Shadow Health - Tina Jones, Health History (Latest 2022/2023) Updated Version, Exams of Nursing

Download Shadow Health - Tina Jones, Health History (Latest 2022/2023) Updated Version and more Exams Nursing in PDF only on Docsity! Shadow Health - Tina Jones, Health History Medications - Albuterol MDI, 2 puffs every 4 hours as needed for wheezing Acetaminophen 325 mg tabs by mouth, 2 tabs every 4 hours as needed for fever greater than 38.6C /101.5F Clindamycin 600mg/50ml every 6 hours intravenously 0.9 NaCl intravenously 100 ml/hr continuously x2 Liters Lortab 5mg 1-2 tabs by mouth as needed for pain Oxycodone 5mg 1 tab by mouth as needed Insulin glargine 10 units at bedtime Health History Tips & Tricks: - Student: Hello! - Diana Shadow: Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript. Student: What is the situation? - Diana Shadow: Your patient is Tina Jones:, a 28-year- old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones' health history, a key component of her admission process. Student: What are my objectives in this assessment? - Diana Shadow: A health history requires you to ask questions related to Ms. Jones' past and present health, from her current foot wound to her pre-existing conditions. You will also want to review Ms. Jones' systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones' overall health. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. Jones' health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. Student: What else will this exam involve? - Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation. Student: How will I be evaluated? - Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically. Student: How does this assignment prepare me for the real world? - Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses. Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient's complete health history? - Student: Getting a complete health history enables the nurse to make informed judgments about the client including formulating nursing diagnoses requiring nursing care, identifying collaborative problems requiring interdisciplinary care, medical issues requiring immediate referral, and the need for client teaching. Diana Shadow: Time to begin. - Patient Exam - Vital Signs: - Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98% Patient Exam - Interview: - Student: Hello, my name is Rachel and I am your nurse today. - Tina Jones: Hey. Student: Can you confirm your name? - Tina Jones: Tina Jones:. Student: What brings you in today? - Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me. Student: How often do you have asthma exacerbations? - Tina Jones: I haven't had a full attack in years. But my breathing definitely acts up. . .not always. Max twice a week. Student: What asthma symptoms have you experienced? - Tina Jones: My chest and throat get tight, and I start to wheeze. It feels like I can't take in air, like I can't get enough air into my lungs. Student: Does anything else worsen your asthma? - Tina Jones: Cats are the worst for my asthma--no matter what, if I'm around cats, my breathing gets bad. But sometimes it gets bad from being around dust or having to run upstairs, too. Student: Do you have a rescue inhaler? - Tina Jones: Yeah, I use it when my asthma acts up. Student: How many puffs do you take when using your asthma inhaler? - Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What allergies do you have? - Tina Jones: I'm allergic to cats. Student: How long have you had a cat allergy? - Tina Jones: For as long as I've been around. Student: What medication allergies do you have? - Tina Jones: I'm allergic to penicillin. Student: How old were you when you had an allergic reaction from penicillin? - Tina Jones: I don't remember....I was really young. I must have been sick or something. Student: Do you have any food allergies? - Tina Jones: Nope, no food allergies that I know of. Student: Are you allergic to latex? - Tina Jones: Nope. Student: Are you allergic to dust, mold, or pollen? - Tina Jones: Well. . . I don't know if it's allergies, but sometimes my asthma acts up around dust. Student: Are you up to date on all immunizations? - Tina Jones: I'm pretty sure my shots are current, yeah. Student: What immunizations have you received? - Tina Jones: I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college...I'm sure I have a record somewhere at home. Student: Have you received a flu vaccine? - Tina Jones: No. Student: The most effective way to prevent influenza is by getting a yearly influenza vaccine and using simple infection control measures such as washing your hands. There are also antiviral medicines that can also help prevent infection if you are exposed to the flu. - Tina Jones: ok thanks for the tip. Student: The flu vaccine is especially recommended for adults and children with chronic diseases like diabetes, or chronic lung conditions like asthma. - Tina Jones: Gotcha. Student: Have you had any prior hospitalizations? - Tina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I've been in the hospital since I was probably sixteen, though. Student: What were you admitted to the hospital for previously? - Tina Jones: For my asthma Student: Have you had any gastrointestinal problems? - Tina Jones: No. I've never really had stomach or bowel problems. Student: Do you have a family history of psychiatric illness? - Tina Jones: No. They're crazy, but nobody's diagnosed with anything. Student: Do you have any neck, throat or gland problems? - Tina Jones: No, not that I noticed. Student: Any problems with your ears? - Tina Jones: No. Student: Any problems with your eyes and vision? - Tina Jones: I've actually been noticing problems lately. When I'm reading or studying I'll notice that things start to get kind of blurry. Student: Do you suffer from headaches? - Tina Jones: I get headaches sometimes, but that's all. Student: Do you wear glasses? - Tina Jones: No. Student: Any problems with sinuses or nose? - Tina Jones: My nose is fine right now. Sometimes it runs, but not very often. Student: Do you have problems with your mouth? - Tina Jones: No. Student: Do you have a history of cardiovascular problems? - Tina Jones: My heart's fine, thank God! Student: Have you had any problems with your breasts? - Tina Jones: I haven't noticed any pain there. Student: Have you had any reproductive problems? - Tina Jones: I don't think I have problems in that area. I just get really bad periods, that's all. Student: Have you had any neurological problems? - Tina Jones: No, I haven't. Student: Have you had any musculoskeletal problems? - Tina Jones: No. Student: Do you have a history of skin disorders? - Tina Jones: Um, I have acne, if that counts. Student: Does your mother have any health issues? - Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. Student: Does your father have any health problems? - Tina Jones: Well, he passed away. But he had a couple things... Type 2 diabetes, like me, and high cholesterol and blood pressure. Student: I'm sorry to hear about your father's passing. - Tina Jones: Thanks. Student: How did your father pass away? - Tina Jones: He died in a car accident. Student: When did your father's car accident happen? - Tina Jones: It was last year... I guess a little over a year ago. Student: Do you know what caused your dad's accident? - Tina Jones: He was driving to work, and it was raining...and his car hydroplaned. And hit a tree. So, it was really sudden. Student: How did you cope with your fathers death? - Tina Jones: Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kind of depressed. So, I guess at first I just focused on getting things done--groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months. Student: That must have been very tough for you and your family to go through. - Tina Jones: Student: Does your paternal grandfather have any health problems? - Tina Jones: Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and...I'm pretty sure he had diabetes. And high cholesterol like everyone else in my family. Subjective Data Collection - Checklist: - Chief Complaint - Finding: Established chief complaint - Finding: Reports pain (Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. - Example Question: Do you have any pain? Finding: Reports foot wound (Found)Pro Tip: If a patient mentions pain, it's important to determine what specifically is causing her pain, if she knows. - Example Question: What's causing your pain? History of Presenting Illness - Finding: Asked to rate current pain level on a scale - Finding: Reports current pain is 7/10 (Found)Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care. - 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: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain. - Example Question: Can you please describe the pain? Finding: Reports pain is sharp when she attempts to stand (Found)Pro Tip: Determining what physical activities and movements exacerbate the patient's pain can help you better understand the problems and assess treatment needs. This can also alert you if a patient's activities of daily living are hindered. - Example Question: What is the pain like when you stand on your foot? Finding: Reports pain has increased in the past 2 days (Available)Pro Tip:Finding out how the patient's pain has changed will give you insight into the acceleration of infection. - Example Question: How has the pain changed over time? Finding: Reports feeling pain radiating into ankle (Available)Pro Tip: Asking about where else the patient's pain radiates can help determine the progression of infection. - Example Question: Does the pain radiate anywhere else? Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care. - Example Question: Can you bear weight on your foot? Finding: Asked location of wound - Finding: Reports right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patient's safety. - Example Question: Which foot is in pain? Finding: Reports wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient's biggest complaint. - Example Question: Where is the wound? Finding: Asked details of the injury - Finding: Reports she scraped foot on bottom rung of a step stool (Found)Pro Tip: Discovering how an injury happened helps to assess your patient's risk factors for injury. - Example Question: How did your injury happen? Finding: Reports injury occurred 1 week ago (Available)Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute. - Example Question: When did your injury occur? Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. - Example Question: Did you injure anything besides your foot? Finding: Reports being barefoot at the time of injury (Available)Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances. - Example Question: Were you wearing shoes when you fell? Finding: Denies seeing a healthcare provider for the injury until now (Available)Pro Tip: It's crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound. - Example Question: Have you seen a healthcare provider for this injury? Finding: Asked about drainage from the foot wound - Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound. - Example Question: Did your foot bleed? Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. - Example Question: Did you notice any discharge from the wound? Finding: Reports noticing pus 2 days ago (Available)Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began. - Example Question: When did you first notice the pus? Finding: Followed up on drainage - 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. - Example Question: What color is the drainage from your wound? Finding: Denies odor from the wound (Available)Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics. - Example Question: Does the wound have an odor? Finding: Asked about home treatment of foot wound - Finding: Reports wound care regimen of bandaging (Available)Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. - Example Question: How often do you change your bandage? Finding: Reports cleaning wound twice a day (Available)Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. - Example Question: How often did you clean the wound? Finding: Reports applying bacitracin, neomycin and polymyxin B (Neosporin) (Found)Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy. - Example Question: Did you use any ointment on the wound? Finding: Followed up on effectiveness of ointment - Finding: Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective (Found)Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Tina's diabetes diagnosis will have a large impact on her body's healing ability, which should be taken into consideration during your exam. - Example Question: Did the ointment help? Finding: Asked about other foot wound symptoms - Finding: Reports swelling around foot wound (Found)Pro Tip: Asking about the presence of swelling helps you gather information about your patient's complaint, as well as potential related illnesses. - Example Question: Is there swelling around the wound? Finding: Reports last use of medication was 3 years ago (Available)Pro Tip: It important to discover when Tina stopped taking any medications and what caused her to stop. Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment. - Example Question: When was the last time you took your diabetes medication on a regular basis? Finding: Followed up on stopping diabetes regimen - Finding: Reports disliking diabetes medication side effects (Found)Pro Tip: Asking about side effects from medication can provide information about your patient's reaction to treatment. - Example Question: Did the metformin cause any side effects? Finding: Reports that she didn't like checking sugar and taking daily pills (Found)Pro Tip: Asking reasons for noncompliance can reveal information about your patient's health literacy, side effects, financial situation, and more. - Example Question: What's preventing you from taking your diabetes medication? Finding: Asked about blood glucose monitoring - Finding: Reports infrequent blood glucose monitoring (Found)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. - Example Question: Tell me about your blood sugar monitoring. Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. - Example Question: How often do you check your blood sugar? Finding: Reports confusion about what the numbers mean (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. If you find gaps in the patient's literacy, that is your opportunity to provide education. - Example Question: What are your usual blood sugar levels? Finding: Asked about thirst - Finding: Reports increased thirst (Found)Pro Tip: Your patient's thirst can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - Example Question: Have you been more thirsty lately? Finding: Reports increased water intake (Available)Pro Tip: Your patient's fluid intake can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - Example Question: Are you drinking more water than normal? Finding: Asked about frequency of urination - Finding: Reports more frequent urination (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - Example Question: Have you been urinating more often than usual? Finding: Reports urinating every hour or two during the day (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. - Example Question: How often do you urinate during the day? Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health. - Example Question: How often do you wake up at night to urinate? Finding: Asked about diet - Finding: Reports eating a bowl of cereal for breakfast yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. - Example Question: What did you eat for breakfast yesterday? Finding: Reports eating mac and cheese for lunch yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. - Example Question: What did you eat for lunch yesterday? Finding: Reports eating chicken and roll for dinner yesterday (Available)Pro Tip:Finding out the foods a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status and can affect medications given while in your care. - Example Question: What did you eat for your last meal? Finding: Asked about change in appetite - Finding: Reports increased appetite (Found)Pro Tip: Identifying if a patient has recently experienced a change in appetite is important, as it could indicate an underlying endocrine or psychiatric condition. - Example Question: Have you noticed an increase in appetite? 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. - Example Question: When did you notice the increase in your appetite? Finding: Asked about weight change - Finding: Reports recent loss of 10 lbs (Available)Pro Tip: Determining the exact amount of weight loss can indicate whether it's within expected ranges, or extreme, which may indicate an underlying health problem. Example Question: How much weight have you lost? - Finding: Reports weight loss occurred over the past month (Available)Pro Tip:Finding out the timeline for weight loss can indicate if it's sudden or gradual. - 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 (Found)Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan. - Example Question: Was your weight loss intentional? Finding: Asked about history of asthma exacerbations - Finding: Reports last asthma attack was in high school (Available)Pro Tip: Discovering the patient's most recent asthma attack can provide a timeline of exacerbations and help you better understand the patient's condition and effectiveness of any treatments. - Example Question: When was your last asthma attack? Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patient's most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patient's condition and effectiveness of any treatments. - Example Question: When did you last have issues with asthma? Finding: Asked about asthma symptoms - Finding: Reports chest tightness during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness. - Example Question: What do your asthma symptoms feel like? Finding: Reports difficulty breathing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as difficulty breathing. - Example Question: Do you have trouble breathing? Finding: Reports wheezing during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as wheezing. - Example Question: Do you ever wheeze? Finding: Asked about prior hospitalizations - Finding: Reports sneezing, itchy eyes, and wheezing (Available)Pro Tip: Determining a patient's reaction to an allergen is essential to gauge if the allergy is life-threatening. - Example Question: What is your reaction to cats? Finding: Asked about latex allergy - 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. - Example Question: Are you allergic to latex? Finding: Asked about medication allergies - Finding: Reports penicillin allergy (Found)Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient's safety while she is in your care, as it affects what medications will be safe and appropriate. - Example Question: What medication allergies do you have? Finding: Asked about penicillin reaction - Finding: Reports that penicillin resulted in hives (Available)Pro Tip: Determining a patient's reaction to an allergen is essential to gauge if the allergy is life-threatening. - Example Question: What is your reaction to penicillin? Finding: Reports last penicillin reaction was in childhood (Available)Pro Tip: Determining a patient's last reaction to penicillin is part of gathering thorough information about her allergy. - Example Question: When was your last penicillin reaction? Finding: Asked about food allergies - Finding: Denies food allergies (Found)Pro Tip: Inquiring about food allergies is important for an admitted patient, who will be receiving food during her stay. - Example Question: Do you have any food allergies? Finding: Asked if the patient has allergies to dust, mold, or pollen - Finding: Reports reaction to dust (Found)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important. - Example Question: Do you have any reaction to dust? Finding: Reports dust causes sneezing, itchy eyes, and wheezing (Available)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important. - Example Question: Do you have any environmental allergies? Finding: Denies seasonal allergies (Available)Pro Tip: Asking about seasonal allergies can help you understand a patient's complete set of allergies over the course of a year. - Example Question: Do you have any seasonal allergies? Finding: Asked about general immunizations received - Finding: Reports being up to date on shots (Found)Pro Tip: Discovering your patient's immunization history is important to her safety and reveals any susceptibilities she may have to infectious disease. - Example Question: Are your immunizations current? Finding: Asked about childhood immunizations - Finding: Reports receiving measles-mumps-rubella shot (Available)Pro Tip: Discovering what childhood immunizations a patient has received reveals information about both her medical history and her susceptibility to infectious disease. - Example Question: Did you receive the measles vaccine? Finding: Reports receiving polio shot (Available)Pro Tip: Discovering if a patient received a childhood polio vaccination reveals information about both her medical history and her susceptibility to infectious disease. - Example Question: Did you receive the polio vaccine? Finding: Reports receiving varicella shot (Available)Pro Tip: Discovering if a patient has received a childhood varicella shot reveals information about both her medical history and her susceptibility to infectious disease. - Example Question: Did you receive the chicken pox vaccine? Finding: Reports receiving Hepatitis A and B shot (Available)Pro Tip: Discovering if a patient has received a childhood Hepatitis A and B vaccination reveals information about both her medical history and her susceptibility to infectious disease. - Example Question: Did you receive the Hepatitis vaccine? Finding: Reports receiving meningococcal shot (Available)Pro Tip: Discovering if a patient has received a childhood meningococcal vaccination reveals information about both her medical history and her susceptibility to infectious disease. - Example Question: Did you receive the meningitis vaccine? Finding: Reports receiving HPV vaccine series (Available)Pro Tip: Discovering if a patient has received the HPV vaccination reveals information about both her medical history and her susceptibility to infectious disease. - Example Question: Did you receive the HPV vaccine? Finding: Asked if the patient has received a flu vaccine - Finding: Denies receiving annual flu vaccine (Found)Pro Tip: The flu virus can be particularly hazardous in a hospital setting. It is important to ask your patient about the flu vaccine. - Example Question: Did you get a flu shot this year? Finding: Asked if the patient received a tetanus immunization - Finding: Reports last tetanus vaccination was in the past year (Found)Pro Tip: For a patient with a recent scrape on a metal surface, confirming the last date of a tetanus shot is essential to prevent any diseases from contact. - Example Question: When was your last tetanus booster? Finding: Asked about use of pain medication - Finding: Reports taking ibuprofen (Advil) at home (Found)Pro Tip: Discovering how a patient has been medicating for pain is a crucial element of understanding and treating her condition or injury. - Example Question: What pain medication have you been taking? Finding: Reports ER administered pain medication (Found)Pro Tip: The differences between prescription and over-the-counter pain medications can be vast and asking about the type of pain medication your patient has been using will help you fully understand her home treatment habits. - Example Question: Have you taken any prescription pain medications? Finding: Followed up on home pain medication - Finding: Reports taking ibuprofen (Advil) for 2 days (Found)Pro Tip: Discovering how long your patient has been taking pain medication is a crucial part of the history of her condition or injury. - Example Question: How many days have you needed pain medication? Finding: Reports taking doses at morning, noon and night (Available)Pro Tip: The frequency with which your patient takes pain medication can indicate the severity of her condition or injury. - Example Question: How many times a day do you take pain medication? Finding: Reports taking 2 pills each time (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. - Example Question: How many pain pills do you take at a time? Finding: Reports ibuprofen is regular strength (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. - Example Question: What is the dose of the pain medication? Finding: Asked about the effectiveness of pain medication at home - Finding: Reports ibuprofen helped a little (Found)Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient's individual response to Finding: Asked about illicit drug use - Finding: Reports history of recreational marijuana smoking (Found)Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted. - Example Question: Have you ever smoked marijuana? Finding: Followed up on drug use - Finding: Reports last use was at age 20 or 21 (Found)Pro Tip: When a patient reports drug use, it's important to determine the reason for drug use, as well as the timeline. Depending on when the drug was most recently taken, it could interfere with medications. You also want to identify any potential issues with substance abuse. - Example Question: When did you last smoke marijuana? 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 happened to cause you to stop smoking pot? - Finding: Asked about alcoholic intake - Finding: Reports last alcoholic drink was 3 weeks ago (Available)Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated. - Example Question: When was your last alcoholic drink? Finding: Reports no more than 2 or 3 alcoholic drinks in one sitting (Available)Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient. - Example Question: How many alcoholic drinks do you have in one sitting? Finding: Reports no more than 1 or 2 nights a week drinking alcohol (Available)Pro Tip: Finding out how many nights a week your patient has alcohol gives insight into potential habits or abuse. - Example Question: How many nights a week do you drink alcohol? Finding: Asked about tobacco use - Finding: Denies smoking tobacco (Found)Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health, and is a potential factor in delayed wound healing. - Example Question: Have you ever smoked cigarettes? Finding: Denies Vaping (Available)Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and is a potential factor in delayed wound healing. - Example Question: Do you vape? Finding: Asked about secondhand smoke - Finding: Denies exposure to secondhand smoke (Found)Pro Tip: Exposure to secondhand smoke can be especially detrimental to an asthmatic patient's health. - Example Question: Are you ever exposed to secondhand smoke? Family Medical History - Finding: Asked about mother's health - Finding: Reports mother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her mother had high blood pressure can reveal generational patterns. - Example Question: Does your mother have health conditions? Finding: Reports mother diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her mother had high cholesterol can reveal generational patterns. - Example Question: Does your mother have health conditions? Finding: Asked about father's health - Finding: Reports father was diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had diabetes can reveal generational patterns. - Example Question: Does your father have health conditions? Finding: Reports father was diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high blood pressure can reveal generational patterns. - Example Question: Does your father have health conditions? Finding: Reports father was diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her father had high cholesterol can reveal generational patterns. - Example Question: Does your father have health conditions? Finding: Followed up on father's death - Finding: Reports father died at age 58 (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. Uncovering the age of death can help you assess the patient's current risks. - Example Question: How old was your father when he died? Finding: Reports cause of death was a car accident (Found)Pro Tip: Following up on the death of an immediate family member is important for gathering details that could be relevant to the patient's case. Uncovering the cause of death can help you assess the patient's current risks. - Example Question: What caused your father's death? Finding: Followed up on coping with father's death - Finding: Reports past grief (Found)Pro Tip: Asking about Tina's reaction to her father's death is a vital part of patient-centered care. You may discover that a patient experiencing grief needs additional resources and support. - Example Question: How are you coping with your father's death? Finding: Reports feeling at peace now (Found)Pro Tip: Asking about Tina's reaction to her father's death is a vital part of patient-centered care. You should assess her needs to determine if providing any addition resources or support is appropriate. - Example Question: How are you coping now? Finding: Asked about paternal grandfather's health - Finding: Reports paternal grandfather diagnosed with Type 2 diabetes (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had diabetes can reveal generational patterns. - Example Question: Does your paternal grandfather have health conditions? Finding: Reports paternal grandfather diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had high blood pressure can reveal generational patterns. - Example Question: Does your paternal grandfather have health conditions? Finding: Reports paternal grandfather diagnosed with high cholesterol (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandfather had high cholesterol can reveal generational patterns. - Example Question: Does your paternal grandfather have health conditions? Finding: Reports paternal grandfather died of colon cancer (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if any of her family members had cancer is essential for understanding her risks. - Example Question: Have you had any family members with cancer? Finding: Asked about paternal grandmother's health - Finding: Reports paternal grandmother diagnosed with high blood pressure (Found)Pro Tip: Family histories might indicate a genetic predisposition. Asking Tina if her paternal grandmother had high blood pressure can reveal generational patterns. - Example Question: Does your paternal grandmother have health conditions? Finding: Asked about maternal grandfather's health - 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. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Example Question: Have you had night sweats? Finding: Asked about review of systems for mental health - Finding: Denies depression (Available)Pro Tip: Asking about the patient's history with depression is one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Example Question: Do you have a history of depression? Finding: Denies suicidal ideation or attempts (Available)Pro Tip: Asking about the patient's suicidal ideation one possible component of a review of systems interview and may provide insight into their ability to cope in the event of painful physical trauma. Higher levels of pain have been associated with thoughts of self-harm. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Example Question: Do you have a history of suicidal thinking? Finding: Asked about review of systems for head - Finding: Reports occasional headaches (Available)Pro Tip: Asking about headache frequency is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Example Question: Do you ever get headaches? 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. - Example Question: Do you have a headache? Finding: Denies head injury (Available)Pro Tip: Asking about the patient's history of physical trauma, including head injury, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Example Question: Have you had any head injuries? Finding: Asked about review of systems for ears - Finding: Denies change in hearing (Available)Pro Tip: Asking about changes in hearing is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems, such as hearing loss, not discovered during the discussion of the patient's chief complaint. - Example Question: Has your hearing changed? Finding: Denies ringing or tinnitus (Available)Pro Tip: Ringing in the ears can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing, or hearing loss. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. - Example Question: Do you ever have ringing in your ears? Finding: Denies ear pain (Available)Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. - Example Question: Have you had ear pain? Finding: Denies ear discharge (Available)Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer's ear. Asking whether she's noticed ear discharge could indicate whether she has a ruptured eardrum. - Example Question: Have you had ear discharge? Finding: Asked about review of systems for eyes and vision - Finding: Reports periods of blurry vision (Found)Pro Tip: Asking about changes in vision is one possible component of a review of systems interview. 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. - Example Question: Have you noticed any changes in your vision? Finding: Denies corrective lenses (Available)Pro Tip: Asking about the patient's use of corrective lenses is one possible component of a review of systems interview. 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. - Example Question: Do you wear glasses or contacts? Finding: Reports infrequent itchy eyes (Available)Pro Tip: Asking about symptoms, such as itchy eyes, is one possible component of a review of systems interview. 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. - Example Question: Have you had itchy eyes? Finding: Reports infrequent eye redness (Available)Pro Tip: Asking about symptoms, such as eye redness, is one possible component of a review of systems interview. 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. - Example Question: Have you had red eyes? Finding: Reports infrequent discharge, crusting or wateriness (Available)Pro Tip: Asking about symptoms, such as eye discharge, is one possible component of a review of systems interview. 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. Example Question: Have you had watery eyes? - Finding: Denies eye pain (Available)Pro Tip: Asking about symptoms, such as eye pain, is one possible component of a review of systems interview. 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, infection, or physical trauma. - Example Question: Have you had eye pain? Finding: Denies dry eyes (Available)Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom. - Example Question: Have you had dry eyes? Finding: Asked about review of systems for nose - Finding: Denies current nose problems (Found)Pro Tip: Asking about symptoms, such as nose problems, is one possible component of a review of systems interview. 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, infection, or physical trauma. - Example Question: Do you have any nose problems right now? Finding: Reports infrequent runny nose (Found)Pro Tip: Asking about symptoms, such as runny nose, is one possible component of a review of systems interview. 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 unspecified allergies. - Example Question: Have you had a runny nose? Finding: Reports infrequent sinus problems (Available)Pro Tip: Asking about symptoms, such as frequent sinus issues, is one possible component of a review of systems interview. 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 unspecified allergies. - Example Question: Have you had problems with your sinuses? Finding: Denies nosebleeds (Available)Pro Tip: Asking about symptoms, such as frequent nosebleeds, is one possible component of a review of systems interview. The patient's response to questions about this topic may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Example Question: Have you had nosebleeds? Finding: Denies voice changes (Available)Pro Tip: Asking about changes in a patient's voice is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Have you had voice changes? Finding: Asked about breast health - Finding: Reports doing occasional breast exams (Available)Pro Tip: Asking if a patient perform breast self-examinations is important because it reveals a patient's level of health literacy. - Example Question: Do you perform breast self-examinations? Finding: Denies swelling (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as swelling, is one way of assessing overall breast health. - Example Question: Do you have any breast swelling? Finding: Denies breast rashes (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as a rash, is one way of assessing overall breast health. - Example Question: Do you have a rash on your breasts? 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. Lumps have a range of severity, as they could be the result of breast injury or cancerous growths, but any abnormalities should be handled with the highest level of concern. - Example Question: Do you have any lumps in your breasts? Finding: Denies nipple discharge (Available)Pro Tip: Asking about abnormal characteristics of a patient's breasts, such as nipple discharge, is one way of assessing overall breast health. - Example Question: Have you experienced nipple discharge? Finding: Denies ever having a mammogram (Available)Pro Tip: Inquiring into what breast screenings Tina has had can lead to a discussion about any test results and their implications for her cardiovascular health. If she has not had any screenings, it provides an opportunity for patient education. - Example Question: Have you had a mammogram? Finding: Denies history of breast cancer (Available)Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. You may also need to provide further support and resources to the patient. - Example Question: Have you had breast cancer? Finding: Asked about review of systems for respiratory - Finding: Denies current breathing problems (Available)Pro Tip: Asking about general breathing problems can provide a comparative baseline for assessing Tina's current condition and previous breathing concerns. - Example Question: Have you had breathing problems? Finding: Denies current wheezing (Available)Pro Tip: Patients who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she's been wheezing illustrates how her asthma is presenting. - Example Question: Have you been wheezing? Finding: Denies current chest tightness (Available)Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest tightness, it could be a symptom of asthma or another respiratory problem. - Example Question: Have you had chest tightness? Finding: Denies pain while breathing (Available)Pro Tip: Asking about pain during breathing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of pain during breathing, it could be a symptom of asthma or another respiratory problem. - Example Question: Does it hurt when you breathe? Finding: Denies frequent coughing (Available)Pro Tip: Asking about coughing is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate an asthma exacerbation or a new respiratory infection. - Example Question: Have you been coughing? Finding: Asked about review of systems for cardiovascular - Finding: Denies chest pain or discomfort (Available)Pro Tip: Asking about chest pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of chest pain, it could be a symptom of a recurring cardiovascular problem. - Example Question: Do you ever have chest pain? Finding: Denies palpitations (Available)Pro Tip: Asking about palpitations is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of palpitations, it could be a symptom of a recurring cardiovascular problem. - Example Question: Have you had palpitations? Finding: Denies irregular heartbeat (Available)Pro Tip: Asking about heartbeat patterns is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports a history of irregular heartbeat, it could be a symptom of a recurring cardiovascular problem. - Example Question: Has your heartbeat been irregular? Finding: Denies easy bruising (Available)Pro Tip: Asking if a patient bruises easily is one possible component of a review of systems interview. Bruising easily can be indicative of anemia or a more serious blood disorder. - Example Question: Have you noticed bruising more than usual? Finding: Denies edema (Available)Pro Tip: Asking about edema is one possible component of a review of systems interview. Edema is caused by the presence of excess fluid in the tissues, and it can indicate an infection, weak heart or veins, or other organ problems. - Example Question: Have you noticed any swelling in your legs? Finding: Denies circulation problems (Available)Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Asking Tina whether she's experienced poor circulation indicates whether she might suffer from underlying cardiac concerns. - Example Question: Do you have circulation problems? Finding: Asked review of systems for gastrointestinal - Finding: Denies nausea (Available)Pro Tip: Currently presenting nausea can be caused by changes in blood sugar, a reaction to medication, stress, or even spreading infection. If the patient reports a history of nausea, it could be a symptom of a recurring gastrointestinal problem. - Example Question: Have you had nausea? Finding: Denies vomiting (Available)Pro Tip: Vomiting can be caused by a pain response, a reaction to medication, stress, or even spreading infection. If the patient reports a history of vomiting, it could be a symptom of a recurring gastrointestinal problem. - Example Question: Have you been vomiting? Finding: Denies stomach pain (Available)Pro Tip: Asking about stomach pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports recurring stomach pain, it could be a symptom of a gastrointestinal problem. - Example Question: Do you have stomach pain? Finding: Denies change in bowel movements (Available)Pro Tip: Asking about changes in bowel movements can help you understand a patient's baseline patterns. Any recent or abrupt changes could impact the patient's care plan, such as administering treatment for constipation or diarrhea. - Example Question: Have you had changes in your bowel movements? Finding: Denies heartburn, GERD, or indigestion (Available)Pro Tip: Asking about stomach conditions such as heartburn or GERD is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Do you ever get heartburn? Finding: Reports past condom use (Available)Pro Tip: Asking about a patient's past condom use is one possible component of a review of systems interview. Sexual activity without condoms increases a patient's risk of STIs, and can be an indicator of a patient's health literacy. - Example Question: Do you use condoms when you are sexually active? Finding: Denies current birth control (Available)Pro Tip: A patient's use of birth control can impact the care plan, such as which medications are prescribed. Understanding a patient's history of birth control can be an indicator of health literacy. - Example Question: Are you currently on birth control? Finding: Asked review of systems for musculoskeletal - Finding: Denies muscle pain (Found)Pro Tip: Asking about muscle pain is one possible component of a review of systems interview. The most common causes of muscle pain are strain, overuse, illness, or infection. - Example Question: Do you have muscle pain? Finding: Denies joint pain (Available)Pro Tip: Asking about joint pain is one possible component of a review of systems interview. The most common causes of muscle pain are overuse, and conditions such as arthritis. - Example Question: Do you have joint pain? Finding: Denies muscle weakness (Available)Pro Tip: Asking about muscle weakness is one possible component of a review of systems interview. Muscle weakness can be a sign of neurological problems, or a reaction to medication. - Example Question: Do you have muscle weakness? Finding: Denies muscle swelling (Available)Pro Tip: Asking about muscle swelling is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Do you have muscle swelling? Finding: Asked review of systems for neurological - Finding: Denies dizziness or vertigo (Available)Pro Tip: Asking about dizziness or vertigo is one possible component of a review of systems interview. Presence of dizziness could indicate a reaction to medication, an inner ear problem, or changes in blood sugar or blood pressure. - Example Question: Do you get dizzy? Finding: Denies lightheadedness (Available)Pro Tip: Asking about light-headedness is one possible component of a review of systems interview. Feeling light-headed could indicate a reaction to medication, changes in blood sugar or blood pressure, or a neurological problem. - Example Question: Do you get light-headed? Finding: Denies tingling (Available)Pro Tip: Asking about tingling sensations is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems, such as nerve damage. - Example Question: Do you ever get tingling? Finding: Denies loss of coordination (Available)Pro Tip: Asking if the patient has experienced loss of coordination is one possible component of a review of systems interview. The patient's response to these questions may uncover neurological problems. - Example Question: Do you notice being more clumsy than usual? Finding: Denies loss of sensation (Available)Pro Tip: Diabetic patients often experience numbness due to neuropathy, especially in the arms, legs, hands, and feet. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Do you have a loss of sensation anywhere? Finding: Reports no seizures (Available)Pro Tip: Asking about seizures is one possible component of a review of systems interview. The patient's response to these questions may uncover neurological problems. - Example Question: Have you ever had a seizure? Finding: Denies problems with balance or disequilibrium (Available)Pro Tip: Problems with balance can indicate neurological problems, or issues with the inner ear. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Do you lose your balance often? Finding: Asked review of systems for skin, hair and nails - Finding: Reports acne (Found)Pro Tip: Adult acne can suggest stress or changes in hormone levels. Asking Tina about her present acne and history of acne can help you understand any skin conditions or hormonal changes. - Example Question: Do you still have acne? Finding: Reports excessive facial or body hair (Available)Pro Tip: Increases in body hair can suggest changes in hormone levels. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Do you have facial hair? Finding: Reports changes to neck skin (Available)Pro Tip: Asking about changes in skin color is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Do you have any skin discoloration? Finding: Reports moles (Available)Pro Tip: Monitoring moles is key in preventing cancerous growths. Asking Tina if her moles have changed will indicate whether any of her moles should be assessed further.E - xample Question: Have your moles changed? Finding: Denies dandruff (Available)Pro Tip: Dandruff is a chronic scalp condition characterized by flaking skin. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Do you have dandruff? Finding: Denies hair loss (Available)Pro Tip: Asking about hair loss or balding is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Have you noticed any hair loss? Finding: Denies nail abnormalities (Available)Pro Tip: Nail fungus might cause discoloration and disfigurement of the nails. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Do you have nail fungus? Finding: Reports occasional dry skin (Available)Pro Tip: Chronic or severe dry skin might require a patient to be seen by a dermatologist. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Example Question: Do you have dry skin? Finding: Denies skin rashes - Education & Empathy - 1.Expression of pain Followed Up - Description: Tina expresses frustration about her level of pain. Student: How effective was the Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job. Student: Can you walk with your foot being injured? Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain. Student: What preexisting medical conditions do you have? Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot! Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. Tina Jones: Thanks. Model Statement: "I'm sorry to hear that your pain is returning. We want you to be in as little pain as possible. I can give you some Advil at this time, and in a few hours, you can have more tramadol. I can also walk through some pain management exercises with you that don't involve medication, if you are interested." 2.Impact of injury on daily life Followed Up - Description: Tina brings up her pain and frustration at how being unable to bear weight on her foot impacts her life. Student: What are stressors? Tina Jones: I feel really stressed out right now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too. Student: We are going to take care of everything as quickly as possible. Tina Jones: Thanks. Model Statement: "This sounds like a challenging time for you. I understand your frustration at having your life interrupted by foot pain. Please let me know if there is anything I can help you with, such as contacting your employer or 3. Impaired walking - Priority - High Priority Pro Tip: This is a high priority. The patient is unable to bear weight on her affected leg, which prevents walking. This impacts her daily life and increases her risk for falls and deep-vein thrombosis. Evidence - Relevant: "I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on." "I got this scrape on my foot a while ago, and it got really infected. It's killing me." "No, I can't. I can't put any weight on it without like, shooting pain." 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. Other supporting data points are the presence of her foot wound and her general reports of pain. Planning - Relevant: Assess - Musculoskeletal: Assess the patient's ability to bear weight and gait. Assess - Musculoskeletal: Assess the patient's mobility. Consult / Refer: Consult with physical therapist to develop a plan to improve the patient's mobility. Intervene - Mobility: Assist the patient as needed with mobility. Intervene - Mobility: Provide assistive devices to facilitate mobility (crutches, therapeutic boot to minimize pressure on plantar surface, wheelchair). Planning Pro Tip: Assess how well the patient can bear weight and walk. While the patient is in your care, work with other healthcare professionals to keep the pain managed and improve the patient's mobility. Provide assistance with activities such as toileting and ensure that the patient can access and use assistive devices. 4. Ineffective diabetes management - Priority - High Priority Pro Tip: Poorly managed diabetes and uncontrolled blood glucose complicate wound healing. As the underlying cause for delayed healing and infection, they must be addressed. Evidence - Relevant: "No, I don't take anything for my diabetes anymore." "I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills." "I have a monitor at home, but to be honest I don't really use it that often." Evidence Pro Tip: Tina directly reports ineffective diabetes management when discussing her lack of treatment. She expresses gaps in health literacy about the risk of ceasing prescribed medication and blood glucose monitoring. Supporting evidence comes from her inability to incorporate meaningful dietary changes or increase her exercise. Planning - Relevant: Assess - Health Literacy and Patterns: Assess the patient's knowledge related to diabetic disease process, assess personal/social supports. Assess - Health Literacy and Patterns: Assess the patient's perceived barriers to adherence to the prescribed regimen (cost, adverse effects, lack of knowledge). Assess - Health Literacy and Patterns: Assess the patient's readiness for change/education. Educate - Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. Planning Pro Tip: To gain a deep understanding of your patient's situation, determine her level of health literacy, her feelings and beliefs about the disease, and the motivation behind her choices. Educate the patient about what risks are, and what good diabetes care looks like. Most importantly, ask about her goals and changes she may be willing to make. 5. Risk for falls - Priority - High Priority Pro Tip: The patient's foot wound impairs her walking, which in turn increases her risk for falls while she is an admitted patient. Her past history of injury also adds to this risk. 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. Other supporting evidence is her recent injury caused by falling. Planning - Relevant: Planning Pro Tip: Protect your patient by taking all fall precautions, and educate your patient about how to be safe as she goes through her daily activities at the hospital. Make sure that the patient feels comfortable asking for your assistance. 6. Risk for unstable blood glucose level - Priority - High Priority Pro Tip: Uncontrolled blood glucose levels delay or prevent wound healing, and must be addressed to resolve the infection. Unstable blood glucose levels could increase the patient's risk for falls. 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. Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are significantly higher than her baseline. Planning - Relevant: Assess - Vitals: Assess the patient's blood glucose levels according to orders. Educate - Disease Process: Educate the patient on the signs and symptoms of hyper- and hypoglycemia. Intervene - Diet: Provide the patient a diet without concentrated sweets. Intervene - Hypoglycemia: Administer insulin and/or oral hypoglycemics, per physician orders. Planning Pro Tip: First, gauge your patient's current status by checking hydration, vital signs, and perfusion. Measure the patient's blood glucose and provide medication as per the physician's orders. While the patient is in your care, ensure that their meals align with a low glycemic diet, and educate the patient on monitoring her own health status. 7. Obesity - Priority - Low Priority Pro Tip: A BMI greater than 30 indicates obesity, but this diagnosis is a low priority at present. Obesity is a long-term health concern that cannot be addressed in a single visit. Evidence - Relevant: "BMI: 31" Evidence Pro Tip: Tina's BMI is 31, which is in the obese range. This numerical evidence is required to establish obesity. Other contributing factors are her family history of diabetes mellitus and a lack of physical exercise. Planning - Relevant: Educate - Diet: Educate the patient on balanced nutritional intake. Educate - Disease Process: Educate the patient on health risks related to obesity. Educate - Exercise: Educate the patient about the benefits of exercise. Planning Pro Tip: To help your patient address her obesity, which is often a sensitive topic, use therapeutic communication techniques. First, gain a deep understanding of your patient's situation. Determine her level of health literacy, her feelings and beliefs related to the disease, and the motivation behind their choices. Then educate the patient on risks of obesity, recommended dietary changes, and healthy exercise. 8. Risk for ineffective respiratory function - Priority - Low Priority Pro Tip: When caring for a patient diagnosed with asthma, it's important to be aware of the possibility of emerging respiratory symptoms. However, for a patient with no active respiratory complaints, this problem does not need to be addressed immediately. Evidence - Relevant: Evidence Pro Tip: Tina's asthma puts her at general risk for breathing problems. She also reports sometimes needing more puffs to resolve symptoms. Contributing factors are a past history of hospitalization and asthma attacks, as well as sedentary lifestyle and obesity. Planning - Relevant: Planning Pro Tip: Take a general survey of the patient for changes in skin color, and assess respiratory rate, rhythm, depth, and quality to confirm there are no acute breathing issues. Gather data on the patient's breathing status by checking pulse and blood pressure. Auscultate the lungs to listen for abnormal sounds. While the patient is in your care, educate her on the cause and symptoms of shortness of breath so that she can let you know about emerging problems. Empower the patient to take part in her own care by educating her on controlled breathing techniques. 9. Sedentary lifestyle - Priority - Low Priority Pro Tip: A patient's sedentary lifestyle compromises her overall health and problems such as diabetes. However, this issue is low priority for a patient with acute pain and a wound that prevents her from walking. Evidence - Relevant: Evidence Pro Tip: Tina directly reports that she doesn't exercise, which is the primary evidence for a sedentary lifestyle. She describes being too busy to exercise and reports that her primary activity is being on her feet at work, a belief which demonstrates her misunderstanding of exercise. Planning - Relevant: Planning Pro Tip: Interview the patient to determine her level of health literacy, and her attitudes and beliefs toward exercise. Educate the patient about the benefits to overall health and blood sugar control and finding an appropriate form of exercise. Ask the patient questions about what changes she may be willing to make. Chief Complaint - Scrape injury to ball of right foot, pain, fever History of Present Illness - Tina Jones is a 28 yr old African American woman who presents to the ER for evaluation of right foot injury with drainage and fever. She was admitted, started IV antibiotics and pain management. Injury is to the ball of her right foot she scrape on a metal step while changing light bulb approximately 1 week ago. She reports her pain has increased and radiates up to the ankle. Her pain is rated a 7 at rest and 9-10 when ambulating. She notes her fever started yesterday and reports it was 102F. Her appetite has decreased and has stayed in bed for a couple of days. She has self-treated with Advil with little pain relief. She reports cleaning the wound, applying Neosporin and keeping it bandaged. Pain improved with Lortab and oxycodone in ER. Pain Assessment - Pain is in the ball of the right foot radiating up to the ankle. Pain rated at 7 while at rest and at 9 or 10 with sharp, shooting pain when bearing weight. Patient treated at home with Advil, but reports little pain relief. Patient reports some relief noted when elevated and not bearing weight. Vitals within range. Allergies - Penicillin: rash, hives Cats: wheezing, itchy watery eyes, sneezing, asthma exacerbation Dust: asthma exacerbation No food allergies No latex allergies Immunizations - Immunizations up to date. Reports tetanus and HPV vaccines within last year. Denies recent flu vaccine.