Evidence Relevant: Evidence Pro Tip: Tina directly reports that she doesnt exercise, which is the primary evidence for a sedentary lifestyle. May indicate abnormal clotting factors. This new feature enables different reading modes for our document viewer. I dont want to miss work or school but now it looks like Ill have to. Finding: Denies current birth control (Available)Pro Tip: A patients use of birth control can impact the care plan, such as which medications are prescribed. Example Question: Are you currently on birth control? 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. Other contributing factors are her family history of diabetes mellitus and a lack of physical exercise. Educated Diabetes can cause flakes or plaques to form on the front of your legs, to keep moisturized and not to scratch or pick the areas. Anytime. If the patient reports a history of chest tightness, it could be a symptom of asthma or another respiratory problem. Student: How effective was the Neosporin? 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. Before I came in, I was just taking Advil. Its like a half hour from here. It's 4 p.m. on Tina Jones' second day as a patient here at Shadow General Hospital. Texture: smooth, firm and even surface Thickness: uniformly thin over most of the body Edema Mobility and turgor: ease of rising and ability to promptly return Vascularity or bruising: Cherry (senile) angiomas Edema: edema is fluid accumulating in the intercellular spaces. Priority High Priority Pro Tip: The patients foot wound impairs her walking, which in turn increases her risk for falls while she is an admitted patient. "I have a monitor at home, but to be honest I dont really use it that often." My brother and my dad are kind of big, but I wouldnt say they were obese or anything. Example Question: Does your paternal grandmother have health conditions? Finding: Asked about family history of obesity. She seems happy. Example Question: Have you been hospitalized in the past? Your email address will not be published. Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your Examples: impetigo and acne. Reports skin has only itched due to cat exposure. Came here in the dead of winter - the parking lot to turn into from 800 North (snowing and ice everywhere) is not recommended - you can hit your car's tires on the sidewalk due to it being covered and not being shoveled/maintained! Hair Salons. Educate Disease Process: Educate the patient on the signs and symptoms of hyper- and hypoglycemia. The patients response to these questions may uncover additional problems not discovered during discussion of the patients chief complaint. Finding: Reports pain has increased in the past 2 days (Available)Pro Tip:Finding out how the patients pain has changed will give you insight into the acceleration of infection. Finding: Reports receiving Hepatitis A and B shot (Available)Pro Tip: Discovering if a patient has received a childhood Hepatitis A and B vaccination reveals information about both her medical history and her susceptibility to infectious disease. Example Question: Have you had nosebleeds? 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. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses. The patients response to these questions may uncover additional problems not discovered during discussion of the patients chief complaint. Asking Tina if her moles have changed will indicate whether any of her moles should be assessed further.E. Example Question: Did you use any ointment on the wound? Example Question: Have you had a sore throat? Finding: Denies current nose problems (Found)Pro Tip: Asking about symptoms, such as nose problems, is one possible component of a review of systems interview. Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will need. Koilonychia literally means "spoon nails." Finding: Denies joint pain (Available)Pro Tip: Asking about joint pain is one possible component of a review of systems interview. about her health history. Asking Tina if her paternal grandfather had high cholesterol can reveal generational patterns. Examples: sebaceous cyst So, it was really sudden. Distance. In Tinas case, it will help you better understand her asthma and create a timeline. If the patient reports a history of chest pain, it could be a symptom of a recurring cardiovascular problem. Finding: Reports ER administered pain medication (Found)Pro Tip: The differences between prescription and over-the-counter pain medications can be vast and asking about the type of pain medication your patient has been using will help you fully understand her home treatment habits. Priority Low Priority Pro Tip: A BMI greater than 30 indicates obesity, but this diagnosis is a low priority at present. Asking Tina how her foot wound has been healing specifies the symptoms she is Reports a photograph from years earlier shows darkening skin. 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. Finding: Asked about review of systems for mental health. Planning Relevant: Assess Musculoskeletal: Assess the patients ability to bear weight and gait. Student: How often do you have asthma exacerbations? Finding: Asked about review of systems for neck, throat and glands. "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. Asking Tina if her skin has been itching solicits important health history information. 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. Example Question: Do you have any environmental allergies? Asking Tina if there is any discharge coming from her wound specifies the symptoms she is experiencing. Tina Jones: Mom has high cholesterol and blood pressure, I think. Student: How many puffs do you take when using your asthma inhaler? Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. Shadow health assessment Tina Jones comprehensive assessment completed shadow health undergraduate students, become tester for shadow health! Finding: Reports increased water intake (Available)Pro Tip: Your patients fluid intake can offer insight into underlying medical conditions. A history of flank pain could be a symptom of genitourinary problems. Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will need. Vesicle: Elevated cavity containing free fluid, up to 1cm; a "blister" Clear serum flows if wall is ruptured. 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. Example Question: Does your sister have health conditions? Example Question: Does the wound feel warm? Past Week Student: We are going to take care of everything as quickly as possible. 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. As a currently presenting symptom, it could result in a change to the patients care plan. Tina Jones: Yeah, lately Ive definitely been much hungrier than usual. 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. click here for Skip to document Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions University of the People Maryville University Harvard University Example Question: Have you had chest tightness? Finding: Reports that she does not currently take medication for diabetes (Found)Pro Tip: Asking about diabetes medication is important to understanding if your patients disease is under control. Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your Finding: Denies corrective lenses (Available)Pro Tip: Asking about the patients use of corrective lenses is one possible component of a review of systems interview. Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Finding: Denies change in sense of taste (Available)Pro Tip: Asking about symptoms, such as a change in taste, is one possible component of a review of systems interview. Pigmentation: Caf au lait, mongolian spots Example Question: Can you bear weight on your foot? Finding: Denies seasonal allergies (Available)Pro Tip: Asking about seasonal allergies can help you understand a patients complete set of allergies over the course of a year. Tina Jones: I dont know. Asking Tina about her history of acne solicits important information about her health history. Planning Relevant: Assess Pain: Assess the patients pain at regular intervals and with each assessment of vital signs. Ends 8/31/2022. Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Example Question: Do you have circulation problems? Student: Does your mother have any health problems? The patients response to questions about this topic may uncover additional problems not discovered during the discussion of the patients chief complaint. the skin's oil glands. Student: What made you stop taking medication for your diabetes? Ask the patient questions about what changes she may be willing to make. Symptoms like these could indicate a yeast or sexually transmitted infection. Student: Have you had any problems with your breasts? Finding: Denies current chest tightness (Available)Pro Tip: Asking about chest tightness is one possible component of a review of systems interview. Finding: Asked about family history of substance abuse. Papule Example Question: What is your highest level of education? Gender-neutral restrooms. Reports last seeing a doctor for acne in high school. but I dont do that anymore. Tina Jones: Well, Im here, so I guess it didnt do its job. . Example Question: Does your foot pain affect your work? For shadow health assessment Tina Jones: Mom has high cholesterol can reveal generational patterns symptoms she experiencing! Identified diagnoses treat her symptoms coming from her wound specifies the symptoms she reports... You currently on birth control the care that she doesnt exercise, which is the primary evidence for sedentary... 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