Assignment 2: (DCE) Health History Assessment NURS 6512

Assignment 2: (DCE) Health History Assessment NURS 6512

Assignment 2 (DCE) Health History Assessment NURS 6512

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

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.

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. When she is forced to bear weights, she describes the pain as throbbing and sharp. Her ankle “ached,” she says, but it is now better.

The most recent tramadol dose has reduced the level of pain to a 7 out of 10. The pain level when bearing weight is a 9. She claims that the ball of her foot has swollen and turned red in the last two days, and that she noticed discharge pouring from the wound yesterday. She also claims that the swelling has worsened. She claims there is no odor emanating from the wound. Her shoes appear to be too small for her feet. She has been seen wearing shoes with no laces. She had a temperature of 102 last night. She denies having been ill recently. An increased appetite is reported, as well as an unintentional weight loss of ten pounds over the course of the month. Denies changing 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.

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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.

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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.

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.
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.

DCE Health History Assessment:

Complete the following in Shadow Health:

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.
Note: You must pass this assignment with a minimum score of 80%  in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.
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 submit this required part of the Assignment:

Week 4 Documentation Notes for Assignment 2

To Submit your Student Acknowledgement Form:

Submit your Week 4 Assignment 2 DCE Student Acknowledgement Form

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): A painful wound on the right foot.

History of Present Illness (HPI): An African American woman named Tina, 28, alleges that a week ago while walking, she stumbled over a concrete step and twisted her right ankle, scraping the ball of her foot in the process. She went to a neighboring emergency unit, where an X-ray was ordered and found to be negative. Tramadol was nonetheless provided to her to help with the discomfort. She says she cleans the wound twice daily, applies antibiotic cream, and wraps it in a bandage. Even though the pain and swelling at the location of the injury have fully subsided, she claims that the bottom of her foot is still quite uncomfortable. She describes the discomfort as being weight-bearing, throbbing, and intense. But, the discomfort in her ankle has already subsided. She continues to rate the pain as 7/10 even after a recent dose of tramadol.

She gives the pain when bearing weight, a 9 out of 10. She describes a swollen football that has become redder over the last two days. A day before the current appointment, the wound was already dripping with an odorless discharge. She claims that recently, her shoes have been uncomfortable, so she has started wearing slippers instead. Her fever was 1020F last night. She, though, denies having been unwell recently. She reports an increase in hunger and an unintentional 10-pound weight reduction over the past month. She asserts that her diet and energy levels have not changed.

Medications:

1. Ibuprofen 600mg orally three times each day for menstrual cramps.
2. Acetaminophen 500-100 mg orally, as needed for headaches.
3. Tramadol 50 mg orally twice a day if foot pain persists.
4. Albuterol 90mcg/spray multiple-dose inhalation up to two puffs every 6 hours for wheeze caused by cat allergies. She had last used the medication around three days before the current appointment.

Allergies:

1. There are no documented latex or food sensitivities.
2. Penicillin hypersensitivity
3. Establishes dust and cat allergies
4. Allergic reaction: runny nose, puffy and itchy eyes, and worsening asthma symptoms.

Past Medical History (PMH): At the age of two and a half years, was given an asthma diagnosis. Two to three times each week, she utilizes an Albuterol inhaler to control her symptoms when she is exposed to dust or cats. She was exposed to cats three days ago, and she used an inhaler, which was quite efficient in controlling the symptoms. She was hospitalized for asthma the last time she was in high school. She, on the other hand, denies ever being intubated.

When she was 24, she was diagnosed with diabetes mellitus. She had been taking metformin but had discontinued roughly three years ago because of flatulence adverse effects. She also reports that taking the tablets and checking her blood glucose simultaneously has been exhausting. She denies that she has been monitoring her blood glucose levels since then. She claims that the last time her levels of sugar in her blood soared was a week ago at the emergency department.

Past Surgical History (PSH): None

Sexual/Reproductive History: At the age of 11, she had her first menstrual cycle. heterosexual; first sexual experience occurred at the age of 18. denies ever becoming a mother. Menstrual cycles have been heavy and irregular in the last year, lasting 9 to 10 days every 4 to 8 weeks, with the most recent period starting around 3 weeks before the current appointment. She acknowledges using oral contraceptives mostly in past, but she is now single. denies wearing condoms when engaging in sexual activity. No reported history of STIs. The patient claims to have never had an HIV/AIDS test before. Her previous pap smear exam was roughly four years ago, according to her.

Personal/Social History: The patient enjoys going to clubs and drinking alcohol on occasion. Her bachelor’s degree is in accountancy. She has a loving family and friends. There will be no cigarette or marijuana use. He goes to a Baptist church.

Immunization History: She had a tetanus booster last year. Her influenza vaccination is out of date. Her human papillomavirus vaccination was not given to her. She received her meningococcal vaccine when she was still attending college and believes she was immunized as a teenager.

Health Maintenance: No physical activity. She recalls her nutrition over the previous 24 hours. The day before the current visit, he claims to have skipped bre