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FIRST PART IS ALREADY COMPLETED I NEED THE HELP WITH THE TEMPLET
EditDIGITAL 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.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCE
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.
complete the template with information you provide me
Unformatted Attachment Preview
Name: Miss Tina Jones
Section: Section IV
Week 4
Shadow Health Digital Clinical Experience Health History Documentation
SUBJECTIVE DATA:
Chief Complaint (CC): Painful, infected scrape on the right foot.
History of Present Illness (HPI): Ms. Jones reports that a week ago, she tripped while walking on
concrete stairs, 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, applying antibiotic ointment, and a bandage.
Ankle swelling and pain have resolved, but the bottom of the foot is increasingly painful, described
as “throbbing” and “sharp” with weight bearing. Pain is rated 7 out of 10 after a recent dose of
tramadol, and 9 with weight bearing. The ball of the foot has become swollen and increasingly
red over the past two days. She noted discharge oozing from the wound. She denies there was
any odor from the wound. Her shoes feel tight, and she has been wearing slip-ons. Reports a fever
of 102 last night. Denies recent illness. Reports a 10-pound unintentional weight loss over the
month and increased appetite. Denies change in diet or level of activity.
Medications:
i.
Acetaminophen 500-1000 mg PO prn (headaches)
ii.
Ibuprofen 600 mg PO TID prn (menstrual cramps)
iii.
Tramadol 50 mg PO BID prn (foot pain)
iv.
Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use
three days ago)
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Allergies: None
Past Medical History (PMH):
i.
Asthma diagnosed at age 2 1/2, using albuterol inhaler 2-3 times per week
ii.
Type 2 diabetes, diagnosed at age 24; stopped metformin three years ago
Past Surgical History (PSH): No surgeries Recorded
Sexual/Reproductive History:
Menarche at age 11
First sexual encounter at age 18
Sex with men, identifies as heterosexual
Never pregnant
Last menstrual period 3 weeks ago, irregular cycles (every 4-8 weeks) with heavy
bleeding lasting 9-10 days
No current partner
Used oral contraceptives in the past; did not use condoms when sexually active
Personal/Social History:
Employed 32 hours per week as a supervisor at Mid-American Copy and Ship
Part-time student, last semester for a bachelor’s degree in accounting
Has a car, cell phone, and computer
Receives basic health insurance from work but deterred from healthcare due to out-ofpocket costs
Enjoys spending time with friends, attending Bible study, volunteering in her church,
and dancing
Active in her church with a strong family and social support system
Occasional cannabis use from age 15 to age 21
Drinks alcohol 2-3 times per month, no more than 3 drinks per episode
Drinks 4 caffeinated drinks per day (diet soda)
No foreign travel
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No pets
Not currently in an intimate relationship
Immunization History:
•
Tetanus booster received within the past year
•
Influenza is not current
•
Human papillomavirus vaccine not received
Health Maintenance:
•
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
Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings,
and children):
Mother: age 50, hypertension, elevated cholesterol
Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol,
and type 2 diabetes
Brother (Michael, 25): overweight
Sister (Britney, 14): asthma
Maternal grandmother: died at age 73 of a stroke, history of hypertension, high
cholesterol
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Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterl
Paternal grandmother: still living, age 82, hypertension
Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
Paternal uncle: alcoholism
Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell
anemia, thyroid problems
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint,
History of Present Illness, and History). Remember that the information you include in this
section is based on what the patient tells you. To ensure that you include all essentials in your
case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI
data here.
Reports recent weight loss of 10 pounds, increased appetite
No recent weakness, fatigue, or fever
HEENT: Null
Neck: Null
Breasts: Null
Respiratory:
Asthma diagnosed at age 2 1/2, using albuterol inhaler 2-3 times per week
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Exposure to cats triggered asthma symptoms three days ago
Cardiovascular/Peripheral Vascular: Null
Gastrointestinal: Null
Genitourinary: Null
Musculoskeletal:
Twisted right ankle and scraped the ball of the foot a week ago, pain in the bottom of
the foot with swelling and redness
Psychiatric:
Reports stressors relating to the death of her father and balancing work and school
demands, and finances
Family and church help her cope with stress
Neurological: Null
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 increased facial and body hair
Reports a few moles but no other hair or nail changes
Hematologic:
Denies bleeding, bruising, blood transfusions, and history of blood clots
Endocrine:
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Type 2 diabetes, diagnosed at age 24; stopped metformin three years ago
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IDENTIFYYING DATA AND RELIABLITY
Miss Tina Jones the 28 year old African American female she is pleasant and answer questions
appropriately she presented to us today for injury of her right foot she offers information freely
maintains great eye contact throughout the interview
GENERl survey
Miss Jones is alert to person place and time and situation on the examination table she remains
in an upright position good hydrating dress appropriately and well nourished
CHIEF COMPLAINT
I have a scrape to my right foot that is infected and has not gotten any better that is why I’m
here today and the pain is unbearable
Patient exam vital signs:
height 170 CM weight 90 kilograms BMI 31 random blood glucose 238 temperature 100.1
blood pressure 142/82 heart rate 86 respiratory rate 19 oxygen 98
History Of Present Illness
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 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.
MEDICATIONS
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
MDI2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago)
MEDICAL HISTORY
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 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.
HEALTH MAINTANCE
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.
FAMILY HISTORY
Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident
one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother
(Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at
age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died
at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother:
still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer,
history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness,
other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems
SOCIAL HISTORY
Never married, no children. Lived independently since age 20, currently lives with
mother and sister in a single family home to support family after death of father one year
ago. Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She
enjoys her work and was recently promoted to shift supervisor. She is a part-time
student, in her last semester to earn a bachelor’s degree in accounting. She hopes to
advance to an accounting position within her company. She has a car, cell phone, and
computer. She receives basic health insurance from work, but is deterred from
healthcare due to out-of-pocket costs. She enjoys spending time with friends, attending
Bible study, volunteering in her church, and dancing. Tina is active in her church and
describes a strong family and social support system. She reports stressors relating to
the death of her father and balancing work and school demands, and finances. She
states that family and church help her cope with stress. No tobacco. Occasional
cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines,
and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking
no more than 3 drinks per episode. She drinks 4 caffeinated drinks per day (diet soda).
No foreign travel. No pets. Not currently in an intimate relationship, ended a three-year
serious monogamous relationship two years ago. She plans on getting married and
having children someday.
OBJECTIVE
Wound: 2 cm x 1.5 cm, 2.5 mm deep wou wound edges, right ball of foot, serosang
drainage. Mild erythema surrounding wo edema, no tracking.
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