Description
Shadow Health: Health History Tina Jones
Ms. Jones is a 28-year-old African American female presenting with worsening right foot pain following a scrape injury sustained one week ago while stepping on a metal edge. She reports pain rated 7/10 at rest and up to 9/10 with ambulation, described as dull and constant, improved with elevation and rest. She reports a fever of 102°F at home, decreased appetite, and diarrhea overnight. On assessment, the wound at the ball of the right foot is erythematous, swollen, and draining exudate without odor. Vital signs are currently stable. Pain improved with oxycodone but persists. Findings are consistent with an infected soft tissue injury. Plan includes continuation of IV antibiotics, pain management, wound care, and monitoring for progression of infection or systemic involvement. Patient demonstrates clear communication and understanding of her condition and treatment plan.
Solution: Shadow Health: Health History Tina Jones
Subjective Data Collection: 86 of 88 (97.7%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
-
Found:
Indicates an item that you found.
-
Available:
Indicates an item that is available to be found.
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
Finding:
Established chief complaint
Finding:
Reports pain
(Found)
Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:
Do you have any pain?
Finding:
Reports foot wound
(Found)
Pro Tip: If a patient mentions pain, it’s important to determine what specifically is causing her pain, if she knows.Example Question:
What’s causing your pain?
History of Presenting Illness
Finding:
Asked to rate current pain level on a scale
Finding:
Reports current pain is 7/10
(Found)
Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care.Example Question:
Can you rate the pain on a scale of 0 to 10?
Finding:
Asked for details about the pain
Finding:
Reports pain is throbbing
(Found)
Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.Example Question:
Can you please describe the pain?
Finding:
Reports pain is sharp when she attempts to stand
(Found)
Pro Tip: Determining what physical activities and movements exacerbate the patient’s pain can help you better understand the problems and assess treatment needs. This can also alert you if a patient’s activities of daily living are hindered.Example Question:
What is the pain like when you stand on your foot?
Finding:
Reports pain has increased in the past 2 days
(Found)
Pro Tip: Finding out how the patient’s pain has changed will give you insight into the acceleration of infection.Example Question:
How has the pain changed over time?
Finding:
Reports feeling pain radiating into ankle
(Found)
Pro Tip: Asking about where else the patient’s pain radiates can help determine the progression of infection.Example Question:
Does the pain radiate anywhere else?
Finding:
Reports pain prevents bearing weight on foot
(Found)
Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care.Example Question:
Can you bear weight on your foot?
Finding:
Asked location of wound
Finding:
Reports right foot is injured
(Found)
Pro Tip: Confirming which extremity an injury is located on is a best practice for your patient’s safety.Example Question:
Which foot is in pain?
Finding:
Reports wound is on the plantar surface of her foot
(Found)
Pro Tip: Confirming where a wound is located ensures you are aware of your patient’s biggest complaint.Example Question:
Where is the wound?
Finding:
Asked details of the injury
Finding:
Reports she scraped foot on bottom rung of a step stool
(Found)
Pro Tip: Discovering how an injury happened helps to assess your patient’s risk factors for injury.Example Question:
How did your injury happen?
Finding:
Reports injury occurred 1 week ago
(Found)
Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute.Example Question:
When did your injury occur?
Finding:
Denies other injuries besides foot wound
(Available)
Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury.Example Question:
Did you injure anything besides your foot?
Finding:
Reports being barefoot at the time of injury
(Available)
Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances.Example Question:
Were you wearing shoes when you fell?
Finding:
Denies seeing a healthcare provider for the injury until now
(Found)
Pro Tip: It’s crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound.Example Question:
Have you seen a healthcare provider for this injury?
Finding:
Asked about drainage from the foot wound
Finding:
Reports that the wound bled a little after sustaining the injury
(Available)
Pro Tip: Asking about bleeding helps you determine the characteristics of a wound.Example Question:
Did your foot bleed?
Finding:
Reports seeing pus draining from wound
(Found)
Pro Tip: Asking about discharge helps you determine the characteristics of a wound.Example Question:
Did you notice any discharge from the wound?
Finding:
Reports noticing pus 2 days ago
(Found)
Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began.Example Question:
When did you first notice the pus?
Finding:
Followed up on drainage
Finding:
Reports pus as white or yellow
(Available)
Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics.Example Question:
What color is the drainage from your wound?
Finding:
Denies odor from the wound
(Found)
Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics.Example Question:
Does the wound have an odor?
Finding:
Asked about home treatment of foot wound
Finding:
Reports wound care regimen of bandaging
(Available)
Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.Example Question:
How often do you change your bandage?
Finding:
Reports cleaning wound twice a day
(Available)
Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.Example Question:
How often did you clean the wound?
Finding:
Reports applying bacitracin, neomycin and polymyxin B (Neosporin)
(Found)
Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy.Example Question:
Did you use any ointment on the wound?
Finding:
Followed up on effectiveness of ointment
Finding:
Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective
(Available)
Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Tina’s diabetes diagnosis will have a large impact on her body’s healing ability, which should be taken into consideration during your exam.Example Question:
Did the ointment help?
Finding:
Asked about other foot wound symptoms
Finding:
Reports swelling around foot wound
(Found)
Pro Tip: Asking about the presence of swelling helps you gather information about your patient’s complaint, as well as potential related illnesses.Example Question:
Is there swelling around the wound?
Finding:
Reports swelling worsened in the past 2 days
(Available)
Pro Tip: Finding out how long swelling appeared will help you understand the timeline for the infection progression.Example Question:
How long have you noticed swelling around the wound?
Finding:
Reports redness around the wound
(Found)
Pro Tip: Asking about redness will help you understand the timeline for the infection progression.Example Question:
Did you notice any redness around the wound?
Finding:
Reports that the wound feels warm
(Found)
Pro Tip: Asking about warmth will help you understand the timeline for the infection progression.Example Question:
Does the wound feel warm?
Finding:
Explored impact of patient’s foot injury on activities of daily living
Finding:
Reports pain affects ability to walk
(Found)
Pro Tip: Understanding the impact of your patient’s wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can walk or not, as a lack of mobility can compromise quality of life.Example Question:
Does your injury impact your ability to walk?
Finding:
Reports pain affects ability to stand at work for long periods of time
(Available)
Pro Tip: Understanding the impact of your patient’s wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance.Example Question:
Does your foot pain affect your work?
Finding:
Reports pain prevented her from being able to walk to class
(Available)
Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don’t fall behind.Example Question:
Has your injury prevented you from going to class?
Past Medical History
Finding:
Asked about preexisting medical conditions
-
Finding:
Reports diabetes
(Found)
Pro Tip: It is important to identify any existing medical conditions, as that information is an integral part of a complete health history. Existing conditions can also inform your treatment and understanding of the patient’s current health issues. In Tina’s case, it is important to identify her diabetes diagnosis because that condition has a direct relationship with her current foot infection.Example Question:
Do you have any existing conditions? -
Finding:
Reports asthma
Click link below to purchase completed subjective data nd careplan at only $10
Related:
Reviews
There are no reviews yet.