DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512

Walden University DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512-Step-By-Step Guide

 

This guide will demonstrate how to complete the Walden University DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512 assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

 

How to Research and Prepare for DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512                     

 

Whether one passes or fails an academic assignment such as the Walden University DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512 depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

 

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

 

How to Write the Introduction for DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512                     

The introduction for the Walden University DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512 is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

 

How to Write the Body for DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512                     

 

After the introduction, move into the main part of the DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512 assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

 

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

 

How to Write the Conclusion for DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512                     

 

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

 

How to Format the References List for DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512                     

 

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512

Review of Systems:

General:

HEENT: Occasional headaches when studying. Denies ears, nose, mouth or thoat problems. Reports blurred vision when reading. Does not wear glasses.

Neck: no abnormalities noted

Breasts: denies any problems with her breasts

Respiratory:  History of Asthma and inhaler. Denies SOB at the moment.

Cardiovascular/Peripheral Vascular: Denies heart issues

Gastrointestinal:  Denies N/V  or diarrhea

Genitourinary: Denies discomfort . increased urination frequency with increase thirst

Musculoskeletal: no problems noted

Psychiatric: Denies feeling depressed

Neurological:  Reports occasional headache. Denies any dizziness or tingling.

Skin: wound on  plantar of  R foot

Hematologic:  Denies bleeding.

Endocrine: Hx of type2 DM- noncompliant on medications. Irregular menstrual cycle

DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512

DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512

         

SUBJECTIVE DATA:

Chief Complaint (CC): ‘My right foot hurts’

History of Present Illness (HPI): The patient in the case study comes to the clinic with complains of a painful, swollen, red, warm scrape on her right foot for the last two days. The patient thought it would heal on its own but has been worsening over time. The patient reports that the pain worsened over the last two days. The patient sustained the injury a week ago while going down the back steps when she tripped and twisted her ankle. She also scrapped her foot on the edge of the step. The patient went to the ER an hour after falling because of the strained ankle. The x-ray performed was normal. She was prescribed pain medications. The patient rates the pain 7/10 in the pain rating scale. She reports that the scrape is infected and worsening.

The patient describes the pain as throbbing. It is associated with sharp pain when weight is applied.  The pain radiates to the ankle. The patient reports that the affected foot is non-weight bearing. The patient reports that the wound drains pus, white in color, for the last two days. She has been treating the wound at home by cleaning twice daily and bandaging it. She has been cleaning it with soap, water, and some peroxide if irritated. She has also been applying Neosporin ointment twice daily. The problem has affected her functioning ability since she has missed her work because of the pain. She has also missed her class two days ago. Besides the current problem, she reports losing 10 pounds unintentionally, being thirsty, experiencing oliguria and polyphagia for the past month.

Medications: She currently uses Proventil inhaler if symptoms of asthma persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management.

Allergies: She develops asthma symptoms when she is near cats. She is also allergic to dust and develops asthma symptoms with intensive physical activity. She is also allergic to penicillin.

Past Medical History (PMH): The patient was diagnosed with diabetes type 2 at the age of 24 years. She is also asthmatic since the age of two and half years. Her last asthmatic attack was when she was in high school. She developed breathing problems three days ago at her cousin’s place.  She has a history of using Metformin, which she took it three years ago. The patient has history of five hospitalizations when she was 16 years because of asthma. She has a history of using nebulizer. She manages asthma by avoiding triggers but uses Proventil inhaler if symptoms persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management. She has also been using tramadol 100 mg three times a day for pain for the last two days. She takes Advil when her cramps het bad and Tylenol for headache.

Past Surgical History (PSH): The patient denies any history of surgeries

Sexual/Reproductive History: The patient denies history of sexually transmitted infections

Personal/Social History: The patient is a student currently finishing her bachelor’s degree in accounting. She lives with her mother and her sister. She is worried about her right foot. The patient denies barriers in accessing healthcare. Her family and church are her social support systems.

Immunization History: The patient believes that she received her childhood immunizations. She did not get her flu shot this year. Her tetanus booster was a year ago.

Health Maintenance: The patient reports that she started watching her sugar and avoiding regular soda after she found out that she is diabetic. She only drinks diet coke. She rarely checks her sugars, with the last time being a month ago. She does not understand the meaning of blood glucose numbers. She rarely checks her blood pressure. She stopped taking Metformin because of its side effects and feeling overwhelmed remembering to take the pills and checking her blood sugar. Her typical breakfast comprises muffin or pumpkin bread obtained from a nearby café. Her typical lunch is a meal she usually picks from a nearby campus or subway to get turkey sandwich. Her typical dinner is meatloaf, pasta, casseroles, and chicken. Her typical snacks include pretzels and French fries. She does not pay attention to the amount of salt she eats. She drinks about four-diet coke daily. She last took alcohol three weeks ago. She drinks alcohol once or twice a week during night outs. She is exposed to second-hand smoke from her friends. Her last eye and dental examination was when she was a child. She reports doing self-breast examination a couple times. She has never undergone mammography.

Significant Family History: Her mother has high cholesterol and diabetes. Her deceased father had type 2 diabetes, high cholesterol, and hypertension. Grandfather had colon cancer, diabetes, and hypertension. Paternal grandmother has high cholesterol and hypertension. Her sister is asthmatic. Her brother and father are overweight. Her uncle has alcohol addiction problem.

 

Review of Systems:

Vital signs: Height 170 cm, weight 90kg, BMI 31, Random blood glucose 238, Temperature 101.1F, O2 saturation 99%

General: The patient reports fatigue, fever and chills last night. She denies night sweat or suicidal thoughts.

HEENT: She denies headache, head injuries, changes in hearing, ringing ears, ear pain, and ear discharge. She denies changes in vision, double vision, itchy eyes, watery eyes, and dry eyes. She reports eye pain when she reads for too long. She reports occasional rhinorrhea. She denies sinus pain, changes in sense of smell, nosebleeds, or dental problems. She denies changes in sense of taste, dry mouth, mouth pain, mouth sores, or tongue problems.

Neck: She denies dysphagia, sore throat, lymphadenopathy, voice changes, or neck pain.

Breasts: She denies breast problems, such as pain, lumps, nipple changes, or nipple discharge.

Respiratory: The patient denies wheezing, chest tightness, dyspnea, cough, or chest pain.

Cardiovascular/Peripheral Vascular: The patient denies palpitations, easy bruising, edema, circulation problems, or vascular diseases.

Gastrointestinal: The patient denies nausea, vomiting, stomach pain, changes in bowel movements, heartburn, constipation or diarrhea.

Genitourinary: The patient denies dysuria, urgency, frequency, or history of sexually transmitted infections.

Musculoskeletal: The patient reports right ankle sprain, which is non-weight bearing. She denies fractures.

Psychiatric: The patient denies depression, anxiety, or stress.

Neurological: The patient denies ataxia, numbness, tingling, loss of balance, and difficulties in coordinating movement.

Skin: The patient denies rash. She reports swollen right foot with a wound draining pus.

Hematologic: The patient denies easy bruising or prolonged bleeding

Endocrine: The patient denies heat or cold intolerance. She reports unintentional weight loss, polydipsia, polyphagia, and polyuria.

SUBJECTIVE DATA:

 Chief Complaint (CC): “I got a 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 (HPI): Ms. Jones claimed that one week ago, she was walking on stairs outside when she tripped and fell, causing her right ankle to twist and the ball of her foot to scrape. She went to the emergency room of the nearby hospital, where she received negative results from the x-rays and was given tramadol for the pain she was experiencing. She has been cleaning the wound twice. She has been treating the wound with an antibiotic medication and bandaging it. She adds that the pain and swelling in her ankle have subsided, but that the bottom of her foot is becoming increasingly uncomfortable. She describes the pain as throbbing and sharp when she is forced to bear weights.

She reports that her ankle “ached” but it is better now. After taking the most recent dose of tramadol, the level of pain has decreased to a 7 out of 10. The degree of pain when bearing weight is a 9. She says that the ball of foot has become swelled and more red over the previous two days and that yesterday, she noticed discharge pouring from the wound. She also says that the swelling has gotten worse. She claims that there is no smell coming from the wound. Her shoes appear to be too small. She has been seen wearing shoes that are without laces. Last night, she reported a temperature of 102. She denies recent illness. An increased appetite is reported alongside with an accidental weight loss of ten pounds that occurred over the course of the month. Denies making any changes to their diet or amount of physical activity.

Medications: Acetaminophen 500 to 1000 mg PO as needed (headaches). Ibuprofen 600 mg PO twice daily as needed (menstrual cramps). Tramadol 50 mg PO BID prn (foot pain). Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (Wheezing while neat cats, most recent administration: three days ago)

DIGITAL CLINICAL EXPERIENCE(DCE): HEALTH HISTORY ASSESSMENT NURS 6512

Allergies: Rash caused by penicillin, Allergic to cats and dust but not food or latex sensitivities. She claims that being among allergens causes her to experience runny nose, itchy and swollen eyes, and an increase in the severity of her asthma symptoms.

 Past Medical History (PMH): At the age of 2 and a half, the asthma was identified. When she is in an environment with cats or dust, she utilizes the albuterol inhaler that she carries with her. Two of three times a week, she makes use of her inhaler. Three days ago, she was around cats, and she had to use her inhaler once to get some respite from the symptoms that were bothering her. Her last asthma related hospitalization was when she was in high-school. Never had an intubation. Diabetes type 2 was discovered at the age of 24. She had been taking Metformin in the past but stopped doing so three years ago, citing the fact that the drugs caused her to have gas and that “it was stressful taking pills and testing my sugar”. She does not keep an eye on her sugar levels. In the hospital’s emergency room, the patient’s sugar levels were high the week before last. No surgeries. Hematologic: Acne has been a problem for her ever since she hit adolescence and she also gets bumps on the backs of her arms if her skin is dry. Complains of a darkening of the skin on her neck as well as an increase in the hair on her face and body. She has noted that she has a few moles, but no noticeable alterations to her hair or nails.

Past Surgical History (PSH): No history of past surgery.

Sexual/Reproductive History: Menarche, age 11. First sexual experience at the age of 18, which encounters were with men, and the individual identifies as straight. Never pregnant. It’s been three weeks since her last menstruation. During the last year, her menstrual period has been quite erratic, occurring every 4-6 weeks and she has had heavy bleeding that lasts 9-10 days. She does not have a partner currently. She used oral contraceptives when she was younger. She claims that she did not use condoms when she was sexually active. Never had an HIV/AIDS test done. No record of previous sexually transmitted infections or signs of STIs. When she was last teste, four years have elapsed.

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Personal/Social History: Never married and does not have any children. Since the age of 20, has lived on her own, and since her father passed away a year ago, they now share a home with their mother and a sister in a single family dwelling in order to support the family. Currently working as a supervisor at Mid-American Copy and Ship for a total of 32 hours per week. She was just elevated to the position of shift supervisor, which she thoroughly enjoys. She attends school on a part-time basis and is currently in her final semester of work toward obtaining a bachelor’s degree in accounting. She has her sights set on becoming an accountant for the company she currently works for.

She is well off as she owns a car, a cellphone and a computer. Even though she is covered by the employer’s basic health insurance, she avoids seeking medical attention because of the out-of-pocket expenses involved. She takes pleasure in socializing with her friends, going to Bible study, being active in the ministry of her church and dancing. Tina has a solid family and social support structure and she is also involved in her local church community. She describes feeling stressed as a result of the death of her father, as well as the responsibilities of her job and education and her financial situation.

She states that coping with the stress has been easy because of her family and the church. No tobacco usage. Cannabis use on an irregular basis between the ages of 15 and 21. She denies ever having used cocaine, methamphetamines, or heroine. Utilizes alcoholic beverages “when out with pals, two or three times a month.” and claims to consume no more than three drinks throughout each occasion. She consumes four beverages containing caffeine and diet soda daily. No foreign travel. No pets. She is not in an intimate relationship currently but she completed a significant monogamous relationship that lasted for three years two years ago. It is in her future intentions to start a family by getting married and having children.

Health Maintenance: The most recent Pap smear was performed in 2014. The last eye exam was conducted when she was a child. The last time she had a dental exam was a couple of years ago. PPD test was negative less than two years ago. No workout. 24-hour diet recall: She admits that she skipped her breakfast the day before and that she normally consumes baked good for breakfast, sandwich for lunch and either meatloaf or chicken for dinner. However, she did not have any of these foods yesterday. Her munchies are either usually either pretzels of French fries.

 Immunization History: Regarding immunizations, a tetanus booster shot was administered during the past year; however, a flu shot and vaccine against human papillovirus were not given nor received. She states that she feels that she is up to date on all of her childhood vaccines and that she received the meningococcal vaccine while she was in college. Safety: She does not ride a bike, possesses smoke alarms at home, and always puts on seatbelt whilst driving. Does not use sunscreen. The home has firearms that once belonged to her father and are currently secured in the room used by her parents.

Significant Family History: The mother is 50 years old and has hypertension and high cholesterol. Father died in a car accident a year ago at the age of 58; he has hypertension, high cholesterol, and type 2 diabetes. Brother (Michael, age 25), suffers from obesity Sister (Brittany, age 14) struggles with asthma Grandmother on the maternal side passed away at the age of 73 as a result of stroke; she had a history of hypertension and excessive cholesterol. Grandfather on the maternal side passed away at the age of 78 as a result of a stroke; he had a history of hypertension and excessive cholesterol. Grandmother on the father’s side is still alive and has hypertension despite being 82 years old. Grandfather on the father’s side passed away at the age of 65 from colon cancer, family history of type 2 diabetes. Negative for mental illness other malignancies, unexpected death, kidney disease, sickle cell anemia, and thyroid disorders. An uncle on the father’s side had a problem with alcoholism.

 Review of Systems

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

            HEENT:

HEAD: The patient’s head is round, symmetrical, and normocephalic; palpation reveals no nodules, masses, or depressions.

EYES: The bulbar conjunctiva was translucent with few capillaries obvious, and there is no edema or tears in the lacrimal gland. However, the patient’s vision is blurry at the moment. Eye lashes appeared to be uniformly distributed. However, the patient’s eyesight is blurry at the moment. During the test of the additional ocular muscle, both eyes moved in sync and aligned themselves parallel to one another.

EAR: The auricle membranes are spotless and are the same color as the skin on the face.

NOSE: The nose seemed straight, symmetrical, and of a single color.

THROAT: The patient denies having any pain, there being any swelling present, and having any trouble swallowing.

Neck: The patient demonstrated synchronized smooth head movement without any signs of discomfort, indicating that the neck muscles are of comparable size.

            Breasts: Patient shows no signs of pain or discomfort.

            Respiratory: The patient has a history of asthma but claims they are not having any respiratory problems. The breathing sounds were regular, and there was no evidence of discomfort

            Cardiovascular/Peripheral Vascular:  The patient states that they are not experiencing any chest pain and that they have no history of hypertension. The patient’s blood pressure is on the cusp of being dangerous. Only experiences chest pressure when she is having trouble breathing, which is otherwise painless.

            Gastrointestinal: The patient reports no discomfort in the abdomen region, and all four quadrants exhibited positive bowel sounds.

             Genitourinary: Denies that urinating causes any discomfort

            Musculoskeletal: The patient is experiencing discomfort in their foot

             Psychiatric: Denied any history of previous mental health issues.

            Neurological: Patient is alert, oriented x3

            Skin: On the foot, there was a skin break that measured approximately 2 centimeters by 1.5 centimeters and was 2.5 millimeters deep. It was draining pus. Her hands and feet each have skin that is parched and cracked.

            Hematologic: Rejects that they have any blood disorders.

            Endocrine: The patient’s blood glucose level is 238 mg/dl and they have a history of diabetes.

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

Chief Complaint (CC): A painful wound on the right foot.

History of Present Illness (HPI): An African American woman named Tina, 28, alleges that a week ago while walking, she stumbled over a concrete step and twisted her right ankle, scraping the ball of her foot in the process. She went to a neighboring emergency unit, where an X-ray was ordered and found to be negative. Tramadol was nonetheless provided to her to help with the discomfort. She says she cleans the wound twice daily, applies antibiotic cream, and wraps it in a bandage. Even though the pain and swelling at the location of the injury have fully subsided, she claims that the bottom of her foot is still quite uncomfortable. She describes the discomfort as being weight-bearing, throbbing, and intense.

But, the discomfort in her ankle has already subsided. She continues to rate the pain as 7/10 even after a recent dose of tramadol. She gives the pain when bearing weight, a 9 out of 10. She describes a swollen football that has become redder over the last two days. A day before the current appointment, the wound was already dripping with an odorless discharge. She claims that recently, her shoes have been uncomfortable, so she has started wearing slippers instead. Her fever was 1020F last night. She, though, denies having been unwell recently. She reports an increase in hunger and an unintentional 10-pound weight reduction over the past month. She asserts that her diet and energy levels have not changed.

Medications:

1. Ibuprofen 600mg orally three times each day for menstrual cramps.
2. Acetaminophen 500-100 mg orally, as needed for headaches.
3. Tramadol 50 mg orally twice a day if foot pain persists.
4. Albuterol 90mcg/spray multiple-dose inhalation up to two puffs every 6 hours for wheeze caused by cat allergies. She had last used the medication around three days before the current appointment.

Allergies:

1. There are no documented latex or food sensitivities.
2. Penicillin hypersensitivity
3. Establishes dust and cat allergies
4. Allergic reaction: runny nose, puffy and itchy eyes, and worsening asthma symptoms.

Past Medical History (PMH): At the age of two and a half years, was given an asthma diagnosis. Two to three times each week, she utilizes an Albuterol inhaler to control her symptoms when she is exposed to dust or cats. She was exposed to cats three days ago, and she used an inhaler, which was quite efficient in controlling the symptoms. She was hospitalized for asthma the last time she was in high school. She, on the other hand, denies ever being intubated. When she was 24, she was diagnosed with diabetes mellitus. She had been taking metformin but had discontinued roughly three years ago because of flatulence adverse effects. She also reports that taking the tablets and checking her blood glucose simultaneously has been exhausting. She denies that she has been monitoring her blood glucose levels since then. She claims that the last time her levels of sugar in her blood soared was a week ago at the emergency department.

Past Surgical History (PSH): None

Sexual/Reproductive History: At the age of 11, she had her first menstrual cycle. heterosexual; first sexual experience occurred at the age of 18. denies ever becoming a mother. Menstrual cycles have been heavy and irregular in the last year, lasting 9 to 10 days every 4 to 8 weeks, with the most recent period starting around 3 weeks before the current appointment. She acknowledges using oral contraceptives mostly in past, but she is now single. denies wearing condoms when engaging in sexual activity. No reported history of STIs. The patient claims to have never had an HIV/AIDS test before. Her previous pap smear exam was roughly four years ago, according to her.

Personal/Social History: The patient enjoys going to clubs and drinking alcohol on occasion. Her bachelor’s degree is in accountancy. She has a loving family and friends. There will be no cigarette or marijuana use. He goes to a Baptist church.

Immunization History: She had a tetanus booster last year. Her influenza vaccination is out of date. Her human papillomavirus vaccination was not given to her. She received her meningococcal vaccine when she was still attending college and believes she was immunized as a teenager.

Health Maintenance: No physical activity. She recalls her nutrition over the previous 24 hours. The day before the current visit, he claims to have skipped breakfast and had a lunch of a sandwich and chicken or steak for dinner. She brings mostly French fries or pretzels as snacks. Smoke detectors have been put in her home. She admits to wearing a seatbelt in the automobile but denies riding a bike. He denies wearing sunblock. Her father’s firearms are still in the house, but they are locked up in their parents’ room.

Significant Family: The mother, who is 50, has high cholesterol. Her Father died in an automobile accident when he was 58 years old. Diabetes and hypertension were present. Her sister suffers from asthma. Brother has no medical issues. At the age of 73, her maternal granny passed away after a stroke. At the age of 78, her maternal grandfather passed away after a stroke. At the age of 65, her paternal grandfather passed away from colon cancer. Her paternal grandmother is still living. There is no history of addiction, mental health problems, headaches, malignancies, or thyroid problems.

Review of Systems:

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

General: Tina is polite, friendly, and well-organized in general. She is also well-groomed, responds well to queries, and is not depressed.

HEENT: The patient complains of headaches when studying. He has impaired eyesight but does not use glasses. There is no runny nose or ear discharge. There is no swelling or painful throat.

Neck: There are no lymphatic problems or inflammation around the neck.

Breasts: There is no nipple discharge or soreness in the breasts.

Respiratory: No breathlessness, chest pain, or tightness.

Cardiovascular/peripheral: There are no blood clots in the cardiovascular or peripheral systems.

Gastrointestinal: No constipation, bowel disturbances, or watery stools. The patient feels thirsty and has an increased appetite.

Gastrointestinal: No bowel changes, constipation, or watery stool. The patient has an increased appetite and is thirsty.

Genitourinary: The patient’s periods are irregular.

Musculoskeletal: No back or muscular discomfort. Psychiatric: There are no signs of depression or hallucinations.

Neurological: There is no tingling or dizziness.

Skin: Acne-free skin with no chin hair.

Hematologic: There is no history of significant bleeding in the patient. There is no sweating, shivers, or fever.

                Endocrine: Denies heat or cold intolerance.

Name:

Section:

Week 4                

Shadow Health Digital Clinical Experience Health History Documentation

Initials: T.J.

Age: 22 years

Sex: female

Race: African American

Height: 170 cm.

Weight: 90 kg.

BMI: 31

Blood Pressure: 142/82 mmHg.

Random Blood Glucose: 238

Temperature: 101.1 F

Pulse: 86

Respiratory rate: 19

Saturation: 99% on room air.

SUBJECTIVE DATA:

Chief Complaint (CC): “ 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 (HPI): T.J. is a 22-year-old African American female who presents to the clinic with complaints of pain for 1 week following a scrape on her foot. The pain is on the right foot as a result of a wound on the planter surface with a severity of 7/10. The pain is throbbing but becomes sharp on standing. It radiates to the ankle and has worsened over the past 2 days. The pain has also prevented weight bearing on her right foot. T.J. scrapped her foot (barefooted) on a cement step a week ago sustaining the injury on her foot as well as a mild ankle injury. The wound bled a little. She went to the ER and an X-ray was done which showed no broken bones after which she was prescribed pain medications. However, she noticed pus draining from the wound 2 days ago. The pus was yellow in color but no odor was noted from the wound. She reports cleaning the wound at home twice daily with hydrogen peroxide before applying topical bacitracin, neomycin, and polymyxin B (Neosporin). Currently, the pain is so severe that has affected her ability to walk, stand at work, and walk to class. Finally, she reports swelling, warmth, and redness around the wound.

Medications:

• Tramadol PO 50 mg 3 times daily for 2 days ( last use this morning)
• Albuterol inhaler 1-3 puffs as needed (last use 3 days ago)
• Tylenol occasionally for headaches
• Ibuprofen for cramps

Allergies: She is allergic to dust, cats, penicillin, and dust which triggers and exacerbates her asthma symptoms. Denies seasonal allergies, latex, and food allergies.

Past Medical History (PMH): She was diagnosed with type 2 diabetes at age of 24 years.  She was prescribed metformin which she last took 3 years ago. She cites demands of medication compliance and side effects of metformin as central to her diabetes treatment noncompliance. Currently attempts lifestyle changes such as eating less sugary foods. Reports less frequent blood sugar monitoring. Her last glucose check was a week ago but does not recall the value. She was diagnosed with asthma at the age of 2.5 years. She uses an albuterol inhaler for her asthma symptoms. Has had a total of five hospitalizations due to asthma during childhood and teenage years. Her last hospitalization was at the age of 16 years while her last asthmatic exacerbation was 3 days ago. She highlights cats, dust, and climbing stairs as triggers of her asthma symptoms. Denies past diagnosis of hypertension. Her last blood pressure reading was approximately 140/80 mmHg.

Past Surgical History (PSH): Denies previous surgeries or blood transfusion.

Sexual/Reproductive History: Her last menstrual period was 3 weeks ago. Her periods are irregular, appearing after every 6 weeks to 2 months. Her typical period lasts for 9 days. Reports heavy menstrual flow for up to 5 days during which she uses super absorbency tampons that she changes every 2 to 3 hours. She also reports heavy cramping during the initial days of her period for which she uses heat pads and ibuprofen for relief.  Heterosexual. Sexual debut at 18 years. Denies recent sexual activity although she was sexually active in the past 2 years. Has had 3 partners. Denies current use of contraceptives. However, she reports using oral contraceptives as well as condoms in the past. Denies current and past pregnancies.

Personal/Social History: She is currently in college and working towards obtaining an undergraduate degree in accounting. She stays with her mother and sister who help her with activities. She is currently under high stress. her last meal was dinner time the previous night and consisted of baked chicken and mashed potatoes. Her typical breakfast is a muffin or pumpkin bread while her lunch is typically a sandwich. On the other hand, dinner is usually a home-cooked meat dish and vegetables. Finally, she takes pretzels or French fries for snacks. She reports habitual diet soda drinking (up to 4 per day) but denies caffeine intake or adding salt to food. Reports a history of recreational marijuana smoking, last use at the age of 21 but stopped due to waning interest and health reasons. She takes alcohol although not more than 2 nights per week and no more than 3 alcoholic drinks per sitting. Her last alcohol use was 3 weeks ago. Denies vaping, smoking tobacco, or exposure to secondhand smoke.

Immunization History: Reports having received all her childhood vaccinations. Has not yet received her annual flu vaccine. The last tetanus vaccination was a year ago.

Health Maintenance: Denies finances and transportation as barriers to her access to healthcare services. Her last eye exam was in childhood. The last dental visit was several years ago. The last STI testing and pap smear test was 4 years ago. Denies STI symptoms or abnormal pap smear tests. However, she is uncertain about past partners and their STI testing.

Significant Family History: Her mother has hypertension and high cholesterol. Father died at the age of 58 years following a road traffic accident although he had hypertension, type 2 diabetes, and high cholesterol. Her paternal grandfather died of colon cancer although he had type 2 diabetes, high blood pressure, and high cholesterol. The Paternal grandmother has hypertension and high cholesterol. Similarly, her maternal grandfather was diagnosed with hypertension and high cholesterol. Her maternal grandmother also has hypertension and high cholesterol. Her sister has asthma while her brother has not been diagnosed with any medical condition. However, all her family members are overweight. Her uncle has an alcohol use disorder. Finally, there is no family history of thyroid disorders and headaches.

Review of Systems

General: Reports fever, chills, occasional tiredness, and ordinary sleep patterns. Also, reports increased appetite and unintentional weight loss (10 lbs. over the past month). Denies night sweats

HEENT: Reports occasional headaches. Denies head injury, change in hearing, tinnitus, ringing, ear pain, or ear discharge. Reports episodes of blurry vision and infrequent itchy eyes. Denies use of corrective lenses, double vision, watery eyes, eye discharge, eye redness, eye pain, or dry eyes. Reports infrequent runny nose. Denies nose bleeds, sinus pain, or alteration in smell sensation. Denies dental problems, gum bleeds, mouth pain, mouth sores, dry mouth, changes in taste sensation, tongue problems, or jaw concerns. Denies sore throat, swollen glands, lymph node problems, or voice changes.

            Neck: Denies neck pain and general neck problems.

            Breasts: Reports occasional breast exams. Denies nipple changes, nipple discharge, breast lumps, breast pain, and general breast conditions. Has not had a mammogram before.

            Respiratory: Denies difficulty in breathing, wheezing, chest tightness, pain while breathing, or frequent coughing.

            Cardiovascular/Peripheral Vascular: Denies chest pain, palpitations, irregular heartbeat, easy bruising, peripheral limb edema, vascular diseases, or circulation problems.

            Gastrointestinal: Denies nausea, vomiting, abdominal pain, changes in bowel movements, heartburn, GERD, or indigestion. No diarrhea, constipation, blood in stool, flatulence, or bloating.

            Genitourinary: Reports frequency, nocturia, and polyuria. Denies hematuria, flank pain, dysuria, incontinence, or bladder infection. Denies abnormal vaginal discharge.

            Musculoskeletal: Denies muscle pain, joint pain, muscle weakness, joint swelling, back pain, or history of fractures.

            Psychiatric: Denies anxiety, depression, hallucinations, delusions, suicidal thoughts, or mania.

            Neurological: Denies vertigo, syncope, loss of consciousness, dizziness, lightheadedness, visual disturbances, tingling, loss of sensation, loss of coordination, memory loss, seizures, or balance issues.

            Skin: Reports skin discoloration to the skin around the neck, moles, occasional dryness of skin, acne, and excessive facial and body hair. Denies dandruff, nail abnormalities, body sores, or skin rashes. Reports rarely using sunscreens.

            Hematologic: Denies anemia, easing bruising or bleeding.

            Endocrine: Reports polyuria, polyphagia, and polydipsia. Denies heat or cold intolerance.

Digital 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.

DCE Health History Assessment:

Complete the following in Shadow Health:

Orientation

• DCE Orientation (15 minutes)
• Conversation Concept Lab (50 minutes, Required)

Health History

• Health History of Tina Jones (180 minutes)

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 4 Day 7 deadline.

submission information

• Complete your Health Assessment DCE assignments in Shadow Health via the Shadow Health link in Canvas.
• Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas for your faculty review. 
• (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass

• Links to an external site.
• Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link below.
• To submit your completed assignment, save your Assignment as WK4Assgn2+last name+first initial.
• Then, click on Start Assignment near the top of the page.
• Next, click on Upload File and select both files and then Submit Assignment for review.
• Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.

By submitting this assignment, you confirm that you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.