illnesses in the nuclear and extended families. The circumstances during pregnancy that are worth examining include the maternal nutritional knowledge level. The mother’s nutrition during the prenatal period and nutrition of the child in the postnatal life would be responsible for the weight status of the patient.
Information about sugar control and diabetes in the family is also important in assessing the weight status of the child. Type I diabetes, common in childhood, sometimes has a genetic component. Diabetes presents with weight loss that could be responsible for the child’s underweight status (Balcha et al., 2018). Other chronic illnesses too inhibit proper growth and weight increase.
Specific Questions about the Child to Gather More Information
The etio-pathogenesis of underweight status and malnutrition in not limited to nutritional causes. Therefore, specific questions will be necessary to gather more information to make more accurate diagnosis and build a more accurate health history. I would ask the child’s informant the following specific questions:
- What food does your family take regularly?
- Is there any genetic condition that runs in your family?
- Has your child lost any developmental achievements that she had already achieved?
These three questions would assess the nutritional status of the family, inherited conditions, and the severity or developmental consequences of the low weight for age.
Two Strategies that would encourage the Parents to be Proactive about their Child’s Health and Weight
Barriers in health promotion for weight and nutritional management exist between healthcare providers and the caretakers or the parents of children. The fulltime caregivers for the child are the parents and therefore, I would enhance patient education and health maintenance through collaboration with the parents. The two strategies that I would use include proper and effective communication and nutritional recommendations.
Further, I would need to fully understand the cultural origin and eating patterns of the patient’s family. This will be achieved through nutritional assessment before applying the recommendations and strategies. Often, social stigma arises due to low weights and malnutrition among families. Sometimes parents are not willing to discuss these with their care providers. They end up holding vital information that would help the clinician to solve the nutritional issues in a cheaper and more efficient ways (Dev et al., 2017).
I would ensure open and free communication to discuss with the parents about their knowledge of under-nutrition and low weight for age, as well as the risks associated with child under-nutrition. At this time, the actual etiologies of under-nutrition for the patient are unknown and this discussion would provide the possible etiologies and therapies. I would reassure the parents on their abilities and role in maintaining an adequate weight and health for their child and that their child’s low weight may not primarily be the result of their parenting skills.
Finally, the nutritional strategy would include advising the parents on their role on the child’s food intake and lifestyle. I would encourage the parents to give the child more meals in small quantities in a day. Increasing the frequency and reducing the amount of food intake allows the body to maximize the calories intake and absorption.
I would also encourage adequate sleep and increase in playing time for the child to promote cardiovascular function (Centers for Disease Control and Prevention, n.d.). The parents would also be advised to provide adequate amounts of water to their child after meals and limit too much fatty foods as it would not be healthy for the child’s cardiovascular system.
NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children Case References
- Balcha, S., Phillips, D., & Trimble, E. (2018). Type 1 Diabetes in a Resource-Poor Setting: Malnutrition Related, Malnutrition Modified, or Just Diabetes?. Current Diabetes Reports, 18(7). https://doi.org/10.1007/s11892-018-1003-7
- Centers for Disease Control and Prevention. Help Children Maintain Healthy Weight. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/healthyweight/children/index.html.
- Dev, D., Byrd-Williams, C., Ramsay, S., McBride, B., Srivastava, D., & Murriel, A. et al. (2017). Engaging Parents to Promote Children’s Nutrition and Health. American Journal f Health Promotion, 31(2), 153-162. https://doi.org/10.1177/0890117116685426
- Harpsøe, M., Nielsen, N., Friis-Møller, N., Andersson, M., Wohlfahrt, J., & Linneberg, A. Nohr, E. A., & Jess, T.. (2016). Body Mass Index and Risk of Infections Among Women in the Danish National Birth Cohort. American Journal of Epidemiology, 183(11), 1008-1017. https://doi.org/10.1093/aje/kwv300
- Kumar, R., Abbas, F., Mahmood, T., & Somrongthong, R. (2019). Prevalence and factors associated with underweight children: a population-based subnational analysis from Pakistan. BMJ Open, 9(7), e028972. https://doi.org/10.1136/bmjopen-2019-028972
- Lorem, G., Schirmer, H., & Emaus, N. (2017). What is the impact of underweight on self-reported health trajectories and mortality rates: a cohort study. Health And Quality Of Life Outcomes, 15(1). https://doi.org/10.1186/s12955-017-0766-x
- Park, D., Lee, J., & Han, S. (2017). Underweight. Medicine, 96(48), e8769. https://doi.org/10.1097/md.0000000000008769
- Tatsumi, Y., Higashiyama, A., Kubota, Y., Sugiyama, D., Nishida, Y., & Hirata, T., Kadota, A., Nishimura, K., Imano, H., Miyamatsu, N., Miyamoto, Y., & Okamura, T. (2016). Underweight Young Women Without Later Weight Gain Are at High Risk for Osteopenia After Midlife: The KOBE Study. Journal of Epidemiology, 26(11), 572-578. https://doi.org/10.2188/jea.je20150267
- World Health Organization, WHO. (2010). Nutrition landscape information system. Retrieved from https://www.who.int/nutrition/nlis_interpretation_guide.pdf
Tina Jones Health History Subjective Data Collection: 98 of 100 (98.0%)
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
(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:
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
(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
(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 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
(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 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
(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 often did you clean the wound?
Finding:
Reports cleaning wound with hydrogen peroxide
(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 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
(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 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
(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 your foot pain affect your work?
Finding:
Reports pain prevented her from being able to walk to class
(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:
Has your injury prevented you from going to class?
Past Medical History
Finding:
Asked about preexisting medical conditions
Finding:
Reports diabetes
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have diabetes?
Finding:
Reports asthma
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have asthma?
Finding:
Followed up on diabetes diagnosis
Finding:
Reports specific age of diagnosis was 24
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
At what age were you diagnosed with diabetes?
Finding:
Reports that her diabetes is Type 2
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you know what type of diabetes you have?
Finding:
Asked about diabetes management through lifestyle changes
Finding:
Reports staying away from sweets
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Tell me more about any sugars you consume.
Finding:
Reports drinking diet soda instead of regular
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you drink sugary drinks?
Finding:
Asked about current diabetes medication use
Finding:
Reports that she does not currently take medication for diabetes
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you take prescribed medication for your diabetes?
Finding:
Asked about past diabetes medication use
Finding:
Reports that she used to take diabetes medication
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you ever taken medication for your diabetes?
Finding:
Reports previous medication was prescription metformin
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you remember what you were prescribed for diabetes?
Finding:
Reports last use of medication was 3 years ago
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When was the last time you took your diabetes medication on a regular basis?
Finding:
Asked about blood glucose monitoring
Finding:
Reports infrequent blood glucose monitoring
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Tell me about your blood sugar monitoring.
Finding:
Reports last glucose check was a week ago at the ER
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How often do you check your blood sugar?
Finding:
Reports confusion about what the numbers mean
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What are your usual blood sugar levels?
Finding:
Asked about thirst
Finding:
Reports increased thirst
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you been more thirsty lately?
Finding:
Reports increased water intake
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Are you drinking more water than normal?
Finding:
Asked about frequency of urination
Finding:
Reports more frequent urination
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you been urinating more often than usual?
Finding:
Reports urinating every hour or two during the day
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How often do you urinate during the day?
Finding:
Reports urinating 2 to 3 times during the night
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How often do you wake up at night to urinate?
Finding:
Asked about change in appetite
Finding:
Reports increased appetite
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Have you noticed an increase in appetite?
Finding:
Reports change in appetite began a month ago
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When did you notice the increase in your appetite?
Finding:
Asked about weight change
Finding:
Reports recent loss of 10 lbs
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How much weight have you lost?
Finding:
Reports weight loss occurred over the past month
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
How long did it take you to lose 10 pounds?
Finding:
Followed up on reason for weight change
Finding:
Reports weight loss was unintentional
(Available)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Was your weight loss intentional?
Finding:
Asked about history of asthma exacerbations
Finding:
Reports last asthma attack was in high school
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When was your last asthma attack?
Finding:
Reports last exacerbation was three days ago
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
When did you last have issues with asthma?
Finding:
Asked about asthma symptoms
Finding:
Reports chest tightness during exacerbation
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
What do your asthma symptoms feel like?
Finding:
Reports difficulty breathing during exacerbation
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have trouble breathing?
Finding:
Reports wheezing during exacerbation
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you ever wheeze?
Finding:
Asked about prior hospitalizations
Finding:
Reports past hospitalizations
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Also Read: NRNP 6635 Case History Reports Example 2
