Week 9 - Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

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Home >Nursing homework help >Week 9 - Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

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

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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)

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Question 06/10/18 3:23 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.)

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Question 06/10/18 3:29 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.

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Question 06/10/18 3:33 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.)

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Question 06/10/18 3:40 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

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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

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Question 06/10/18 4:21 PM

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I haven't had any asthma problems, really, ever since I started on the daily inhaler. My last breathing problem was three months ago, probably, and it had been months before that.

Do you feel you're in good health now?Do you feel you're in good health now?

All of my health stuff is a lot better now. I feel like my diabetes is in control, I'm in better shape. . . I'm eating healthier. I'm less stressed. Things are going really well.

That sounds really greatThat sounds really great

Thanks.

It is important that you keep on this regimen in order to stay in BetterIt is important that you keep on this regimen in order to stay in Better HealthHealth

Thanks for telling me.

When were you diagnosed with diabetes?When were you diagnosed with diabetes?

I was diagnosed when I was 24.

Sorry to hear thatSorry to hear that

Thanks.

How long have you been on Metformin?How long have you been on Metformin?

I started taking it five months ago. I went in for my annual physical and talked with the nurse practitioner about taking better care of my diabetes.

It's really important to stay on track with your diabetesIt's really important to stay on track with your diabetes

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Question 06/10/18 4:23 PM

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Thanks for telling me.

Do you check your blood sugars?Do you check your blood sugars?

Yeah, I check it once a day, in the morning.

When did you last check your blood sugar?When did you last check your blood sugar?

I check it around the same time every morning.

What is your average blood sugar number?What is your average blood sugar number?

My blood sugar's usually around 90.

Do you check your blood sugar before meals?Do you check your blood sugar before meals?

Yeah, I check it once a day, in the morning.

According to the American diabetic Association a morning bloodAccording to the American diabetic Association a morning blood glucose taken before meds for some who have diabetes should beglucose taken before meds for some who have diabetes should be around 80-130. So you're doing great with your blood sugar be 90around 80-130. So you're doing great with your blood sugar be 90

Thanks for telling me.

Do you have any side effects with the metformin?Do you have any side effects with the metformin?

Last time I took it I felt sick and gassy all the time, and it happened again when I started taking it, but now I eat yogurt every day and it seems to have helped.

A common reaction from metformin is flatulence so if the yogurt isA common reaction from metformin is flatulence so if the yogurt is helping with a side effect that's greathelping with a side effect that's great

Thanks for telling me.

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When did you start your birth control? (Clarified to how long haveWhen did you start your birth control? (Clarified to how long have you been taking the pill.)you been taking the pill.)

About four months ago. I went to the gynecologist, and she prescribed it.

Great following up on the gynecologist but we'd like you to do.Great following up on the gynecologist but we'd like you to do. American College of Obstetricians and gynecologist to have anAmerican College of Obstetricians and gynecologist to have an annual women's well exam to screen for things like cancer, STDs, orannual women's well exam to screen for things like cancer, STDs, or other conditions. Such as PCOSother conditions. Such as PCOS

Thanks for telling me.

When was your last menstrual cycle?When was your last menstrual cycle?

Um. . . about two weeks ago.

Did you take your pill at the same time everyday?Did you take your pill at the same time everyday?

I take it every morning, with breakfast.

How are your periods before you started birth control?How are your periods before you started birth control?

I used to have really bad cramps, but they're not so bad anymore, since I started the pill.

You take me over the counter medication? (Clarified to What kind ofYou take me over the counter medication? (Clarified to What kind of over the counter medicines do you take?.)over the counter medicines do you take?.)

I take Advil for cramps sometimes, though those have been a lot better because I'm on birth control.

How much Advil do you take?How much Advil do you take?

I used to take a lot, but honestly I haven't really had to take it since I started birth control.

What kind of Advil do you take?What kind of Advil do you take?

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I just take the regular kind I think. It's not extra strength or anything. [Nurse confirmed with Pharmacy: 3-4x ibuprofen 200mg]

Do you use any herbal products?Do you use any herbal products?

I don't take any supplements.

Do you take any vitamins?Do you take any vitamins?

I don't take any vitamins.

When was your first sexual encounter?When was your first sexual encounter?

I was in high school. . . eighteen.

At what age should you start your menstrual cycleAt what age should you start your menstrual cycle

I think I was eleven.

Have you ever been pregnant?Have you ever been pregnant?

I've never been pregnant.

Are you currently in a relationship?Are you currently in a relationship?

Yeah. I'm in a new relationship now, actually. It's been about a month.

Have you had sexual intercourse in the last month (Clarified to haveHave you had sexual intercourse in the last month (Clarified to have you had sex in the last six months.)you had sex in the last six months.)

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It's been a few years, actually, but I have a boyfriend now who I like, and I think we'll probably start having sex soon.

Do you plan to use condoms? (Clarified to Will you use condomsDo you plan to use condoms? (Clarified to Will you use condoms when you have sex with your boyfriend.)when you have sex with your boyfriend.)

We'll use condoms for sure. . . I know he's been tested pretty recently, and it was clean, but I want us both to get tested again before I think about not using condoms.

Have you been tested for HIV?Have you been tested for HIV?

No. I don't think I need one. I don't know anybody with HIV or AIDS.

Have you been tested for STDs?Have you been tested for STDs?

Yeah, I'm sure they did those tests when I went for a pap smear before.

Did they test you for HIV when you when to the gynecologist? (NoDid they test you for HIV when you when to the gynecologist? (No matching questions found.)matching questions found.)

Have you noticed any new allergies?Have you noticed any new allergies?

No new allergies--just cats, dust, and penicillin.

Have you been having seasonal allergies?Have you been having seasonal allergies?

I had those allergy problems I came in about a while ago. . . but that hasn't happened since.

Are you taking any medication for allergies?Are you taking any medication for allergies?

Other than my two inhalers, I don't take anything for allergies.

How are you managing your diabetes?How are you managing your diabetes?

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I take metformin, exercise, eat healthy, and check my blood sugar.

That's greatThat's great

Thanks.

Do you have enough supplies to monitor your blood glucose?Do you have enough supplies to monitor your blood glucose?

Yeah, I have enough.

Do you have difficulty breathing?Do you have difficulty breathing?

My breathing is fine right now.

Do you have any recent asthma symptoms?Do you have any recent asthma symptoms?

My asthma has been so much better ever since I started using my daily inhaler--like, I can't believe I lived so long with the breathing problems I was having. I didn't even realize how bad they were until they went away, you know?

Have you had a headache recently?Have you had a headache recently?

I think taking better care of myself and getting these glasses have really helped--I haven't had a headache in a while.

That's greatThat's great

Thanks.

When did you last visit the eye doctor?When did you last visit the eye doctor?

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I hadn't gone in a long while, but I went three months ago. She tested my vision and prescribed these glasses. I'm supposed to go back next year.

Yearly my doctor's visits are needed especially in diabetic patientsYearly my doctor's visits are needed especially in diabetic patients for patients with any visual problemsfor patients with any visual problems

Thanks for telling me.

Did you get prescription glasses?Did you get prescription glasses?

I went in to the eye doctor about three months ago, and she said I was near sighted and prescribed these glasses.

Do you like Do you like your glasses?your glasses?

Yeah, they've definitely helped me.

Is your vision blurry?Is your vision blurry?

Without my glasses, yeah, it's always blurry.

Have you had any surgeries?Have you had any surgeries?

I've still never had surgery.

Can you tell me how you stay healthy?Can you tell me how you stay healthy?

I've been really trying eat healthier, and I've been trying really hard to stay active, so I'm feeling pretty good about my lifestyle fight now.

What types of things do you do to stay active?What types of things do you do to stay active?

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I've been exercising more lately, actually. I try to go on a walk for thirty or forty minutes four or five times a week, and Selena and I go swimming at the Y once a week, too.

That sounds fun swimmingThat sounds fun swimming

Thanks.

It's great that you are challenging yourself to exercise regularly.It's great that you are challenging yourself to exercise regularly. Exercising help keep our bodies active and strengthen muscles toExercising help keep our bodies active and strengthen muscles to reduce developing chronic conditions when combined with healthyreduce developing chronic conditions when combined with healthy eating habits and lifestyle choiceseating habits and lifestyle choices

Thanks for telling me.

What kind of foods do you typically eat?What kind of foods do you typically eat?

Let's see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner.

When was your last dental exam?When was your last dental exam?

I finally went in five months ago, actually.

What did the dentist say?What did the dentist say?

I finally went in five months ago, actually.

How has your diet changed?How has your diet changed?

I'm not eating less, really, but I'm eating much healthier.

What is your average daily mealWhat is your average daily meal

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It kind of depends on the meal, but I've been making a lot of meals from recipes I found on a blog for people with diabetes.

How do you feel about your nutrition?How do you feel about your nutrition?

I've really improved my diet recently. I eat less carbs, and I don't eat sweets at all. I try to eat whole grains, and stuff that's low fat. I've found ways to prepare vegetables that I really like. I think I'm doing really well.

What do you eat on an average day?What do you eat on an average day?

Well. . . for breakfast, a smoothie made with frozen fruit and yogurt or an egg on wheat toast with yogurt on the side. For lunch, I eat leftovers from dinner the night before, or I'll have a sandwich on wheat bread. Then for dinner, I'll have chicken or fish, usually, with vegetables and brown rice or quinoa on the side.

Do you enjoy eating healthy?Do you enjoy eating healthy?

Sort of. I try to stay away from sweets and fast food. I'm not much of a salad person, but I try not to eat, like, pizza and French fries every day.

Do you have snacks?Do you have snacks?

I don't really eat snacks that often anymore. If I do, it'll just be carrot sticks or an apple, something like that.

Those are really healthy choices that's great that you're making aThose are really healthy choices that's great that you're making a positive change for your healthpositive change for your health

Thanks.

How is your appetite?How is your appetite?

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I was hungrier for a while because of my diabetes, but since I started taking medication for it, my appetite has been pretty normal.

The Experience nausea or vomiting?The Experience nausea or vomiting?

I haven't thrown up in a long time.

Do you ever experience nausea?Do you ever experience nausea?

No, I haven't been nauseous at all.

Have you noticed any weight changes?Have you noticed any weight changes?

I've lost weight recently, I think. . . I'm not, like, actively trying to lose weight, but I am trying to eat healthier and exercise for my diabetes.

That's great to hearThat's great to hear

Thanks.

Are you having heart palpitations?Are you having heart palpitations?

My heart has felt fine since I came in. . . I think limiting my caffeine really helped.

That sounds greatThat sounds great

Thanks.

Have you been having heart palpitations recently?Have you been having heart palpitations recently?

My heart has felt fine since I came in. . . I think limiting my caffeine really helped.

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How have you been treating your hypertension?How have you been treating your hypertension?

I've been eating better and exercising more, so I feel like my blood pressure is probably better--someone checked it a few months ago and said it was fine.

Good to hear.Good to hear.

Thanks.

Are your vaccinations up-to-date?Are your vaccinations up-to-date?

I'm pretty sure I am, yeah.

When was your last tetanus shot?When was your last tetanus shot?

I got a tetanus booster about a year ago.

What was your last influenza vaccine?What was your last influenza vaccine?

Oh, probably five or six years ago.

Would you like to influenza vaccine?Would you like to influenza vaccine?

Not today, but I guess I should consider it.

It is very important to have your influenza shot every year especiallyIt is very important to have your influenza shot every year especially patients with diabetes or any type of immune disorderpatients with diabetes or any type of immune disorder

Thanks for telling me.

Have you had heartburn recently?Have you had heartburn recently?

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I haven't had any heartburn in a few months. . . and never anything as bad as when I came in for it.

Are you still taking medication for GERD?Are you still taking medication for GERD?

I was prescribed, um. . . Zantac. And it seems to have worked because I haven't had any problems.

Are you still taking zantac?Are you still taking zantac?

I took the Zantac for about a month, and then I stopped. I haven't had any problems since then.

Are you having back pain?Are you having back pain?

I came in for it a while ago. . . I was helping my friend Selena move, and I tweaked my back as I lifted a box. It really hurt for about a week, but I saw a physical therapist and he gave me some stretches and told me to heat and ice it, and it went away.

Have you had back pain recently?Have you had back pain recently?

Have you limited your caffeine? (Clarified to Have you limited yourHave you limited your caffeine? (Clarified to Have you limited your caffeine intake.)caffeine intake.)

Yeah, I've really been trying not to drink too much caffeine lately.

Do you drink coffee?Do you drink coffee?

I don't drink coffee. . . it's too bitter.

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

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Question 06/10/18 5:06 PM

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What caffeinated drinks do you like?What caffeinated drinks do you like?

I still just drink diet Cokes.

How many Diet Cokes do you drink per day?How many Diet Cokes do you drink per day?

I don't drink every day--a couple times a month, I'll go out on the weekend and have a few drinks.

How many sodas do you drink the day?How many sodas do you drink the day?

I try not to have more than two diet Cokes a day, always before 1 P.M., though sometimes I'll have one in the early afternoon. . . never after 3 or 4, though.

Good to hear.Good to hear.

Thanks.

Do you drink alcohol?Do you drink alcohol?

I do sometimes, yeah, when I go out with my friends.

How many nights a week do you drink?How many nights a week do you drink?

Just a couple times a month, really. Three at most.

How many dreams do you have in one sitting? (Clarified to HowHow many dreams do you have in one sitting? (Clarified to How much alcohol do you usually drink in one sitting?.)much alcohol do you usually drink in one sitting?.)

I never have more than two or three. If I go over that, I feel like hell the next day, so I stick to just a few.

What size are your alcoholic drinks?What size are your alcoholic drinks?

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

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Question 06/10/18 5:08 PM

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Question 06/10/18 5:09 PM

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Educate 06/10/18 5:09 PM

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Question 06/10/18 5:10 PM

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Question 06/10/18 5:11 PM

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Just the normal size you get at a bar.

What kind of alcohol do you drink questionWhat kind of alcohol do you drink question

I usually get rum and diet Coke. I don't know why that matters.

It is a question we have to askIt is a question we have to ask

Thanks for telling me.

Did you graduate from college?Did you graduate from college?

I got my B.A. in accounting a few months ago.

Tell me more about your new job?Tell me more about your new job?

How do you feel about your new job?How do you feel about your new job?

I'm so excited about my new job. I think it's going to be a great experience, and I can't wait to learn how to do a bunch of new things.

That sounds exciting congratulationsThat sounds exciting congratulations

Thanks.

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

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Question 06/10/18 5:12 PM

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When do you start your new job?When do you start your new job?

It starts in two weeks.

Are you nervous? (No matching questions found.)Are you nervous? (No matching questions found.)

Are you nervous (No matching questions found.)Are you nervous (No matching questions found.)

Are you nervous about your new job? (Clarified to are you excitedAre you nervous about your new job? (Clarified to are you excited about your new position.)about your new position.)

I'm feeling really good about my new job. . . I think it will be a lot of work, but I'm sure I'll manage.

What is your current living situation?What is your current living situation?

I've been back at my mom's house, but I'm moving into an apartment closer to my new job. The lease starts in about a month.

That sounds greatThat sounds great

Thanks.

Have you ever lived independently? (Clarified to have you livedHave you ever lived independently? (Clarified to have you lived alone.)alone.)

Yeah, I lived with my friend Selena, and then when she moved I had my own place for a while.

How old were you when you live on your own? (No matchingHow old were you when you live on your own? (No matching questions found.)questions found.)

At what age did you live independently? (No matching questionsAt what age did you live independently? (No matching questions found.)found.)

Have you ever been married?Have you ever been married?

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

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Question 06/10/18 5:15 PM

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Question 06/10/18 5:19 PM

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No, I've never been married.

Do you have any children?Do you have any children?

I don't have any kids.

Do you have close friends?Do you have close friends?

I have a few friends I've known since middle or high school, and we're all pretty close. Plus I have my friends from church.

How close are you with your family?How close are you with your family?

Family's a big part of my life, so I'm pretty close to everyone. Mom and I have gotten a lot closer since Dad died, too. Now we're kind of a team.

I'm sorry to hear about your fatherI'm sorry to hear about your father

Thanks.

Are you still involved in church?Are you still involved in church?

Yes. Now that I'm less busy, I have more time for doing extra stuff at church, which I like. I go every Sunday, and I'm back into my Bible study on Wednesday nights.

Are you feeling stressed?Are you feeling stressed?

I'm actually feeling really good lately. . . not stressed at all.

How do you cope with stress?How do you cope with stress?

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

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Question 06/10/18 5:19 PM

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I've realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I've been trying to address problems as they come when I can, and that helps. That, plus the stuff I've always done-- going to church, especially--is all working well for me.

That's good to hearThat's good to hear

Thanks.

Are you feeling depressed?Are you feeling depressed?

No, I'm actually feeling really good these days.

How do you feel about your life?How do you feel about your life?

Well, I'm starting my new job in two weeks, and I'm really excited about that. I'm going to be an Accounting Clerk at this really nice accounting firm. I'm hoping I'll learn a lot in that position, and within a couple years, I'll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job.

Are you feeling anxious?Are you feeling anxious?

I guess I had anxiety back when I was having those sleep problems. . . I've been feeling much better lately, though.

Are you still having difficulty falling asleep ?Are you still having difficulty falling asleep ?

I'm sleeping a lot better now, which is a relief.

Good to hearGood to hear

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Question 06/10/18 5:21 PM

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Thanks.

How many hours are you sleeping a night?How many hours are you sleeping a night?

I'm usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night.

That's greatThat's great

Thanks.

Have you ever used tobacco?Have you ever used tobacco?

No, never.

Have you ever use cocaine?Have you ever use cocaine?

No way, I have no interest in that. That stuff can mess you up.

Have you ever use heroin?Have you ever use heroin?

Uh, no.

Have you ever used illegal drugs?Have you ever used illegal drugs?

Well, I used to smoke pot. . . but I don't do that anymore.

What was the last time you smoke potWhat was the last time you smoke pot

I haven't smoked pot since I was twenty or twenty-one.

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

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Question 06/10/18 5:26 PM

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Do you have any family history of mental illness?Do you have any family history of mental illness?

No. They're crazy, but nobody's diagnosed with anything.

Any thoughts of suicide? (Clarified to have you ever had thoughts ofAny thoughts of suicide? (Clarified to have you ever had thoughts of suicide.)suicide.)

No, I've never done that.

Any new family medical history to report.Any new family medical history to report.

My mom has some issues, and I think some of my grandparents did, too.

How old is your mom?How old is your mom?

Mom is 50.

What medical problems does your mom have?What medical problems does your mom have?

Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

How old was your father when he diedHow old was your father when he died

Two-and-a-half years ago, when Dad passed, he was only 58.

I'm sorry to hear thatI'm sorry to hear that

Thanks.

What medical problems did your father have?What medical problems did your father have?

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Question 06/10/18 5:32 PM

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He had high blood pressure and cholesterol, and diabetes too...the same kind as me.

How old is your brother?How old is your brother?

He's almost 27.

If you have any medical problems?If you have any medical 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.

Does your brother have any medical history?Does your brother have any medical history?

No, I don't think so. He's a little big, maybe.

How old is your sister?How old is your sister?

She's 15.

Does your sister have any medical problems?Does your sister have any medical problems?

She's pretty healthy. She has asthma but almost never has attacks.

How old is your maternal grandmotherHow old is your maternal grandmother

Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.

How old is your maternal grandfatherHow old is your maternal grandfather

Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.

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Question 06/10/18 5:36 PM

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Question 06/11/18 12:49 PM

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Any medical history for your paternal grandmotherAny medical history for your paternal grandmother

She takes some blood pressure pills, and I think she has high cholesterol, but Granny's doing great for 82.

Any medical problems for your paternal grandfather (Clarified to doesAny medical problems for your paternal grandfather (Clarified to does your dad's father have health issues.)your dad's father have health issues.)

Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and...I'm pretty sure he had diabetes.

Is Grandpa Jones still alive?Is Grandpa Jones still alive?

No, he died when I was really little.

I'm sorry to hear thatI'm sorry to hear that

Thanks.

How old was Grandpa Jones when he diedHow old was Grandpa Jones when he died

Let me think. He died when I was really little... I think he was in his mid-sixties. He died of colon cancer.

I'm sorry to hear thatI'm sorry to hear that

Thanks.

Have you had any recent illness?Have you had any recent illness?

No. . . the last time I was sick was when I was having those heartburn problems a while ago.

Any fever?Any fever?

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

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Question 06/11/18 12:50 PM

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I haven't had a fever.

Any chills?Any chills?

Nope, no chills.

Any night sweats?Any night sweats?

Nope, no night sweats.

Any acne?Any acne?

I took something for my acne. . . tetracycline, I think, back in high school. Since then I've just washed my face, I haven't used anything special. But my zits have gotten better, and I think it's because I'm on birth control now.

Has your body hair improved?Has your body hair improved?

I think I have a little less body hair than I used to.

How about facial hair?How about facial hair?

I think it's been getting better recently, like the past couple months. The gynecologist said going on birth control could help it, since it would help with my PCOS.

How's the darkening on your neck?How's the darkening on your neck?

I think it's been a couple years at this point.

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

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Question 06/11/18 12:53 PM

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how are the dark areas on your neck?how are the dark areas on your neck?

I think it's been a couple years at this point.

Are you having itchy eyes? (Clarified to do your eyes feel itchy.)Are you having itchy eyes? (Clarified to do your eyes feel itchy.)

They haven't been itchy lately at all.

Are you have any redness in your eyesAre you have any redness in your eyes

My eyes haven't been red lately. . . not since I came in with those allergies a while ago.

Are your eyes dry?Are your eyes dry?

My eyes don't feel dry.

Do you have any pain in your eyesDo you have any pain in your eyes

I haven't had any eye problems lately--I went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good.

Do you wear contacts?Do you wear contacts?

Well, I have glasses now. . . I went to the eye doctor three months ago, and she prescribed them for me.

Are you having any ear problemsAre you having any ear problems

My ears feel fine.

Any changes in your hearing?Any changes in your hearing?

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

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Question 06/11/18 12:56 PM

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Question 06/11/18 12:59 PM

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My hearing is good.

Any ear pain?Any ear pain?

My ears feel fine.

Ear drainage? (Clarified to do you have drainage from your ears.)Ear drainage? (Clarified to do you have drainage from your ears.)

Nothing is coming out of my ears.

Any changes in your sense of smell?Any changes in your sense of smell?

No.

Any nose bleeds?Any nose bleeds?

Nope, my nose isn't bleeding at all.

Any sinus pressure?Any sinus pressure?

My sinuses have been fine.

Runny nose?Runny nose?

No, my nose hasn't been running at all.

Has your sense of taste change?Has your sense of taste change?

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

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Question 06/11/18 12:59 PM

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No, I think my sense of taste is fine.

Are you having dry mouthAre you having dry mouth

My mouth hasn't been dry.

A pain in your mouthA pain in your mouth

No, my mouth feels fine.

A sores in your mouthA sores in your mouth

Nothing's been wrong with my mouth.

Any issues with your gums?Any issues with your gums?

My gums have been fine.

Any issues with your tongue?Any issues with your tongue?

My tongue feels fine.

Issues with your jaw?Issues with your jaw?

My jaw feels fine.

Are you having difficulty swallowing?Are you having difficulty swallowing?

I can swallow fine.

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

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Question 06/11/18 1:02 PM

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Sore throat?Sore throat?

No, it's fine.

Voice changes?Voice changes?

My voice has been fine.

Any swollen lymph nodes?Any swollen lymph nodes?

My lymph nodes seem fine.

Are you having any nausea?Are you having any nausea?

No, I haven't been nauseous at all.

Any vomiting?Any vomiting?

No.

Any pain in abdomen?Any pain in abdomen?

I haven't really had any stomach problems since I came in with them a while ago.

Any constipation?Any constipation?

I don't have that problem.

Any diarrhea?Any diarrhea?

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

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Question 06/11/18 1:05 PM

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I haven't had any problems with diarrhea.

Excessive flatulenceExcessive flatulence

I haven't been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked.

Any food intolerances?Any food intolerances?

I can eat just about anything.

Any burning when you urinateAny burning when you urinate

No, it doesn't burn when I pee.

You get up in the middle of the night to pee (Clarified to How oftenYou get up in the middle of the night to pee (Clarified to How often do you wake up at night to urinate?.)do you wake up at night to urinate?.)

Only once, if at all.

Are you peeing multiple times a dayAre you peeing multiple times a day

I think I pee a normal amount. . . maybe five times during the day, and then once at night?

In blood in your urineIn blood in your urine

No! That doesn't sound like it would be good.

flank pain? (No matching questions found.)flank pain? (No matching questions found.)

amy flank pain (No matching questions found.)amy flank pain (No matching questions found.)

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Question 06/11/18 1:09 PM

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are you having pain to flank area? (Clarified to are you having painare you having pain to flank area? (Clarified to are you having pain right now.)right now.)

I don't have any pain anywhere.

Any vaginal discharge?Any vaginal discharge?

My discharge is normal, I think. . . I have a little, and it's kind of clear, sometimes white-ish.

Vaginal itching?Vaginal itching?

No, it feels normal.

Are you having any problems with your breasts,Are you having any problems with your breasts,

My breasts feel fine.

Have you noticed any lumps in your breast?Have you noticed any lumps in your breast?

No.

Any pain in your breast?Any pain in your breast?

No, my breasts feel fine.

Are you having any dizzinessAre you having any dizziness

I haven't been getting dizzy at all.

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Question 06/11/18 1:11 PM

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Any lightheadednessAny lightheadedness

No, I don't really get lightheaded.

Any tinglingAny tingling

Nope, no tingling.

Loss of coordinationLoss of coordination

No. I mean, I'm clumsy, but it's not that bad.

Loss of sensation (Clarified to Have you had changes in sensation?.)Loss of sensation (Clarified to Have you had changes in sensation?.)

I haven't noticed any changes.

any seizuresany seizures

No, I've still never had problems with seizures, fortunately.

Any problems with your equilibrium? (Clarified to do you haveAny problems with your equilibrium? (Clarified to do you have memory problems.)memory problems.)

I think my memory has been fine.

any muscle painany muscle pain

My muscles have felt great, especially since I started exercising more.

joint painjoint pain

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Question 06/11/18 1:14 PM

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Exam Action 06/11/18 1:16 PM

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My joints always seem fine.

Any muscle weakness?Any muscle weakness?

No, I haven't felt weak at all.

Any swelling?Any swelling?

Nothing is swollen.

Performed pulse oximetry Performed pulse oximetry

Performed spirometry Performed spirometry

Comments

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