NR 509 Week 1 Shadow Health History Assignment/NR 509 Advanced Physical Assessment:Chamberlain College Of Nursing (Complete Solution)
Student
... [Show More] Response Model Documentation
General Survey
Tina is a 28 year old African American female that appears healthy and stated age. Alert, oriented, and cooperative. No signs of distress.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well- nourished, well-developed, and dressed appropriately with good hygiene.
History Of Present Illness
First noticed scrape on right foot two days ago. Tripped and fell down steps, scraped foot on the edge of the step. Sharp, throbbing pain rated a 7 on 0-10 scale. White drainage. Unable to bear weight on right foot and has missed two days of work. No chills or fever noted. Reports temperature of 102 last night.
Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot. She sought care in a local emergency department where she had x-rays that were negative; she was treated with tramadol for pain. She has been cleansing the site twice a day. She has been applying antibiotic ointment and a bandage. She reports that ankle swelling and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 7 out of 10 after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the wound. Her
Medications Tramadol 50 mg tablet, 2 tablets by
mouth three times a day as needed for pain Proventil 90 mcg/spray MDI, 2 puffs by mouth as needed for asthma No vitamins or herbal supplements Advil as needed for menstrual cramps
Allergies Allergic to penicillin, develops rash,
hives. Allergic to cats, develops itchy eyes, shortness of breath. No food allergies. No seasonal allergies. No latex allergy.
shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night. She denies recent illness. Reports a 10-pound, unintentional weight loss over the month and increased appetite. Denies change in diet or level of activity.
Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps) • Tramadol 50 mg PO BID prn (foot pain) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago)
Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust.
When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.
Medical History
Chickenpox in second or third grade. No measles, mumps, pertussis. Strep once a year as a child but not since high school. No rheumatic fever, scarlet fever, or polio. Diagnosed with asthma at age
2. Diagnosed with diabetes a few years ago. Hospitalized several times as a child for asthma attacks, last time was age 16. Gravida 0/Para 0/Abortion 0. Recent weight loss of 10 pounds. No excessive bruising. No fever or sweats. No broken bones. No burns. No eczema or psoriasis. Darkening of skin on neck reported. Excessive dryness on arms and legs. Excessive thirst. Wakes up 2-3 times a night to urinate. No hair loss or change in nails. Doesn't get much sun, reports use of sunscreen when outdoors. No headaches, head injury, dizziness, or tinnitus. No seizures. No
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats and dust. She uses her inhaler 2 to 3 times per week. She was exposed to cats three days ago and had to use her inhaler once with positive relief of symptoms.
She was last hospitalized for asthma “in high school”. Never intubated. Type 2 diabetes, diagnosed at age 24. She previously took metformin, but she stopped three years ago, stating that the pills made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn't monitor her blood sugar. Last blood glucose was elevated last week in the emergency room. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10
Health Maintenance
surgeries. Reports blurry vision. Wears no corrective lenses.
Develops headache after reading too long. No eye pain. No earaches, cleans ears with Q Tips.
Recommended use of washcloth to clean ears. No nose discharge, no sinus pain, no runny nose. No mouth pain or bleeding gums. No dysphagia. Brushes teeth twice a day. No neck pain. No nipple discharge. No chest pain. No wheezing. No cough. Shortness of breath only during asthma attack. Must use inhaler when climbs steps to third floor for class quickly. No trouble breathing at night. No numbness or tingling in hands or feet. No swelling in legs. Swelling on bottom of right foot around scrape. Appetite good with three meals a day. No heartburn, pain, nausea, or vomiting. Bowel movement 1/day or every other day, soft, brown. No constipation, diarrhea or blood with bowel movement. No hemorrhoids. No uses of laxatives or antacids.
Frequency in urinations. No dysuria or straining. Urine color light yellow, clear. Menarche at 11.
Cycle usually last 7-10 days. Menstrual pain. No vaginal itching or discharge.
Childhood immunizations up to date. Last dental visit was a few years ago. Last eye doctor visit was as a kid. Last pap smear was 4 years ago, normal. Last physical was 2 years ago. Does not perform breast self-exams. Last chest x-ray at 16. Last TB skin test 2 years ago. No ECG.
days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs four years ago.
Hematologic: Denies bleeding, bruising, blood transfusions and history of blood clots. Skin: Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes.
Last Pap smear 4 years ago. Last eye exam in childhood. Last dental exam “a few years ago.” PPD (negative) ~2 years ago. No exercise. 24-hour Diet Recall: States that she skipped breakfast yesterday, and would typically have a baked good for breakfast, a sandwich for lunch, and a meatloaf or chicken for dinner. Her snacks consist of pretzels or French fries. Immunizations: Tetanus
booster was received within the past year, influenza is not current, and human papillomavirus has not been received.
She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine in college.
Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Does not use sunscreen.
Guns, having belonged to her dad, are in the home, locked in parent’s room.
Social History Feels safe at home and work. No
history of tobacco use. No one in household smokes. History of smoking pot, last time was age 21. Drinks alcohol 1-2 times a week, few drinks each time. Baptist religion. Lives with mother and sister. Close with family. No children. Not currently sexually active but reports use of condoms when active. [Show Less]