Description

Shadow Health: Comprehensive Assessment Tina Jones

Assignment Description: This Comprehensive Assessment assignment provides the opportunity to conduct a full health assessment on a patient in a single clinic visit. On average, this assignment should take from 120-180 minutes to complete.

• Estimated Time to Complete: 120-180 minutes

• •  Results At Completion: Your faculty has chosen to make your detailed results available as soon as you complete this assignment.
  •  Reopening Attempts: You can manually reopen your completed attempts until this assignment’s due date has passed.
  •  Flexible ‘Turn In’: You can choose which attempt to turn in to your instructor until this assignment’s due date has passed.

  Solution: Shadow Health: Comprehensive Assessment Tina Jones

  

  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.

  Current Health Status

  • 
    

    Finding:

    Reports diabetes

    (Found)

    Pro Tip: Confirming a patient’s medical conditions, such as diabetes, will enable you to provide the best care possible.

    Example Question:

    Can you confirm your diabetes?
  • 
    

    Finding:

    Reports asthma

    (Found)

    Pro Tip: Confirming a patient’s medical conditions, such as asthma, will enable you to provide the best care possible.

    Example Question:

    Can you confirm your asthma?

  • 
    

    Finding:

    Asked about last visit to a healthcare provider

  • 
    

    Finding:

    Reports last visit to a healthcare provider was 4 months ago

    (Found)

    Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

    Example Question:

    When did you see a healthcare provider?
  • 
    

    Finding:

    Reports reason for last visit was annual gynecological exam

    (Found)

    Pro Tip: Establishing a timeline for Tina’s gynecological exams will allow you to develop a comprehensive health history.

    Example Question:

    Why did you see a healthcare provider?
  • 
    

    Finding:

    Reports last general physical examination was 5 months ago

    (Available)

    Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

    Example Question:

    When was your last physical exam?

  • 
    

    Finding:

    Asked about current prescription medications

  • 
    

    Finding:

    Reports taking diabetes medication

    (Found)

    Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.

    Example Question:

    Have you been taking medication for your diabetes?
  • 
    

    Finding:

    Reports having an inhaler

    (Found)

    Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.

    Example Question:

    Do you have an inhaler?
  • 
    

    Finding:

    Reports taking prescription birth control pills

    (Found)

    Pro Tip: A patient’s use of birth control can impact the care plan, such as which medications are prescribed. Understanding a patient’s history of birth control can be an indicator of health literacy.

    Example Question:

    Are you taking any form of birth control?

  • 
    

    Finding:

    Followed up about diabetes medication

  • 
    

    Finding:

    Reports diabetes medication is metformin

    (Found)

    Pro Tip: Follow up questions about Tina’s diabetes medication will help you to understand her treatment plan and recent health history.

    Example Question:

    What is the name of your diabetes medication?
  • 
    

    Finding:

    Reports starting taking diabetes medication 5 months ago

    (Available)

    Pro Tip: Follow up questions about Tina’s diabetes medication history and timeline will help you to understand her treatment plan and recent health history.

    Example Question:

    How long have you been taking metformin?
  • 
    

    Finding:

    Reports that side effects of diabetes medication abated over time

    (Available)

    Pro Tip: Determining if Tina has experienced any side effects of her diabetes medication will help you determine the efficacy and appropriateness of her medication.

    Example Question:

    Have you noticed any side effects from the metformin?
  • 
    

    Finding:

    Reports taking diabetes medication twice daily

    (Available)

    Pro Tip: Follow up questions about Tina’s medication adherence will help you to understand her treatment plan and recent health history.

    Example Question:

    How many times a day do you take metformin?
  • 
    

    Finding:

    Reports diabetes medication dose is 850 mg

    (Available)

    Pro Tip: Follow up questions about the dosage of Tina’s diabetes medication will help you to understand her treatment plan and recent health history.

    Example Question:

    What is the dose of your metformin?
  • 
    

    Finding:

    Denies adverse effects of diabetes medication

    (Available)

    Pro Tip: Determining if Tina has experienced any adverse effects of her diabetes medication will help you determine the efficacy and appropriateness of her medication.

    Example Question:

    Are you experiencing adverse effects from your diabetes medication?

  • 
    

    Finding:

    Reports asthma medication has not changed

    (Available)

    Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.

    Example Question:

    Has your asthma medication changed?
  • 
    

    Finding:

    Reports inhaler is albuterol (Proventil)

    (Available)

    Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.

    Example Question:

    Do you have a rescue inhaler?
  • 
    

    Finding:

    Reports using inhaler no more than 2 times per week

    (Found)

    Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking how frequently Tina uses her inhaler can indicate how she’s been treating her symptoms.

    Example Question:

    How often do you use your inhaler?
  • 
    

    Finding:

    Reports recommended dose is 1-3 puffs as needed

    (Available)

    Pro Tip: Asking Tina about the recommended dose of her inhaler can help you determine if the treatment is effective and appropriate for her health needs.

    Example Question:

    What is the recommended dosage for your inhaler?
  • 
    

    Finding:

    Reports typically taking 2 puffs

    (Available)

    Pro Tip: Asking Tina about how many puffs of her inhaler she typically takes can help you determine if the treatment is effective and appropriate for her health needs.

    Example Question:

    How many puffs of your inhaler do you typically take?
  • 
    

    Finding:

    Reports sometimes needing 3 puffs to control symptoms

    (Available)

    Pro Tip: Asking Tina about how many puffs of her inhaler she takes can help you determine if the treatment is effective and appropriate for her health needs.

    Example Question:

    What’s the most puffs you ever take?
  • 
    

    Finding:

    Denies adverse effects of asthma medication

   

  Finding:

  Asked about current health problems

  Finding:

  Asked about asthma medication

   

  Finding:

  Denies current acute health problems

  (Found)

  Pro Tip: Determining if the patient has any current acute health problems is essential in conducting a productive exam and prioritzing the patient’s needs.

  Example Question:

  Are you having any health problems?

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