NRS 420 Shadow Health: Health History
NRS 420 Shadow Health: Health History
In this assignment you will interview your first Digital Standardized Patient, Tina Jones; document her comprehensive health history; and complete post-exam activities. Within the Shadow Health platform, complete Health History. The estimated average time to complete this assignment each time is 1 hour and 55 minutes. Please note, this is an average time. Some students may need additional time GCU.
You can attempt this assignment as many times as you would like. After completing the health history, you will be awarded a Digital Clinical Experience (DCE) score. The DCE score will appear on your Lab Pass which you will submit to the classroom drop box. The DCE score will be used as your percentage grade for this assignment.
You are not required to submit this assignment to LopesWrite.
American Association of Colleges of Nursing Core Competencies for Professional Nursing Education
This assignment aligns to AACN Core Competency 2.4.
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): “recent right foot injury.”
History of Present Illness (HPI): Miss Jones, a 28-year-old African American, came to the healthcare facility to establish care. The client got twisted and scraped on her right foot a week ago after falling while climbing the stairs. She thought the pain could go away, but it has not, and the wound looks pretty bad, and she is experiencing excruciating pain. She visited the emergency department for help, and an X-ray was done; the results showed no significant problem.
As part of routine care, as advised, she cleans, applies antibiotic ointments, and bandages the wound. The care resolved the pain and swelling on her ankle, but the pain on the scarped foot has worsened, and the area is erythematous and swollen, producing some discharge. The wound is odorless. She complains that wearing shoes aggravates the pain, hence the choice of slippers. More so, she reports that the tramadol relieves pain and rates pain at 7/10 while on tramadol and 10/10 when not on tramadol. She had a fever of 102 in the last month. She reports a 10-pound weight loss despite increased appetite over the last month.
Medications: PO Acetaminophen 500- 1000 mg PRN for headaches, PO Ibuprofen 600mg TID PRN for cramping during cramps, Tramadol 50mg BID for pain (ankle and foot), and MD1 2puffs Albuterol 90 mcg/Spray PRN for asthmatic attacks. Albuterol use was three days ago after an asthmatic attack.
Allergies: No food or latex allergies reported; reacts to penicillin with a rush. Allergic to cats and dust, reacts with a runny nose, increased asthma symptoms, and swollen and itchy eyes.
Past Medical History (PMH): Ms. Jones was diagnosed with asthma at two and a half years due to dust and cat fur allergy. She manages the problem using an Albuterol inhaler. She was hospitalized in high school due to asthma, but was not intubated. Her diabetes was diagnosed four years ago, and she was started on metformin but discontinued the treatment three years ago, citing that the pills and sugar readings were tiresome. Hence, she also stopped recording her blood pressure. The last blood sugar measurement was last week during the ER department visit, and the results showed high blood sugar.
Past Surgical History (PSH): She has never been operated on
Sexual/Reproductive History: Her first menses was at 11, she first had sex at 18, and is nulliparous. She experiences irregular and painful menses; the last period was three weeks ago. She does not have a partner currently. She has a history of using contraceptives and uses condoms as protection during sexual intercourse. She has not tested for HIV/AIDS, has no history of STIs, and her last STI test was four years ago.
Personal/Social History: Ms. Jones is a single lady who has lived independently since she was 20. She has no children and has never been married. Her father died a year ago and moved in with her mother and sister to provide social support for her family. Apparently, she works at Mid-American Copy & Ship as a supervisor and studies part-time for a bachelor’s degree in accounting. She has plans to advance her career. She owns a car, smartphone, computer, and basic health insurance coverage.
During her free time, she spends time with friends, participates in bible study and dances, and volunteers in the church. Ms. Jones reports being stressed after her father died. She has to balance work and school with the available finances. Her strongest social support system is her church and family. She denies tobacco use and reports using marijuana between the ages of 15 and 21 for fun. She denies any other history of drug and substance use. She reports taking alcohol occasionally after going out with friends about twice or thrice a month, in which she takes less than three bottles. She has pets, is not in a relationship, but plans on having a family someday.
Immunization History: She has had a tetanus booster in the past year. Her influenza and H1N1 shots are not current. She also had a meningococcal vaccine while in college. Her childhood immunizations are up to date.
Health Maintenance: The patient had a pap smear four years ago, and her eyes were last examined in childhood. She denies exercising, and her 24-hour diet recall reveals talking muffins for breakfast, PB & J for lunch, and chicken and potatoes for supper. The diet is imbalanced, and there is a need for education on dieting. At home, she has smoke detectors, guns, and other firearms packed away safely for safety reasons. She also wears seatbelts when traveling by car. She does not ride bicycles and utilizes sunscreens in skin-exposure activities such as swimming.
Significant Family History: The mother, 50, is hypertensive and hypercholesterolemic. Father died at 58 after a road traffic accident and was hypertensive, hypercholesterolemic, and diabetic. Her brother, 25, is overweight. Her sister, 14, is asthmatic. Maternal grandfather passed at 73, was hypertensive, and had high cholesterol. Her maternal grandfather passed at 78 and had hypertension and high cholesterol. Paternal grandmother, 82, is hypertensive. Her maternal grandfather died at 65 and had a history of type 2 diabetes. Her paternal uncle is an alcoholic. She denies a family history of mental illness, sudden death, sickle cell anemia, thyroid problems, and kidney disease.
Review of Systems:
General: The patient reports increased foot pain and swelling. He had an increased weight of 10 pounds and a fever of 102
HEENT: denies any headache or head injury, the patient denies any pain swallowing, denies eye pain, or vision change, denies any hearing loss or change in hearing, denies mouth or throat soreness, bleeding gums, denies
Neck: Patient denies any neck pain and reports a full range of motion
Breasts: Patients reporting that the last self-breast exam was two weeks ago deny lumps, pain, or drainage
Respiratory: Patient denies chest pain, coughing, sneezing, or congestion, or shortness of breath
Cardiovascular/Peripheral Vascular: Denies chest pain, tightness, discomfort, or palpitations.
Gastrointestinal: Patient denies nausea, abdominal pain, vomiting, constipation, or diarrhea. Reports increased appetite
Genitourinary: Patient denies any pain with micturition, cloudy, blood-tinged, or colored urine
Musculoskeletal: The patient reports throbbing pain on the right foot, where there is a scrap injury on the ball of the foot, making weight bearing a problem that has worsened over time. The pain radiates to the right ankle and affects the performance of daily activities. The client reports drainage from the wounds; the discharge is white with no odor. She reports cleaning, applying Neosporin antibiotic, and bandaging the wound every night and morning to manage it and is worried that the wound’s condition has been worsening. Denies any other problem with the extremities.
Psychiatric: The patient denies any history of depression, anxiety, or other mental illnesses
Neurological: The patient reports occasional migraines, which she manages using acetaminophen. Denies tingling, numbness, or pain
Skin: The patient reports that her acne began in puberty. She reports that her facial hair and skin darkening around her neck has increased. Denies nail problems and reports having several moles
Hematologic: Patient denies bleeding, easy bruising, transfusion, and blood clotting history.
Endocrine: Patient reports increased appetite despite a loss of weight. She denies excessive sweating, excessive thirst, hunger, or urination.
Also Read: NRS 420 Topic 3 DQ 1 Explore the link to the YRBS results provided
