6/12/2018 Comprehensive Assessment

6/12/2018 Comprehensive Assessment | Completed | Shadow Health

https://chamberlain.shadowhealth.com/assignment_attempts/3569767 1/36

Comprehensive Assessment Results | Turned In Advanced Health Assessment – Chamberlain, NR509-April-2018

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Your Results Lab Pass Lab Pass

Started: Jun 10, 2018 | Patient Exam Time: 448 min

Transcript

Greet 06/10/18 3:17 PM

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Question 06/10/18 3:17 PM

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Question 06/10/18 3:17 PM

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Question 06/10/18 3:18 PM

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Overview

Transcript

Subjective Data Collection

Objective Data Collection

Documentation

Plan My Exam

Self-Reflection

Interview Questions (256)Interview Questions (256) Statements (33)Statements (33) Exam Actions (445)Exam Actions (445)

Hello my name is Sara and FNP student I will be conducting yourHello my name is Sara and FNP student I will be conducting your interview todayinterview today

Hey.

What is your nameWhat is your name

Tina Jones.

Your date of birth?Your date of birth?

February 17th.

And how old are you?And how old are you?

I’m 28.

All Lines (734)All Lines (734)

 

 

6/12/2018 Comprehensive Assessment | Completed | Shadow Health

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Question 06/10/18 3:23 PM

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Question 06/10/18 3:26 PM

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Question 06/10/18 3:29 PM

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What brought you into the clinic today?What brought you into the clinic today?

I came in because I’m required to have a recent physical exam for the health insurance at my new job.

Do you have any current health problems?Do you have any current health problems?

I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days.

Where is your new job? (Clarified to what is your new job.)Where is your new job? (Clarified to what is your new job.)

I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–I’m really excited!

That is great that you are excitedThat is great that you are excited

Thanks.

When was your last physical?When was your last physical?

Let’s see… I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.

And what did your kind of gynecologist say?And what did your kind of gynecologist say?

She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things.

How much birth control are you taking? (Clarified to How often doHow much birth control are you taking? (Clarified to How often do you take birth control.)you take birth control.)

 

 

6/12/2018 Comprehensive Assessment | Completed | Shadow Health

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Question 06/10/18 3:29 PM

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Empathize 06/10/18 3:32 PM

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I take it every morning, with breakfast.

What is the name of your birth control? (Clarified to what was theWhat is the name of your birth control? (Clarified to what was the name of the birth control pill you took.)name of the birth control pill you took.)

They’re called Yaz.

Has your menstrual cycle improved since TAKING YAZ?Has your menstrual cycle improved since TAKING YAZ?

Now that I’m on the pill I’m getting my period every month.

That’s great I am really glad that you are having your period everyThat’s great I am really glad that you are having your period every monthmonth

Thanks.

How long have you had asthma?How long have you had asthma?

I’ve had asthma a long time. . . since I was really little.

What age were you diagnosed with asthma?What age were you diagnosed with asthma?

My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.

That sounds frighteningThat sounds frightening

Thanks.

How do you manage your asthma?How do you manage your asthma?

I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

 

 

6/12/2018 Comprehensive Assessment | Completed | Shadow Health

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Question 06/10/18 3:33 PM

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Question 06/10/18 3:34 PM

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What are your triggers for asthma?What are your triggers for asthma?

Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though.

What happens when you’re around DUST?What happens when you’re around DUST?

I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler.

What daily inhaler do you use?What daily inhaler do you use?

It’s Flovent.

How much fLOVENT do you use a day (No matching questionsHow much fLOVENT do you use a day (No matching questions found.)found.)

How much flovent do you use? (No matching questions found.)How much flovent do you use? (No matching questions found.)

How often do you use flovent?How often do you use flovent?

Twice a day. [Nurse confirmed: fluticasone propionate 88 mcg b.i.d./spray MDI]

When was your last dose of flovent?When was your last dose of flovent?

Probably. . . well, not for my last period. Maybe for the one before? So six weeks ago?

when you last use flovent? (Clarified to when did you last use yourwhen you last use flovent? (Clarified to when did you last use your inhaler.)inhaler.)

 

 

6/12/2018 Comprehensive Assessment | Completed | Shadow Health

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Question 06/10/18 3:40 PM

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Question 06/10/18 3:41 PM

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Question 06/10/18 4:14 PM

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Question 06/10/18 4:15 PM

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Empathize 06/10/18 4:15 PM

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I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too.

How much Albuterol do you use?How much Albuterol do you use?

I do two puffs when I need it, but that rarely happens. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]

How much metformin do you take ? (Clarified to how manyHow much metformin do you take ? (Clarified to how many milligrams of metformin did you take.)milligrams of metformin did you take.)

It’s 850 mg. And I take one pill, twice a day.

When did you last take Metformin?When did you last take Metformin?

I took it this morning.

When were you diagnosed with asthma?When were you diagnosed with asthma?

My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.

Are you taking any other medication?Are you taking any other medication?

Um, I take a lot now, so let me list everything I take… I’m taking Yaz for birth control, metformin, and my daily inhaler. And I have the albuterol inhaler that I don’t seem to need anymore.

That’s good to hear (No matching questions found.)That’s good to hear (No matching questions found.)

That’s good to hearThat’s good to hear

Thanks.

 

 

6/12/2018 Comprehensive Assessment | Completed | Shadow Health

https://chamberlain.shadowhealth.com/assignment_attempts/3569767 6/36

Question 06/10/18 4:16 PM

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Empathize 06/10/18 4:17 PM

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Are you using PEAK AND FLOW?Are you using PEAK AND FLOW?

I haven’t heard that term.

Do you feel like your asthma is well controlled?Do you feel like your asthma is well controlled?

Yeah, ever since I started using my daily inhaler and keeping track of my peak flow I’ve felt much more in control of my breathing.

greatgreat

Thanks.

How often do you use your Peak flow meterHow often do you use your Peak flow meter

Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart.

What are your Peak flow meter results?What are your Peak flow meter results?

Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart.

what are your peak flow averages? (Clarified to Do you check yourwhat are your peak flow averages? (Clarified to Do you check your peak flow regularly?.)peak flow regularly?.)

Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart.

What are your Peak flow meter results?What are your Peak flow meter results?

Yeah, I have a peak flow meter at home, and I use it in the morning and at night and keep track of it on a chart.

When was your last asthma attackWhen was your last asthma attack

 

 

6/12/2018 Comprehensive Assessment | Completed | Shadow Health

https://chamberlain.shadowhealth.com/assignment_attempts/3569767 7/36

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