Tina Jones Health History Simulation Part 5

Finding: Denies vomiting (Available)Pro Tip: Vomiting can be caused by a pain response, a reaction to medication, stress, or even spreading infection. If the patient reports a history of vomiting, it could be a symptom of a recurring gastrointestinal problem.

Finding: Denies stomach pain (Available)Pro Tip: Asking about stomach pain is one possible component of a review of systems interview. As a currently presenting symptom, it could indicate a change in patient status. If the patient reports recurring stomach pain, it could be a symptom of a gastrointestinal problem.

Finding: Denies change in bowel movements (Available)Pro Tip: Asking about changes in bowel movements can help you understand a patient's baseline patterns. Any recent or abrupt changes could impact the patient's care plan, such as administering treatment for constipation or diarrhea.

Finding: Denies heartburn, GERD, or indigestion (Available)Pro Tip: Asking about stomach conditions such as heartburn or GERD is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint.

Finding: Denies constipation (Available)Pro Tip: Asking about constipation is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of constipation, it could be a symptom of dietary or gastrointestinal problems.

Finding: Denies diarrhea or loose stool (Available)Pro Tip: Asking about diarrhea is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of diarrhea, it could be a symptom of dietary or gastrointestinal problems.

Finding: Denies excessive flatulence or bloating (Available)Pro Tip: Asking about gas or bloating is one possible component of a review of systems interview. As a currently presenting symptom, it could impact the patient's care plan. If the patient reports a history of gas, it could be a symptom of dietary or gastrointestinal problems.

Finding: Asked review of systems for urinary

Finding: Denies painful or difficult urination (Available)Pro Tip: Asking about pain during urination is one possible component of a review of systems interview. As a currently presenting symptom, it could result in a change to the patient's care plan. A history of pain during urination could be a symptom of genitourinary problems.

Finding: Reports waking up to urinate during the night (Available)Pro Tip: Frequent urination at night can be a sign of uncontrolled blood sugar or UTI. As a currently presenting symptom, nocturia could result in a change to the patient's care plan. A history of nocturia could be a symptom of genitourinary or endocrine problems such as diabetes.

Finding: Reports large amount of urine (Found)Pro Tip: Polyuria is a common symptom of diabetes. Establishing that Tina is producing a large amount of urine is important for understanding the current state of her condition and treatment needs.

Finding: Denies blood in urine (Available)Pro Tip: As a currently presenting symptom, blood in the urine is a serious symptom that requires immediate intervention. A history of hematuria could be a symptom of genitourinary problems.

Finding: Denies flank pain (Available)Pro Tip: Flank pain can be a sign of kidney infection. As a currently presenting symptom, flank pain could result in a change to the patient's care plan. A history of flank pain could be a symptom of genitourinary problems.

Finding: Denies history of urinary tract or bladder infection (Available)Pro Tip: Asking about a history of bladder or urinary tract infections is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint.

Finding: Asked review of systems for reproductive

Finding: Reports last menstrual period was 3 weeks ago (Available)Pro Tip: Establishing the patient's last menstrual period will help you determine if the patient could be pregnant. A potential pregnancy impacts important parts of the patient's care plan, including which medications are administered.

Finding: Reports that periods are irregular (Available)Pro Tip: Asking about menstrual regularity is one possible component of a review of systems interview. A history of irregular periods could indicate hormonal or endocrine problems.

Finding: Denies past pregnancies (Available)Pro Tip: A patient's history of pregnancy can shed light on other health conditions, body systems, or risk factors. It's important to learn about any past pregnancies, live births, or miscarriages

Finding: Denies vaginal itching or discomfort (Available)Pro Tip: Asking about vaginal discomfort, such as itching or burning, is one possible component of a review of systems interview. Symptoms like these could indicate a yeast or sexually transmitted infection.

Finding: Reports normal vaginal discharge (Available)Pro Tip: Asking about vaginal discharge is one possible component of a review of systems interview. If a patient reports atypical discharge, it could indicate a yeast or sexually transmitted infection.

Finding: Denies history of STIs (Available)Pro Tip: Asking about a patient's history of STIs is one possible component of a review of systems interview. A history of STIs could cause complications with the genitourinary system.

Finding: Reports past condom use (Available)Pro Tip: Asking about a patient's past condom use is one possible component of a review of systems interview. Sexual activity without condoms increases a patient's risk of STIs, and can be an indicator of a patient's health literacy.

Finding: Denies current birth control (Available)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.

Finding: Asked review of systems for musculoskeletal

Finding: Denies muscle pain (Found)Pro Tip: Asking about muscle pain is one possible component of a review of systems interview. The most common causes of muscle pain are strain, overuse, illness, or infection.

Finding: Denies joint pain (Available)Pro Tip: Asking about joint pain is one possible component of a review of systems interview. The most common causes of muscle pain are overuse, and conditions such as arthritis.

Finding: Denies muscle weakness (Available)Pro Tip: Asking about muscle weakness is one possible component of a review of systems interview. Muscle weakness can be a sign of neurological problems, or a reaction to medication.

Finding: Denies muscle swelling (Available)Pro Tip: Asking about muscle swelling is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint.

Finding: Asked review of systems for neurological

Finding: Denies dizziness or vertigo (Available)Pro Tip: Asking about dizziness or vertigo is one possible component of a review of systems interview. Presence of dizziness could indicate a reaction to medication, an inner ear problem, or changes in blood sugar or blood pressure.

Finding: Denies lightheadedness (Available)Pro Tip: Asking about light-headedness is one possible component of a review of systems interview. Feeling light-headed could indicate a reaction to medication, changes in blood sugar or blood pressure, or a neurological problem.

Finding: Denies tingling (Available)Pro Tip: Asking about tingling sensations is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems, such as nerve damage.

Finding: Denies loss of coordination (Available)Pro Tip: Asking if the patient has experienced loss of coordination is one possible component of a review of systems interview. The patient's response to these questions may uncover neurological problems.

Finding: Denies loss of sensation (Available)Pro Tip: Diabetic patients often experience numbness due to neuropathy, especially in the arms, legs, hands, and feet. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint.

Finding: Reports no seizures (Available)Pro Tip: Asking about seizures is one possible component of a review of systems interview. The patient's response to these questions may uncover neurological problems.

Finding: Denies problems with balance or disequilibrium (Available)Pro Tip: Problems with balance can indicate neurological problems, or issues with the inner ear. Asking your patient about past fractures may uncover additional problems not discovered during discussion of the patient's chief complaint.

Finding: Asked review of systems for skin, hair and nails

Finding: Reports acne (Found)Pro Tip: Adult acne can suggest stress or changes in hormone levels. Asking Tina about her present acne and history of acne can help you understand any skin conditions or hormonal changes.

Finding: Reports excessive facial or body hair (Available)Pro Tip: Increases in body hair can suggest changes in hormone levels. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint.

Finding: Reports changes to neck skin (Available)Pro Tip: Asking about changes in skin color is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint

Finding: Reports moles (Available)Pro Tip: Monitoring moles is key in preventing cancerous growths. Asking Tina if her moles have changed will indicate whether any of her moles should be assessed further.

Finding: Denies dandruff (Available)Pro Tip: Dandruff is a chronic scalp condition characterized by flaking skin. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint.

Finding: Denies hair loss (Available)Pro Tip: Asking about hair loss or balding is one possible component of a review of systems interview. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint.

Finding: Denies nail abnormalities (Available)Pro Tip: Nail fungus might cause discoloration and disfigurement of the nails. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint.

Finding: Reports occasional dry skin (Available)Pro Tip: Chronic or severe dry skin might require a patient to be seen by a dermatologist. The patient's response to these questions may uncover additional problems not discovered during discussion of the patient's chief complaint.

Description: Tina expresses frustration about her level of pain. Student: How effective was the Neosporin? Tina Jones: Well, I'm here, so I guess it didn't do its job. Student: Can you walk with your foot being injured? Tina Jones: No, I can't. I can't put any weight on it without like, shooting pain. Student: What preexisting medical conditions do you have? Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot! Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly. Tina Jones: Thanks. Model Statement: "I'm sorry to hear that your pain is returning. We want you to be in as little pain as possible. I can give you some Advil at this time, and in a few hours, you can have more tramadol. I can also walk through some pain management exercises with you that don't involve medication, if you are interested."

Description: Tina brings up her pain and frustration at how being unable to bear weight on her foot impacts her life. Student: What are stressors? Tina Jones: I feel really stressed out right now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too. Student: We are going to take care of everything as quickly as possible. Tina Jones: Thanks. Model Statement: "This sounds like a challenging time for you. I understand your frustration at having your life interrupted by foot pain. Please let me know if there is anything I can help you with, such as contacting your employer or asking a family member to bring your schoolwork. We'll do our best to get you feeling better and, on your way, home as soon as possible."

Description: Tina describes controlling her diabetes by avoiding "sweets." Model Statement: "Staying away from sugar is a great start. I can give you some more information on what a balanced diet looks like for someone with diabetes. For example, many starchy foods break down into glucose in the body, like pasta, and so you can eat those in moderation, too. Most people with diabetes feel better when they limit all starches, eat protein, and take regular medication."

Description: Tina reveals that she does not treat her diabetes with medication. Student: Do you currently take medicine for your diabetes? Tina Jones: No, I don't take anything for my diabetes anymore. Student: What made you stop taking medication for your diabetes? Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills. Model Statement: "I understand that it can be challenging to keep up with daily medication. But it's important to keep your blood sugar under control to prevent long-term damage to your health, and medication can really help. I'd like to talk with you more about getting back onto a prescription. We could start you at a low dose, which reduces the side effects."

Description: Tina reveals that she does not check her blood sugar. Student: Do you monitor your blood glucose? Tina Jones: I have a monitor at home, but to be honest I don't really use it that often. Model Statement: "I understand how it can feel like a frustrating chore to check your sugar every day. But it is important to keeping your diabetes under control. When you monitor your sugar, it helps you understand what foods, activities, and times of day contribute to you feeling your best. And keeping your sugar down will help your foot wound heal quickly, too. If you would like, I can help you find a monitor that is as painless as possible. I can also teach you more about what the numbers mean."

Description: Tina describes increased inhaler use and decreased effectiveness, indicating that her asthma is uncontrolled. Student: How many puffs do you take when using your asthma inhaler? Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI] Student: What are some things that trigger your asthma? Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. Student: What allergies do you have? Tina Jones: I'm allergic to cats. Model Statement: "It sounds like your asthma is giving you some problems, and you're not getting full relief from your inhaler. I would like to talk with you about changing your medication and your regimen, to reduce your frequent breathing problems, so that you feel better day-to-day. Most patients find that using a daily inhaler is an easy way to reduce your asthma symptoms even more."

Description: Tina shares information about her father dying. Student: Why don't you have your dad's income? Tina Jones: Um...well, my dad died in a car accident, about a year ago. Model Statement: "I'm sorry to hear about your father's passing. That sounds like a difficult situation."

Description: Tina discusses her past history of marijuana smoking. Student: Have you used illicit drugs? Tina Jones: Well, I used to smoke pot. . . but I don't do that anymore. Student: What type of drugs did you use? Tina Jones: Um...I've smoked pot before. In high school, and after high school... I definitely don't anymore, though. Student: Have you used drugs other than marijuana? Tina Jones: No. Student: When did you last use drugs? Tina Jones: I haven't smoked pot since I was twenty or twenty-one. Model Statement: "Thank you for sharing that information. It's good to hear that you no longer smoke pot. It's better for your asthma and your overall health."

Priority: High Priority Pro Tip: Managing acute pain is an immediate high priority, because other health concerns cannot be effectively addressed while a patient experiences severe pain. Evidence - Relevant: "...Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit." "It's throbbing and like, sharp if I try to put weight on it." Evidence Pro Tip: Tina expresses pain, which is the strongest evidence for this problem. She reports intense pain on a numerical scale and describes pain characteristics. The presence of a physical injury supports her susceptibility to acute pain. Planning - Relevant: Assess - Pain: Assess the patient's pain at regular intervals and with each assessment of vital signs. Assess - Pain: Assess the patient's response to pain medication. Educate - Medication: Educate the patient on medications used for pain relief. Educate - Pain: Educate the patient on non-pharmaceutical methods to reduce pain intensity. Intervene - Pain: Administer non-pharmacologic interventions to reduce pain. Intervene - Pain: Administer prescribed analgesics to provide optimal pain relief. Planning Pro Tip: To reduce the patient's pain, assess her current rating. Provide an appropriate intervention (pharmaceutical or otherwise) and educate the patient. After an appropriate time interval, assess pain levels again to see how the intervention affected the pain.

Priority: High Priority Pro Tip: This is a high priority. The infection is the most immediate threat to the patient's health, and the wound is at risk for delayed healing because of the patient's uncontrolled blood glucose. Evidence - Relevant: Evidence Pro Tip: As Tina discusses symptoms of her wound, including symptoms such as discharge, redness, warmth, and swelling, she reports strong evidence of impaired skin integrity. Planning - Relevant: Planning Pro Tip: Because wound infections impact the patient's overall health, it's important to assess perfusion, hydration, and swelling. Assess the status of the wound itself and ensure proper cleaning and dressing per the physician's order. Prevent worsening infection by educating the patient about wound care and self-monitoring.

Priority - High Priority Pro Tip: This is a high priority. The patient is unable to bear weight on her affected leg, which prevents walking. This impacts her daily life and increases her risk for falls and deep-vein thrombosis. Evidence - Relevant: "I mean, it's all red and swollen, and there's pus, it feels hot, it hurts like hell... It's got all that going on." "I got this scrape on my foot a while ago, and it got really infected. It's killing me." "No, I can't. I can't put any weight on it without like, shooting pain." Evidence Pro Tip: The strongest evidence of impaired walking is that Tina directly reports she can't bear weight or walk on her affected foot. Other supporting data points are the presence of her foot wound and her general reports of pain. Planning - Relevant: Assess - Musculoskeletal: Assess the patient's ability to bear weight and gait. Assess - Musculoskeletal: Assess the patient's mobility. Consult / Refer: Consult with physical therapist to develop a plan to improve the patient's mobility. Intervene - Mobility: Assist the patient as needed with mobility. Intervene - Mobility: Provide assistive devices to facilitate mobility (crutches, therapeutic boot to minimize pressure on plantar surface, wheelchair). Planning Pro Tip: Assess how well the patient can bear weight and walk. While the patient is in your care, work with other healthcare professionals to keep the pain managed and improve the patient's mobility. Provide assistance with activities such as toileting and ensure that the patient can access and use assistive devices.

Priority - High Priority Pro Tip: Poorly managed diabetes and uncontrolled blood glucose complicate wound healing. As the underlying cause for delayed healing and infection, they must be addressed. Evidence - Relevant: "No, I don't take anything for my diabetes anymore." "I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I'm just eating healthier than I did when I was taking the pills." "I have a monitor at home, but to be honest I don't really use it that often." Evidence Pro Tip: Tina directly reports ineffective diabetes management when discussing her lack of treatment. She expresses gaps in health literacy about the risk of ceasing prescribed medication and blood glucose monitoring. Supporting evidence comes from her inability to incorporate meaningful dietary changes or increase her exercise. Planning - Relevant: Assess - Health Literacy and Patterns: Assess the patient's knowledge related to diabetic disease process, assess personal/social supports. Assess - Health Literacy and Patterns: Assess the patient's perceived barriers to adherence to the prescribed regimen (cost, adverse effects, lack of knowledge). Assess - Health Literacy and Patterns: Assess the patient's readiness for change/education. Educate - Disease Process: Educate the patient on diabetes pathophysiology, risks of morbidity and mortality, importance of self-care. Planning Pro Tip: To gain a deep understanding of your patient's situation, determine her level of health literacy, her feelings and beliefs about the disease, and the motivation behind her choices. Educate the patient about what risks are, and what good diabetes care looks like. Most importantly, ask about her goals and changes she may be willing to make.

Priority - High Priority Pro Tip: The patient's foot wound impairs her walking, which in turn increases her risk for falls while she is an admitted patient. Her past history of injury also adds to this risk. Evidence - Relevant: Evidence Pro Tip: The strongest evidence of Tina's fall risk is reports of being unable to bear weight or walk on her foot. Other supporting evidence is her recent injury caused by falling. Planning - Relevant: Planning Pro Tip: Protect your patient by taking all fall precautions, and educate your patient about how to be safe as she goes through her daily activities at the hospital. Make sure that the patient feels comfortable asking for your assistance.

Priority - High Priority Pro Tip: Uncontrolled blood glucose levels delay or prevent wound healing, and must be addressed to resolve the infection. Unstable blood glucose levels could increase the patient's risk for falls. Evidence - Relevant: "Random blood glucose: 238" Evidence Pro Tip: Tina reports infrequent blood glucose monitoring and a general lack of diabetes management, which increases her risk for fluctuating blood glucose levels. Infection can contribute to poorer glycemic control, and so Tina is likely to experience blood glucose levels that are significantly higher than her baseline. Planning - Relevant: Assess - Vitals: Assess the patient's blood glucose levels according to orders. Educate - Disease Process: Educate the patient on the signs and symptoms of hyper- and hypoglycemia. Intervene - Diet: Provide the patient a diet without concentrated sweets. Intervene - Hypoglycemia: Administer insulin and/or oral hypoglycemics, per physician orders. Planning Pro Tip: First, gauge your patient's current status by checking hydration, vital signs, and perfusion. Measure the patient's blood glucose and provide medication as per the physician's orders. While the patient is in your care, ensure that their meals align with a low glycemic diet, and educate the patient on monitoring her own health status.

Priority - Low Priority Pro Tip: A BMI greater than 30 indicates obesity, but this diagnosis is a low priority at present. Obesity is a long-term health concern that cannot be addressed in a single visit. Evidence - Relevant: "BMI: 31" Evidence Pro Tip: Tina's BMI is 31, which is in the obese range. This numerical evidence is required to establish obesity. Other contributing factors are her family history of diabetes mellitus and a lack of physical exercise. Planning - Relevant: Educate - Diet: Educate the patient on balanced nutritional intake. Educate - Disease Process: Educate the patient on health risks related to obesity. Educate - Exercise: Educate the patient about the benefits of exercise. Planning Pro Tip: To help your patient address her obesity, which is often a sensitive topic, use therapeutic communication techniques. First, gain a deep understanding of your patient's situation. Determine her level of health literacy, her feelings and beliefs related to the disease, and the motivation behind their choices. Then educate the patient on risks of obesity, recommended dietary changes, and healthy exercise.

Priority - Low Priority Pro Tip: When caring for a patient diagnosed with asthma, it's important to be aware of the possibility of emerging respiratory symptoms. However, for a patient with no active respiratory complaints, this problem does not need to be addressed immediately. Evidence - Relevant: Evidence Pro Tip: Tina's asthma puts her at general risk for breathing problems. She also reports sometimes needing more puffs to resolve symptoms. Contributing factors are a past history of hospitalization and asthma attacks, as well as sedentary lifestyle and obesity. Planning - Relevant: Planning Pro Tip: Take a general survey of the patient for changes in skin color, and assess respiratory rate, rhythm, depth, and quality to confirm there are no acute breathing issues. Gather data on the patient's breathing status by checking pulse and blood pressure. Auscultate the lungs to listen for abnormal sounds. While the patient is in your care, educate her on the cause and symptoms of shortness of breath so that she can let you know about emerging problems. Empower the patient to take part in her own care by educating her on controlled breathing techniques.

Priority - Low Priority Pro Tip: A patient's sedentary lifestyle compromises her overall health and problems such as diabetes. However, this issue is low priority for a patient with acute pain and a wound that prevents her from walking. Evidence - Relevant: Evidence Pro Tip: Tina directly reports that she doesn't exercise, which is the primary evidence for a sedentary lifestyle. She describes being too busy to exercise and reports that her primary activity is being on her feet at work, a belief which demonstrates her misunderstanding of exercise. Planning - Relevant: Planning Pro Tip: Interview the patient to determine her level of health literacy, and her attitudes and beliefs toward exercise. Educate the patient about the benefits to overall health and blood sugar control and finding an appropriate form of exercise. Ask the patient questions about what changes she may be willing to make.