N518 Module 1: The Health History and Interview- Shadow Health

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N518 Module 1: The Health History and Interview- Shadow Health Assessment

N 518 Module 1: The Health History and Interview

The Health History and Interview- Shadow Health Assessment : This first discussion assignment is intended to help each student set a context for the course, establish expectations and goals for the course, and provide insights to the instructor enabling tailoring of the course to better fit the needs of the students. Replies to discussion questions must be well considered and scholarly.

Every course you take should provide the knowledge and skills useful in the real world. Not every course will directly link to every task that you perform in your life or current employment, but learning how to review data, develop data analysis, critical thinking, and writing skills are all needed to convince someone that you can think critically and solve problems. Your ability to pull together and leverage information, insights, and lessons from a number of disparate disciplines in novel ways could be precisely what is needed to stay ahead of your competition and give you a competitive edge.

Your first task is to learn about the course and discover how the skills provided in this course are relevant to you. You will prepare for, post, and engage in a discussion with your classmates and your professor.

The Health History and Interview- Shadow Health

Welcome to Health Assessment

Hello class: my name is, and I will be the instructor for this class. For more information on how to get a hold of me, please go under my profile for specific information. However, my email is: ***The best way to contact me though, is through the Private forum***

This course will focus on methods of health history taking, physical examination skills, documentation, and health screening. The course emphasizes the individual as the client, functional health patterns, community resources, and the teaching learning process. This course will take us through infancy to an older adult.

To find course material, go under your Dashboard, then you will see PATH. There are two links to find information regarding this course; course material and syllabus.

Under your Assignments, will have the due date and the rubric posted to look at.

Under the Planner tab, assignments are listed along with the due dates. Clicking the collaborative reminder within the calendar tab will show the assignment, any information that is needed for the assignment, and give the rubric of how the assignment will be graded.

Please refer to all other announcements for Class Policies and Week 1 class.

Feel free to contact me anytime. I look forward to this 5 week journey with each of you

Assessment

Module 1: Discussion Question

Start by reading and following these instructions:

You are responsible for minimally at least 3 posts for each question in your discussion boards; your initial post and reply to two of your classmates. Your initial post(s) should be your response to the questions posed in the Discussion Question. You should research your answer and cite at least one scholarly source when appropriate, and always use quality writing. The discussion board is never a place to use text language or emoticons. You will also be asked to respond to your classmates. This is designed to enhance the academic discussion around the topic. It is all right to disagree with something posted by another, however your responses should always be thoughtful and respectful and reflect your opinions professionally.

Discussion Question:

Complete a comprehensive risk assessment for a friend or family member. Please do not use the patient’s name or identifiers. Discuss your findings. Then, reflect on your interview and discuss which parts went well and which parts you will change the next time you complete a risk assessment.

Your initial posting should be 200 to 300 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 100 words in length. To properly “thread” your discussion posting, please click on REPLY.

When you are ready for the discussion, do the following:

  1. Click on the discussion link above.
  2. Start your answer by clicking “Start a New Thread” button with the title of your answer and the body of text following the guidance above.
  3. To properly post your answer, please click on the “Post” button.
  4. After posting your contribution, you must read what others have posted, reply to at least two of those posts, and respond (when appropriate) to those you have responded to you.

To reply to a classmate’s post:

  1. Click on the title of another student’s post.
  2. Click “Reply to Thread” and type your response to the student.
  3. Click the “Post” button to post your reply.

Module 1: Assignment

Remember to submit your work following the file naming convention FirstInitial.LastName_M01.docx. For example, J.Smith_M01.docx. Remember that it is not necessary to manually type in the file extension; it will automatically append.

Start by reading and following these instructions:

1. Quickly skim the questions or assignment below and the assignment rubric to help you focus.

2. Read the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.

3. Consider the course discussions so far and any insights gained from it.

4. Create your Assignment submission and be sure to cite your sources if needed, use APA style as required, and check your spelling.

Assignment:

Exercises: 

Professional Development

SUBJECTIVE DATA COLLECTION

Subjective Data Collection: 63 of 104 (60.6%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

History of Present Illness

Medical History: Medication

Medical History: Allergies

Medical History: Immunizations

Medical History: Diabetes

Medical History: Asthma

Medical History: Hypertension

Medical History: Gynecological and Sexual History

Social History: Daily Life

Social History: Diet and Nutrition

Social History: Substance Use

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N518 module 1: the health history and interview
N518 module 1: the health history and interview

Review of Systems

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N518 module 1: the health history and interview
N518 module 1: the health history and interview

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N518 module 1: the health history and interview
N518 module 1: the health history and interview

Family History: 3 Generations

Family History: Inherited Risk Factors

Documentation / Electronic Health Record

Document: Provider Notes

Document: Provider Notes

Student Documentation        Model Documentation

Identifying Data & Reliability

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey

Ms. Jones is alert and oriented. She appears to be in pain. patient is well nourished abd groomed, dressed appropriately, good hygiene and ADLs. patient makes appropiate interactions .

Chief Complaint

Ms. Jones chief complaint is that  “I got this 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

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 MDI 2 puffs Q4H prn (Wheezing: “when around cats,” last use three days ago)

Allergies

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

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 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. 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

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 wound, red wound edges, right ball of foot, serosanguinous drainage. Mild erythema surrounding wound, no edema, no tracking.

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