Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N-32

Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N-32

Assignment 2 Digital Clinical Experience (DCE) Health History Assessment NURS 6512N-32

SUBJECTIVE DATA:

Chief Complaint (CC): ‘My right foot hurts’

History of Present Illness (HPI): The patient in the case study comes to the clinic with complains of a painful, swollen, red, warm scrape on her right foot for the last two days. The patient thought it would heal on its own but has been worsening over time. The patient reports that the pain worsened over the last two days. The patient sustained the injury a week ago while going down the back steps when she tripped and twisted her ankle. She also scrapped her foot on the edge of the step. The patient went to the ER an hour after falling because of the strained ankle. The x-ray performed was normal. She was prescribed pain medications. The patient rates the pain 7/10 in the pain rating scale. She reports that the scrape is infected and worsening. The patient describes the pain as throbbing. It is associated with sharp pain when weight is applied.  The pain radiates to the ankle. The patient reports that the affected foot is non-weight bearing. The patient reports that the wound drains pus, white in color, for the last two days. She has been treating the wound at home by cleaning twice daily and bandaging it. She has been cleaning it with soap, water, and some peroxide if irritated. She has also been applying Neosporin ointment twice daily. The problem has affected her functioning ability since she has missed her work because of the pain. She has also missed her class two days ago. Besides the current problem, she reports losing 10 pounds unintentionally, being thirsty, experiencing oliguria and polyphagia for the past month.

Medications: She currently uses Proventil inhaler if symptoms of asthma persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management.

Allergies: She develops asthma symptoms when she is near cats. She is also allergic to dust and develops asthma symptoms with intensive physical activity. She is also allergic to penicillin.

Past Medical History (PMH): The patient was diagnosed with diabetes type 2 at the age of 24 years. She is also asthmatic since the age of two and half years. Her last asthmatic attack was when she was in high school. She developed breathing problems three days ago at her cousin’s place.  She has a history of using Metformin, which she took it three years ago. The patient has history of five hospitalizations when she was 16 years because of asthma. She has a history of using nebulizer. She manages asthma by avoiding triggers but uses Proventil inhaler if symptoms persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management. She has also been using tramadol 100 mg three times a day for pain for the last two days. She takes Advil when her cramps het bad and Tylenol for headache.

Past Surgical History (PSH): The patient denies any history of surgeries

Sexual/Reproductive History: The patient denies history of sexually transmitted infections

Personal/Social History: The patient is a student currently finishing her bachelor’s degree in accounting. She lives with her mother and her sister. She is worried about her right foot. The patient denies barriers in accessing healthcare. Her family and church are her social support systems.

Immunization History: The patient believes that she received her childhood immunizations. She did not get her flu shot this year. Her tetanus booster was a year ago.

Health Maintenance: The patient reports that she started watching her sugar and avoiding regular soda after she found out that she is diabetic. She only drinks diet coke. She rarely checks her sugars, with the last time being a month ago. She does not understand the meaning of blood glucose numbers. She rarely checks her blood pressure. She stopped taking Metformin because of its side effects and feeling overwhelmed remembering to take the pills and checking her blood sugar. Her typical breakfast comprises muffin or pumpkin bread obtained from a nearby café. Her typical lunch is a meal she usually picks from a nearby campus or subway to get turkey sandwich. Her typical dinner is meatloaf, pasta, casseroles, and chicken. Her typical snacks include pretzels and French fries. She does not pay attention to the amount of salt she eats. She drinks about four-diet coke daily. She last took alcohol three weeks ago. She drinks alcohol once or twice a week during night outs. She is exposed to second-hand smoke from her friends. Her last eye and dental examination was when she was a child. She reports doing self-breast examination a couple times. She has never undergone mammography.

Significant Family History: Her mother has high cholesterol and diabetes. Her deceased father had type 2 diabetes, high cholesterol, and hypertension. Grandfather had colon cancer, diabetes, and hypertension. Paternal grandmother has high cholesterol and hypertension. Her sister is asthmatic. Her brother and father are overweight. Her uncle has alcohol addiction problem.

 

Review of Systems:

Vital signs: Height 170 cm, weight 90kg, BMI 31, Random blood glucose 238, Temperature 101.1F, O2 saturation 99%

General: The patient reports fatigue, fever and chills last night. She denies night sweat or suicidal thoughts.

HEENT: She denies headache, head injuries, changes in hearing, ringing ears, ear pain, and ear discharge. She denies changes in vision, double vision, itchy eyes, watery eyes, and dry eyes. She reports eye pain when she reads for too long. She reports occasional rhinorrhea. She denies sinus pain, changes in sense of smell, nosebleeds, or dental problems. She denies changes in sense of taste, dry mouth, mouth pain, mouth sores, or tongue problems.

Neck: She denies dysphagia, sore throat, lymphadenopathy, voice changes, or neck pain.

Breasts: She denies breast problems, such as pain, lumps, nipple changes, or nipple discharge.

Respiratory: The patient denies wheezing, chest tightness, dyspnea, cough, or chest pain.

Cardiovascular/Peripheral Vascular: The patient denies palpitations, easy bruising, edema, circulation problems, or vascular diseases.

Gastrointestinal: The patient denies nausea, vomiting, stomach pain, changes in bowel movements, heartburn, constipation or diarrhea.

Genitourinary: The patient denies dysuria, urgency, frequency, or history of sexually transmitted infections.

Musculoskeletal: The patient reports right ankle sprain, which is non-weight bearing. She denies fractures.

Psychiatric: The patient denies depression, anxiety, or stress.

Neurological: The patient denies ataxia, numbness, tingling, loss of balance, and difficulties in coordinating movement.

Skin: The patient denies rash. She reports swollen right foot with a wound draining pus.

Hematologic: The patient denies easy bruising or prolonged bleeding

Endocrine: The patient denies heat or cold intolerance. She reports unintentional weight loss, polydipsia, polyphagia, and polyuria.

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Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

Ms. Jones claims she tripped on concrete stairs outside a week ago, twisting her right ankle and scraping the ball of her foot. She sought treatment at a local emergency department, where she had negative x-rays and was given tramadol for pain. She has been cleaning the area twice daily. She has been using antibiotic ointment and a bandage on her wound.

Her ankle swelling and pain have subsided, but the bottom of her foot is becoming increasingly painful. With weight bearing, the pain is described as “throbbing” and “sharp.” She says her ankle “ached” but is now healed. After a recent tramadol dose, pain is rated 7 out of 10. Weight bearing causes pain on a scale of 9. She reports that the ball of the foot has become swollen and red over the last two days, and that discharge is oozing from the wound.

She denies any odor emanating from the wound. Her shoes are too small. She was dressed in slip-ons. She had a 102-degree fever the night before. She denies having been ill recently. Reports an unintentional 10-pound weight loss and increased appetite over the month. Denies any changes in diet or activity level.

Also Read: Discussion: NURS 6512 Diversity and Health Assessments

Section: Assignment 2: Digital Clinical Experience (DCE): Health History Assessment

Week 4 Shadow Health Digital Clinical Experience Health History Documentation

SUBJECTIVE DATA:

Chief Complaint (CC): “I got a scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!”

History of Present Illness (HPI): Ms. Jones claimed that one week ago, she was walking on stairs outside when she tripped and fell, causing her right ankle to twist and the ball of her foot to scrape. She went to the emergency room of the nearby hospital, where she received negative results from the x-rays and was given tramadol for the pain she was experiencing. She has been cleaning the wound twice. She has been treating the wound with an antibiotic medication and bandaging it.

She adds that the pain and swelling in her ankle have subsided, but that the bottom of her foot is becoming increasingly uncomfortable. She describes the pain as throbbing and sharp when she is forced to bear weights. She reports that her ankle “ached” but it is better now. After taking the most recent dose of tramadol, the level of pain has decreased to a 7 out of 10. The degree of pain when bearing weight is a 9.

She says that the ball of foot has become swelled and more red over the previous two days and that yesterday, she noticed discharge pouring from the wound. She also says that the swelling has gotten worse. She claims that there is no smell coming from the wound. Her shoes appear to be too small. She has been seen wearing shoes that are without laces.

Last night, she reported a temperature of 102. She denies recent illness. An

increased appetite is reported alongside with an accidental weight loss of ten pounds that occurred over the course of the month. Denies making any changes to their diet or amount of physical activity.

Medications: Acetaminophen 500 to 1000 mg PO as needed (headaches). Ibuprofen 600 mg PO twice daily as needed (menstrual cramps). Tramadol 50 mg PO BID prn (foot pain). Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing while neat cats, most recent administration: three days ago)

 

Allergies: Rash caused by penicillin, Allergic to cats and dust but not food or latex sensitivities. She claims that being among allergens causes her to experience runny nose, itchy and swollen eyes, and an increase in the severity of her asthma symptoms.

 

Past Medical History (PMH): At the age of 2 and a half, the asthma was identified. When she is in an environment with cats or dust, she utilizes the albuterol inhaler that she carries with her. Two of three times a week, she makes use of her inhaler. Three days ago, she was around cats, and she had to use her inhaler once to get some respite from the symptoms that were bothering her.

Her last asthma related hospitalization was when she was in high-school. Never had an intubation. Diabetes type 2 was discovered at the age of 24. She had been taking Metformin in the past but stopped doing so three years ago, citing the fact that the drugs caused her to have gas and that “it was stressful taking pills and testing my sugar”. She does not keep an eye on her sugar levels.

In the hospital’s emergency room, the patient’s sugar levels were high the week before last. No surgeries. Hematologic: Acne has been a problem for her ever since she hit adolescence and she also gets bumps on the backs of her arms if her skin is dry. Complains of a darkening of the skin on her neck as well as an increase in the hair on her face and body. She has noted that she has a few moles, but no noticeable alterations to her hair or nails.

Past Surgical History (PSH): No history of past surgery.

Sexual/Reproductive History: Menarche, age 11. First sexual experience at the age of 18, which encounters were with men, and the individual identifies as straight. Never pregnant. It’s been three weeks since her last menstruation. During the last year, her menstrual period has been quite erratic, occurring every 4-6 weeks and she has had heavy bleeding that lasts 9-10 days.

She does not have a partner currently. She used oral contraceptives when she was younger. She claims that she did not use condoms when she was sexually active. Never had an HIV/AIDS test done. No record of previous sexually transmitted infections or signs of STIs. When she was last teste, four years have elapsed.

Personal/Social History: Never married and does not have any children. Since the age of 20, has lived on her own, and since her father passed away a year ago, they now share a home with their mother and a sister in a single family dwelling in order to support the family. Currently working as a supervisor at Mid-American Copy and Ship for a total of 32 hours per week.

She was just elevated to the position of shift supervisor, which she thoroughly enjoys. She attends school on a part-time basis and is currently in her final semester of work toward obtaining a bachelor’s degree in accounting. She has her sights set on becoming an accountant for the company she currently works for. She is well off as she owns a car, a cellphone and a computer. Even though she is covered by the employer’s basic health insurance, she avoids seeking medical attention because of the out-of-pocket expenses involved.

She takes pleasure in socializing with her friends, going to Bible study, being active in the ministry of her church and dancing. Tina has a solid family and social support structure and she is also involved in her local church community. She describes feeling stressed as a result of the death of her father, as well as the responsibilities of her job and education and her financial situation. She states that coping with the stress has been easy because of her family and the church. No tobacco usage.

Cannabis use on an irregular basis between the ages of 15 and 21. She denies ever having used cocaine, methamphetamines, or heroine. Utilizes alcoholic beverages “when out with pals, two or three times a month.” and claims to consume no more than three drinks throughout each occasion. She consumes four beverages containing caffeine and diet soda daily.

No foreign travel. No pets. She is not in an intimate relationship currently but she completed a significant monogamous relationship that lasted for three years two years ago. It is in her future intentions to start a family by getting married and having children.

Health Maintenance: The most recent Pap smear was performed in 2014. The last eye exam was conducted when she was a child. The last time she had a dental exam was a couple of years ago. PPD test was negative less than two years ago.

No workout. 24-hour diet recall: She admits that she skipped her breakfast the day before and that she normally consumes baked good for breakfast, sandwich for lunch and either meatloaf or chicken for dinner. However, she did not have any of these foods yesterday. Her munchies are either usually either pretzels of French fries.

Immunization History: Regarding immunizations, a tetanus booster shot was administered during the past year; however, a flu shot and vaccine against human papillovirus were not given nor received. She states that she feels that she is up to date on all of her childhood vaccines and that she received the meningococcal vaccine while she was in college.

Safety: She does not ride a bike, possesses smoke alarms at home, and always puts on seatbelt whilst driving. Does not use sunscreen. The home has firearms that once belonged to her father and are currently secured in the room used by her parents.

Significant Family History: The mother is 50 years old and has hypertension and high cholesterol. Father died in a car accident a year ago at the age of 58; he has hypertension, high cholesterol, and type 2 diabetes. Brother (Michael, age 25), suffers from obesity Sister (Brittany, age 14) struggles with asthma Grandmother on the maternal side passed away at the age of 73 as a result of stroke; she had a history of hypertension and excessive cholesterol.

Grandfather on the maternal side passed away at the age of 78 as a result of a stroke; he had a history of hypertension and excessive cholesterol. Grandmother on the father’s side is still alive and has hypertension despite being 82 years old. Grandfather on the father’s side passed away at the age of 65 from colon cancer, family history of type 2 diabetes. Negative for mental illness other malignancies, unexpected death, kidney disease, sickle cell anemia, and thyroid disorders. An uncle on the father’s side had a problem with alcoholism.

Review of Systems

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT:

HEAD: The patient’s head is round, symmetrical, and normocephalic; palpation reveals no nodules, masses, or depressions.

EYES: The bulbar conjunctiva was translucent with few capillaries obvious, and there is no edema or tears in the lacrimal gland. However, the patient’s vision is blurry at the moment. Eye lashes appeared to be uniformly distributed. However, the patient’s eyesight is blurry at the moment. During the test of the additional ocular muscle, both eyes moved in sync and aligned themselves parallel to one another.

EAR: The auricle membranes are spotless and are the same color as the skin on the face.

NOSE: The nose seemed straight, symmetrical, and of a single color.

THROAT: The patient denies having any pain, there being any swelling present, and having any trouble swallowing.

Neck: The patient demonstrated synchronized smooth head movement without any signs of discomfort, indicating that the neck muscles are of comparable size.

            Breasts: Patient shows no signs of pain or discomfort.

            Respiratory: The patient has a history of asthma but claims they are not having any respiratory problems. The breathing sounds were regular, and there was no evidence of discomfort

            Cardiovascular/Peripheral Vascular:  The patient states that they are not experiencing any chest pain and that they have no history of hypertension. The patient’s blood pressure is on the cusp of being dangerous. Only experiences chest pressure when she is having trouble breathing, which is otherwise painless.

            Gastrointestinal: The patient reports no discomfort in the abdomen region, and all four quadrants exhibited positive bowel sounds.

 

            Genitourinary: Denies that urinating causes any discomfort

            Musculoskeletal: The patient is experiencing discomfort in their foot

 

            Psychiatric: Denied any history of previous mental health issues.

            Neurological: Patient is alert, oriented x3

            Skin: On the foot, there was a skin break that measured approximately 2 centimeters by 1.5 centimeters and was 2.5 millimeters deep. It was draining pus. Her hands and feet each have skin that is parched and cracked.

            Hematologic: Rejects that they have any blood disorders.

            Endocrine: The patient’s blood glucose level is 238 mg/dl and they have a history of diabetes.

Assignment 2: Digital Clinical Experience (DCE): Health History Assessment

In Week 3, you began your DCE: Health History Assessment. For this week, you will
complete this Health History Assessment in your simulation tool, Shadow Health and
finalize for submission.

Photo Credit: Sam Edwards / Caiaimage / Getty Images
To Prepare
 Review this week's Learning Resources as well as the Taking a Health History media
program in Week 3, and consider how you might incorporate these strategies.
Download and review the Student Checklist: Health History Guide and the History
Subjective Data Checklist, provided in this week's Learning Resources, to guide you
through the necessary components of the assessment.
 Review the DCE (Shadow Health) Documentation Template for Health History found in
this week’s Learning Resources and use this template to complete your Documentation
Notes for this DCE Assignment.
 Access and login to Shadow Health using the link in the left-hand navigation of the
Blackboard classroom.
 Review the Shadow Health Student Orientation media program and the Useful Tips and
Tricks document provided in the week’s Learning Resources to guide you through
Shadow Health.
 Review the Week 4 DCE Health History Assessment Rubric, provided in the
Assignment submission area, for details on completing the Assignment.
DCE Health History Assessment:
Complete the following in Shadow Health:

https://nursingmasters.blog/assignment-2-digital-clinical-experience-dce-health-history-assessment-nurs-6512n-32/
Orientation
 DCE Orientation (15 minutes)
 Conversation Concept Lab (50 minutes)

Health History
 Health History of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many

times as necessary prior to the due date to achieve a total of 80% or better (this
includes your DCE and your Documentation Notes), but you must take all attempts by
the Week 4 Day 7 deadline.
Submission and Grading Information

By Day 7 of Week 4

 Complete your Health Assessment DCE assignments in Shadow Health via the Shadow
Health link in Blackboard.
 Once you complete your assignment in Shadow Health, you will need to download your
lab pass and upload it to the corresponding assignment in Blackboard for your faculty
review.
 (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You
can find instructions for downloading your lab pass
here: https://link.shadowhealth.com/download-lab-pass
 Once you submit your Documentation Notes to Shadow Health, make sure to copy and
paste the same Documentation Notes into your Assignment submission link below.
 Download, sign, date, and submit your Student Acknowledgement Form found in the
Learning Resources for this week.

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Grading Criteria
To access your rubric:
Week 4 Assignment 2 DCE Rubric
Submit Your Assignment by Day 7 of Week 4
To submit your Lab Pass:
Week 4 Lab Pass
To participate in this Assignment:
Week 4 Documentation Notes for Assignment 2
To Submit your Student Acknowledgement Form:
Submit your Week 4 Assignment 2 DCE Student Acknowledgement Form

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 2: Digital Clinical Experience (DCE): Health History Assessment NURS 6512N-32

Learning Resources

Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Seidel's guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.

 Chapter 9, “Skin,