Shadow Health - Tina Jones, Health History With Complete Solution, Exams of Community Health

Download Shadow Health - Tina Jones, Health History With Complete Solution and more Exams Community Health in PDF only on Docsity! Shadow Health - Tina Jones, Health History With Complete Solution Health History Tips & Tricks: - Correct answer >>>TJ Health Interview Student: Hello! - Correct answer >>>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? - Correct answer >>>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? - Correct answer >>>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? - Correct answer >>>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? - Correct answer >>>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 P a g e 1 | 40 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? - Correct answer >>>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? - Correct answer >>>Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition. Diana Shadow: Time to begin. - Correct answer >>> Patient Exam - Vital Signs: - Correct answer >>>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: - Correct answer >>> Student: Hello, my name is Catlain, I am your nurse today. - Correct answer >>>Tina Jones: Hey. Student: Can you confirm your name? - Correct answer >>>Tina Jones: Tina Jones:. Student: Why did you come in today? - Correct answer >>>Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It's killing me. Student: What additional symptoms have you experienced? - Correct answer >>>Tina Jones: 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. Student: Can you rate your current pain level on a scale of 0 to 10? - Correct answer >>>Tina Jones: ...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit. Student: Please describe the pain. - Correct answer >>>Tina Jones: It's throbbing and like, sharp if I try to put weight on it. Student: How did you hurt your foot? - Correct answer >>>Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn't realize how sharp the edge was! Student: Has your foot been draining any liquids? - Correct answer >>>Tina Jones: Yeah, there's definitely pus. Student: What color was the pus? - Correct answer >>>Tina Jones: It's... white or maybe off-white. P a g e 2 | 40 Student: Do you have a family history of psychiatric illness? - Correct answer >>>Tina Jones: No. They're crazy, but nobody's diagnosed with anything. Student: Do you have any neck, throat or gland problems? - Correct answer >>>Tina Jones: No, not that I noticed. Student: Do you have any problems with your head? - Correct answer >>>Tina Jones: I don't think I have any problems. I get headaches sometimes, but that's all. Student: Any problems with your ears? - Correct answer >>>Tina Jones: No. Student: Any problems with your eyes and vision? - Correct answer >>>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: Any problems with your nose? - Correct answer >>>Tina Jones: My nose is fine right now. Sometimes it runs, but not very often. Student: Do you have problems with your mouth? - Correct answer >>>Tina Jones: No. Student: Do you have a history of cardiovascular problems? - Correct answer >>>Tina Jones: My heart's fine, thank God! Student: Any problems with your heart? - Correct answer >>>Tina Jones: No, my heart's always been fine. Student: Have you had any problems with your breasts? - Correct answer >>>Tina Jones: I haven't noticed any pain there. Student: Have you had any reproductive problems? - Correct answer >>>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? - Correct answer >>>Tina Jones: No, I haven't. Student: Have you had any musculoskeletal problems? - Correct answer >>>Tina Jones: No. Student: Do you have a history of skin disease? - Correct answer >>>Tina Jones: Um, I have acne, if that counts. Student: Does your paternal grandfather have any health problems? - Correct answer >>>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. Student: Does your mother have any health problems? - Correct answer >>>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? - Correct answer >>>Tina Jones: Well, he passed away. But he had a couple things... Type 2 diabetes, like me, and high cholesterol and blood pressure. Student: How did your father die? - Correct answer >>>Tina Jones: He died in a car accident. P a g e 5 | 40 Student: Where is your wound located? - Correct answer >>>Tina Jones: It's on the ball of my foot. Student: Do you get thirsty often? - Correct answer >>>Tina Jones: You know, I did notice lately that I've been really thirsty. Student: What happened with your father's car accident? - Correct answer >>>Tina Jones: It was last year... I guess a little over a year ago. Student: How long ago was your dad's car accident? - Correct answer >>>Tina Jones: It was last year... I guess a little over a year ago. Student: How did you cope with your fathers death? - Correct answer >>>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: What caused your dads accident? - Correct answer >>>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 is your paternal grandmother's health? - Correct answer >>>Tina Jones: Granny's doing good. She's still living on her own. She's slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy. Student: How is your paternal grandfather's health? - Correct answer >>>Tina Jones: Grandpa Jones passed away when I was really little. Student: How is your maternal grandfather's health? - Correct answer >>>Tina Jones: Well, Poppa died about five years ago. Student: How is your maternal grandmother's health? - Correct answer >>>Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. Student: How is your brother's health? - Correct answer >>>Tina Jones: He's a healthy guy. Kind of big like me. Student: How is your sister's health? - Correct answer >>>Tina Jones: She's pretty healthy. She has asthma too, but she almost never has attacks. Student: Does your family have a history of obesity? - Correct answer >>>Tina Jones: No, I don't think so. My brother and my dad are kind of big, but I wouldn't say they were obese or anything. Student: Does your family have a history thyroid issue? - Correct answer >>>Tina Jones: No, I don't think so. P a g e 6 | 40 Student: Does your family have a history of substance abuse? - Correct answer >>>Tina Jones: One person in the family, my dad's brother, has an alcohol problem, but we never see him. Student: Does your family have a history of headaches? - Correct answer >>>Tina Jones: No, not that I know of. Student: How much alcohol do you drink? - Correct answer >>>Tina Jones: I only have a few drinks when I go out. Student: What is your level of education? - Correct answer >>>Tina Jones: Well, I'm finishing up my bachelor's degree right now. Student: What are stressors? - Correct answer >>>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. - Correct answer >>>Tina Jones: Thanks. Student: Where do you live? - Correct answer >>>Tina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. It's like a half hour from here. Student: What is your belief system? - Correct answer >>>Tina Jones: I'm Baptist. My faith is a big part of my life--when things get hard like they've been this past year, I know I can trust that God's looking out for me. I've been going to the same church since I was a kid, too, so the people at church are practically part of my family. Student: Have you experienced abuse? - Correct answer >>>Tina Jones: I've never had been in any kind of situation like that... It's scary to think about. Student: Have you used illicit drugs? - Correct answer >>>Tina Jones: Well, I used to smoke pot. . . but I don't do that anymore. Student: What type of drugs did you use? - Correct answer >>>Tina Jones: Um...I've smoked pot before. In high school, and after high school... I definitely don't anymore, though. Student: Have you used drugs other than marijuana? - Correct answer >>>Tina Jones: No. Student: When did you last use drugs? - Correct answer >>>Tina Jones: I haven't smoked pot since I was twenty or twenty-one. Student: Have you ever smoked cigarettes? - Correct answer >>>Tina Jones: No. I think it's gross. Student: Have you been around people that are smoking? - Correct answer >>>Tina Jones: Some of my friend's smoke when we go out drinking. But I don't smoke, and nobody at home smokes. Student: How old were you when your father died? - Correct answer >>>Tina Jones: He died last year, so I was 27. P a g e 7 | 40 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: When did you first notice the pus? Finding: Followed up on drainage - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>Example Question: Does the wound have an odor? Finding: Asked about home treatment of foot wound - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: Did you use any ointment on the wound? Finding: Followed up on effectiveness of ointment - Correct answer >>> 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. - Correct answer >>>Example Question: Did the ointment help? Finding: Asked about other foot wound symptoms - Correct answer >>> P a g e 10 | 40 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. - Correct answer >>>Example Question: Is there swelling around the wound? Finding: Reports swelling worsened in the past 2 days (Available)Pro Tip:Finding out how long swelling appeared will help you understand the timeline for the infection progression. - Correct answer >>>Example Question: How long have you noticed swelling around the wound? Finding: Reports redness around the wound (Found)Pro Tip: Asking about redness will help you understand the timeline for the infection progression. - Correct answer >>>Example Question: Did you notice any redness around the wound? Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression. - Correct answer >>>Example Question: Does the wound feel warm? Finding: Explored impact of patient's foot injury on activities of daily living - Correct answer >>> Finding: Reports pain affects ability to walk (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can walk or not, as a lack of mobility can compromise quality of life. - Correct answer >>>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: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance. - Correct answer >>>Example Question: Does your foot pain affect your work? Finding: Reports pain prevented her from being able to walk to class (Available)Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don't fall behind. - Correct answer >>>Example Question: Has your injury prevented you from going to class? Past Medical History - Correct answer >>> Finding: Asked about preexisting medical conditions - Correct answer >>> Finding: Reports diabetes (Found)Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. In Tina's case, it is important to identify her diabetes diagnosis because that condition has a direct relationship with her current foot infection. - Correct answer >>>Example Question: Do you have any existing conditions? Finding: Reports asthma (Found)Pro Tip: It is important to identify any existing medical conditions, such as Tina's asthma, because that information is an integral part of her health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. - Correct answer >>>Example Question: Do you have any other conditions? P a g e 11 | 40 Finding: Followed up on diabetes diagnosis - Correct answer >>> Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patient's illness is an essential element of the illnesses history. - Correct answer >>>Example Question: At what age were you diagnosed with diabetes? Finding: Reports that her diabetes is Type 2 (Available)Pro Tip: The type of diabetes your patient has will drastically affect how you care for her. - Correct answer >>>Example Question: Do you know what type of diabetes you have? Finding: Asked about diabetes management through lifestyle changes - Correct answer >>> Finding: Reports staying away from sweets (Available)Pro Tip: Asking your patient specifically about sugar intake can help you understand the history of her diabetes as well as her health literacy. - Correct answer >>>Example Question: Tell me more about any sugars you consume. Finding: Reports drinking diet coke instead of regular (Available)Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider. - Correct answer >>>Example Question: Do you drink sugary drinks? Finding: Asked about current diabetes medication use - Correct answer >>> Finding: Reports that she does not currently take medication for diabetes (Found)Pro Tip: Asking about diabetes medication is important to understanding if your patient's disease is under control. - Correct answer >>>Example Question: Do you take prescribed medication for your diabetes? Finding: Asked about past diabetes medication use - Correct answer >>> Finding: Reports that she used to take diabetes medication (Found)Pro Tip: Asking about Tina's medication history for asthma will provide a timeline of treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. - Correct answer >>>Example Question: Have you ever taken medication for your diabetes? Finding: Reports previous medication was prescription metformin (Found)Pro Tip: Asking about a patient's medication history for a particular condition, such as Tina's past prescription for metformin, will provide a timeline of her asthma treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. - Correct answer >>>Example Question: Do you remember what you were prescribed for diabetes? 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. - Correct answer >>>Example Question: When was the last time you took your diabetes medication on a regular basis? Finding: Followed up on stopping diabetes regimen - Correct answer >>> 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. - Correct answer >>>Example Question: Did the metformin cause any side effects? P a g e 12 | 40 patient's condition and effectiveness of any treatments. - Correct answer >>>Example Question: When did you last have issues with asthma? Finding: Asked about asthma symptoms - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: Do you ever wheeze? Finding: Asked about prior hospitalizations - Correct answer >>> Finding: Reports past hospitalizations (Found)Pro Tip: Finding out if the patient has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina's case, it will help you better understand her asthma and create a timeline. - Correct answer >>>Example Question: Have you been hospitalized in the past? Finding: Reports last hospitalization was for asthma (Available)Pro Tip: Finding out if Tina has any past hospitalizations is the first step in understanding any past serious medical issues. In Tina's case, it will help you better understand her asthma and create a timeline. - Correct answer >>>Example Question: Why were you hospitalized last time? Finding: Reports last hospitalization was age 16 (Available)Pro Tip: Finding out the date of Tina's last hospitalization is important for understanding the timeline of her medical issues, asthma in particular. - Correct answer >>>Example Question: When was your last hospitalization? Finding: Reports about 5 total hospitalizations for asthma as a child and teen (Available)Pro Tip: Finding out the number of Tina's previous hospitalizations is important for understanding the history of her asthma. - Correct answer >>>Example Question: How many times have you been hospitalized? Finding: Reports past nebulizer use (Available)Pro Tip: Finding out what treatments Tina received during her hospitalizations will give you a fuller picture of the history of her condition. - Correct answer >>>Example Question: Have you ever used a nebulizer? Finding: Asked about asthma diagnosis - Correct answer >>> Finding: Reports specific age of diagnosis is 2.5 years old (Available)Pro Tip: Asthma can have a profound impact on health, and it is important to learn about the patient's history of the condition, including the age of diagnosis. - Correct answer >>>Example Question: At what age were you diagnosed with asthma? P a g e 15 | 40 Finding: Asked about asthma management - Correct answer >>> Finding: Reports using an inhaler (Found)Pro Tip: Asking how your patient treats her asthma can provide important information about her medical history and health literacy. - Correct answer >>>Example Question: How do you manage your asthma? Finding: Reports inhaler is albuterol (Proventil) (Found)Pro Tip: Finding out the specific medication type or brand is essential in understanding whether it's a maintenance or rescue medication. - Correct answer >>>Example Question: What is the name of the inhaler prescription? Finding: Reports last use of inhaler was 3 days ago (Available)Pro Tip: Determining the patient's last use of an inhaler clues you in to any recent breathing problems. - Correct answer >>>Example Question: When did you last use your inhaler? Finding: Reports using inhaler no more than 2 times per week (Available)Pro Tip: Discovering the frequency with which your patient uses her inhaler is an important aspect of determining the severity of her condition. - Correct answer >>>Example Question: How often do you use your inhaler? Finding: Asked about number of puffs when using asthma inhaler - Correct answer >>> Finding: Reports recommended dose is 1-3 puffs as needed (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. - Correct answer >>>Example Question: How many puffs of your inhaler are you prescribed? Finding: Reports typically taking 2 puffs (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. - Correct answer >>>Example Question: How many puffs do you typically take? Finding: Reports sometimes needing 3 puffs to control symptoms (Found)Pro Tip: Discovering how much your patient uses her inhaler at any given time is a good indicator of the efficacy of her medication. - Correct answer >>>Example Question: What's the most puffs you ever take? Finding: Asked about asthma triggers - Correct answer >>> Finding: Reports asthma triggered by cats (Found)Pro Tip: Discovering occasional environmental triggers, such as animal allergies, gives you insight into exacerbating factors of your patient's condition. - Correct answer >>>Example Question: What triggers your asthma problems? Finding: Reports asthma triggered by dust (Found)Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important. - Correct answer >>>Example Question: Does dust trigger your asthma? Finding: Denies seasonal triggers (Available)Pro Tip: Asking about seasonal triggers can help you understand a patient's complete set of asthma triggers over the course of a year. - Correct answer >>>Example Question: Do you have seasonal asthma triggers? Finding: Asked about general allergies - Correct answer >>> P a g e 16 | 40 Finding: Reports allergy to cats (Found)Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies. - Correct answer >>>Example Question: What allergies do you have? Finding: Followed up on cat allergy symptoms - Correct answer >>> 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. - Correct answer >>>Example Question: What is your reaction to cats? Finding: Asked about latex allergy - Correct answer >>> 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. - Correct answer >>>Example Question: Are you allergic to latex? Finding: Asked about medication allergies - Correct answer >>> 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. - Correct answer >>>Example Question: What medication allergies do you have? Finding: Asked about penicillin reaction - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>Example Question: When was your last penicillin reaction? Finding: Asked about food allergies - Correct answer >>> 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. - Correct answer >>>Example Question: Do you have any food allergies? Finding: Asked if the patient has allergies to dust, mold, or pollen - Correct answer >>> Finding: Reports reaction to dust (Found)Pro Tip: Dust is a common allergen and discovering its effect on asthmatic patients is particularly important. - Correct answer >>>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. - Correct answer >>>Example Question: Do you have any environmental allergies? P a g e 17 | 40 unwanted drug interactions. - Correct answer >>>Example Question: What prescription medications do you take? Finding: Asked about use of OTC medication - Correct answer >>> Finding: Reports occasionally taking ibuprofen for cramps (Available)Pro Tip: Finding out about your patient's use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions. - Correct answer >>>Example Question: Do you take any over the counter medications? Finding: Reports occasionally taking acetaminophen (Tylenol) for headaches (Available)Pro Tip: Finding out about your patient's use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions. - Correct answer >>>Example Question: Do you take any over the counter medications? Finding: Denies taking supplements (Available)Pro Tip: Finding out about your patient's use of supplements will help you get a complete health history and avoid unwanted drug interactions. - Correct answer >>>Example Question: Do you take any supplements? Finding: Denies taking herbals (Available)Pro Tip: Finding out about your patient's use of herbals will help you get a complete health history and avoid unwanted drug interactions. - Correct answer >>>Example Question: Do you take any herbal supplements? Social History - Correct answer >>> Finding: Asked about patient's level of education - Correct answer >>> Finding: Reports currently working toward undergraduate degree (Found)Pro Tip: Finding out a patient's level of education can give you a baseline for her health literacy. - Correct answer >>>Example Question: What is your highest level of education? Finding: Reports her major is accounting (Available)Pro Tip: Asking about a patient's course of study is a good practice to establish rapport with your patient. - Correct answer >>>Example Question: What do you study? Finding: Asked about stressors - Correct answer >>> Finding: Reports she is currently under high stress (Found)Pro Tip: Stress can cause both physical and mental health problems and complications. Determining your patient's stress level is part of an overall picture of her health. - Correct answer >>>Example Question: Can you tell me about your stress level? Finding: Asked about patient's living situation - Correct answer >>> Finding: Reports living with mother and sister (Available)Pro Tip: Learning about your patient's living situation helps develop rapport and gives you a broad picture of her lifestyle. - Correct answer >>>Example Question: Does anyone live at home with you? P a g e 20 | 40 Finding: Reports living in a house (Available)Pro Tip: Learning about your patient's living situation helps develop rapport and gives you a broad picture of her lifestyle. - Correct answer >>>Example Question: Do you live in a house? Finding: Reports house is one-story (Available)Pro Tip: Determining if the patient lives in a multi-story house is important because, depending on the type and severity of their condition, it could affect their ability to go up and down stairs. - Correct answer >>>Example Question: How many stories is your house? Finding: Reports family members will be able to help with activities (Available)Pro Tip: Learning about your patient's living situation helps develop rapport and gives you a broad picture of her lifestyle. - Correct answer >>>Example Question: Tell me more about living at home. Finding: Asked about patient belief system - Correct answer >>> Finding: Reports her religious affiliation is Baptist (Found)Pro Tip: An important part of a health history is developing rapport with the patient and fostering an atmosphere of respect. Learning about the patient's religious beliefs will allow you to provide the appropriate support and resources. - Correct answer >>>Example Question: What is your religious affiliation? Finding: Asked if patient has experienced abuse - Correct answer >>> Finding: Denies experiencing abuse (Found)Pro Tip: Determining if a patient has experienced abuse, whether it be emotional, physical, or financial, is important for understanding the patient's needs. It is necessary to approach this subject with the utmost respect and sensitivity. - Correct answer >>>Example Question: Have you experienced any type of abuse? Finding: Asked about illicit drug use - Correct answer >>> 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. - Correct answer >>>Example Question: Have you ever smoked marijuana? Finding: Followed up on drug use - Correct answer >>> 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. - Correct answer >>>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? - Correct answer >>> Finding: Asked about alcoholic intake - Correct answer >>> P a g e 21 | 40 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: How many nights a week do you drink alcohol? Finding: Asked about tobacco use - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>Example Question: Do you vape? Finding: Asked about secondhand smoke - Correct answer >>> Finding: Denies exposure to secondhand smoke (Found)Pro Tip: Exposure to secondhand smoke can be especially detrimental to an asthmatic patient's health. - Correct answer >>>Example Question: Are you ever exposed to secondhand smoke? Family Medical History - Correct answer >>> Finding: Asked about mother's health - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>Example Question: Does your mother have health conditions? Finding: Asked about father's health - Correct answer >>> 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. - Correct answer >>>Example Question: Does your father have health conditions? P a g e 22 | 40 Finding: Reports that family members are overweight (Found)Pro Tip: Asking about trends such as obesity can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. - Correct answer >>>Example Question: Does obesity run in your family? Finding: Asked about family history of thyroid issues - Correct answer >>> Finding: Denies family history of thyroid issues (Found)Pro Tip: Asking about trends such as thyroid issues can help you fill in holes in the history that your patient may have missed, and can allow you insight into other inherited diseases that affect relatives outside of immediate family. - Correct answer >>>Example Question: Do you have a family history of thyroid problems? Finding: Asked about family history of substance abuse - Correct answer >>> Finding: Reports 1 uncle has alcoholism (Found)Pro Tip: Asking about trends in substance abuse can help you understand your patient's risk for inherited diseases linked to addiction. - Correct answer >>>Example Question: Do you have relatives with addiction problems? Finding: Asked about family history of headaches - Correct answer >>> Finding: Denies family history of headaches (Found)Pro Tip: Asking about trends such as headaches can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. - Correct answer >>>Example Question: Do you have a family history of headaches? Review of Systems - Correct answer >>> Finding: Asked about constitutional health - Correct answer >>> Finding: Reports occasional tiredness or fatigue (Available)Pro Tip: Asking about tiredness or fatigue is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Correct answer >>>Example Question: Are you fatigued? Finding: Reports typical sleep pattern (Available)Pro Tip: Asking about the patient's typical sleep pattern is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Correct answer >>>Example Question: Have you noticed changes in your sleep? Finding: Reports fever (Available)Pro Tip: Asking about additional symptoms, such as fever, is one possible component of a review of systems interview. The patient's response to questions about general, constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint - Correct answer >>>Example Question: Are you feeling feverish right now? Finding: Denies chills (Available)Pro Tip: Asking about additional symptoms, such as chills, is one possible component of a review of systems interview. The patient's response to questions about general, P a g e 25 | 40 constitutional health may uncover additional problems not discovered during the discussion of the patient's chief complaint. - Correct answer >>>Example Question: Have you had chills? 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. - Correct answer >>>Example Question: Have you had night sweats? Finding: Asked about review of systems for mental health - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>Example Question: Do you have a history of suicidal thinking? Finding: Asked about review of systems for head - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: Have you had any head injuries? Finding: Asked about review of systems for ears - Correct answer >>> 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. - Correct answer >>>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 P a g e 26 | 40 hearing loss. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: Have you had ear discharge? Finding: Asked about review of systems for eyes and vision - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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? - Correct answer >>> 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. - Correct answer >>>Example Question: Have you had eye pain? P a g e 27 | 40 additional problems not discovered during discussion of the patient's chief complaint. - Correct answer >>>Example Question: Have you had a sore throat? Finding: Denies lymph node problems (Available)Pro Tip: Asking about a patient's lymph nodes is one possible component of a review of systems interview. Swollen lymph nodes may appear in the neck when an infection is present. - Correct answer >>>Example Question: How are your lymph nodes? Finding: Denies frequent sore throat (Available)Pro Tip: Asking if a patient has recurring throat problems 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. - Correct answer >>>Example Question: Do you have any throat problems? Finding: Denies swollen glands (Found)Pro Tip: Asking about a patient's glands in general could include lymph nodes or thyroid glands. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint. - Correct answer >>>Example Question: Do you have any swollen glands? 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. - Correct answer >>>Example Question: Have you had voice changes? Finding: Asked about breast health - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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 P a g e 30 | 40 health. If she has not had any screenings, it provides an opportunity for patient education. - Correct answer >>>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. - Correct answer >>>Example Question: Have you had breast cancer? Finding: Asked about review of systems for respiratory - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: Have you been coughing? Finding: Asked about review of systems for cardiovascular - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>Example Question: Have you had palpitations? P a g e 31 | 40 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: Do you have circulation problems? Finding: Asked review of systems for gastrointestinal - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: Do you ever get heartburn? Finding: Denies constipation (Available)Pro Tip: Asking about constipation is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If P a g e 32 | 40 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. - Correct answer >>>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. - Correct answer >>>Example Question: Do you have muscle swelling? Finding: Asked review of systems for neurological - Correct answer >>> 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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: Do you lose your balance often? Finding: Asked review of systems for skin, hair and nails - Correct answer >>> 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. - Correct answer >>>Example Question: Do you still have acne? P a g e 35 | 40 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. - Correct answer >>>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. - Correct answer >>>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 - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>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. - Correct answer >>>Example Question: Do you have dry skin? Finding: Denies skin rashes - Correct answer >>> Education & Empathy - Correct answer >>> 1.Expression of pain Followed Up - Correct answer >>>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." P a g e 36 | 40 2.Impact of injury on daily life Followed Up - Correct answer >>>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 asking a family member to bring your schoolwork. We'll do our best to get you feeling better and, on your way, home as soon as possible." 3.Gaps in health literacy around diabetic diet Not Encountered - Correct answer >>>Description: Tina describes controlling her diabetes by avoiding "sweets." Model Statement: "Staying away from sugar is a great start. I can give you some more information on what a balanced diet looks like for someone with diabetes. For example, many starchy foods break down into glucose in the body, like pasta, and so you can eat those in moderation, too. Most people with diabetes feel better when they limit all starches, eat protein, and take regular medication." 4.Lack of treatment with diabetes medication Not Followed Up - Correct answer >>>Description: Tina reveals that she does not treat her diabetes with medication. Student: Do you currently take medicine for your diabetes? Tina Jones: No, I don't take anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? Tina Jones: 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. Model Statement: "I understand that it can be challenging to keep up with daily medication. But it's important to keep your blood sugar under control to prevent long-term damage to your health, and medication can really help. I'd like to talk with you more about getting back onto a prescription. We could start you at a low dose, which reduces the side effects." 5. Lack of blood glucose monitoring Not Followed Up - Correct answer >>>Description: Tina reveals that she does not check her blood sugar. Student: Do you monitor your blood glucose? Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Model Statement: "I understand how it can feel like a frustrating chore to check your sugar every day. But it is important to keeping your diabetes under control. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. And keeping your sugar down will help your foot wound heal quickly, too. If you would like, I can help you find a monitor that is as painless as possible. I can also teach you more about what the numbers mean." 6. Gaps in health literacy around asthma control Not Followed Up - Correct answer >>>Description: Tina describes increased inhaler use and decreased effectiveness, indicating that her asthma is uncontrolled. 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 are some things that trigger your asthma? Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: What allergies do you have? Tina Jones: I'm allergic to cats. Model Statement: "It sounds like your asthma is giving you some problems, and you're not getting full relief from your inhaler. I would like to talk with you about changing your medication and your regimen, to reduce your frequent breathing problems, so that you feel better day-to-day. Most patients find that using a daily inhaler is an easy way to reduce your asthma symptoms even more." P a g e 37 | 40