Focused Exam-Hypertension and Type 2 Diabetes Shadow Health; Subjective Data Collection
Focused Exam-Hypertension and Type 2 Diabetes Shadow
... [Show More] Health; Subjective Data Collection-Latest Update 2020.
Case 02: Focused Exam: Hypertension and Type 2 Diabetes Results | Turned In
Pharmacotherapeutics for Advanced Nursing Practice - Spring 2020, NGR 6172
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Overview Transcript
Subjective Data Collection: 20 of 20 (100.0%)
Subjective Data Collection Objective Data Collection Education & Empathy Documentation
Debrief
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Medication Selection Patient Teaching Prescription Writing
Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
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A combination of open and closed questions will yiel better patient data. The following details are facts of patient's case.
Chief Complaint
Established chief complaint Reports coming in for check-up
History of Present Illness
Asked about relevant health conditions Reports hypertension Reports type 2 diabetes
Reports generalized anxiety disorder
Asked about onset and duration of disorders Reports hypertension diagnosis 1 year ago
Reports diabetes diagnosis 5 years ago Reports GAD diagnosis 13 years ago
Asked about associated symptoms Reports increased thirst Reports increased urination
Reports weight gain of 15 pounds Reports fatigue and discomfort Reports increased worry
Asked about onset and duration of associated symptoms
Reports increased thirst began 1 month ago Reports increased urination began 1 month ago Reports weight gain over the last 3 months Reports fatigue and discomfort over the last 3
months
Asked about non-medicational diabetes management
Reports owning glucometer
Reports checking blood sugar sporadically
2/
Reports sporadic checking is because of disliking the glucometer's pinch
Past Medical History
Asked about allergies Denies known allergies
Asked about previous hospitalizations Denies previous hospitalizations
Home Medications
Asked about home medications Reports taking hydrochlorothiazide for hypertension
Reports taking metformin for type 2 diabetes Reports taking escitalopram for anxiety Denies taking vitamins and supplements
Followed up on hydrochlorothiazide Reports hydrochlorothiazide tablets are each 50 milligrams
Reports taking one hydrochlorothiazide tablet a day
Reports taking hydrochlorothiazide with breakfast Reports starting hydrochlorothiazide 1 year ago Reports taking last dose of hydrochlorothiazide
this morning
Denies hydrochlorothiazide adverse effectsects
Followed up on metformin Reports metformin tablets are each 850 milligrams
Reports taking metformin tablet three times daily Reports taking one metformin tablet each with
breakfast, lunch, and dinner
Reports starting metformin 5 years ago Reports taking last dose of metformin this
morning
Denies metformin adverse effectsects
Followed up on escitalopram Reports escitalopram tablets are each 20 milligrams
Reports taking one escitalopram tablet a day Reports taking escitalopram with breakfast Reports began taking escitalopram 13 years ago Reports taking last dose of escitalopram this
morning
Denies escitalopram adverse effectsects
Asked about medication regimen adherence Denies missing doses
Social History
Asked about activity Reports sedentary activity level
Asked about diet Reports eating take-out frequently
Reports enjoying comfort foods when stressed [Show Less]