Tina Jones: I dont think I have any problems. Example Question: Do you have muscle swelling? Pro Tip: Establishing information about the character of Tina's skin, like whether the skin on her neck hurts, will allow you to compare her symptoms and assess her condition. Finding: Reports occasionally taking acetaminophen (Tylenol) for headaches (Available)Pro Tip: Finding out about your patients use of over-the-counter medications, vitamins, and supplements will help you get a complete health history and avoid unwanted drug interactions. Loss of a family member Not Followed Up, Description: Tina shares information about her father dying. Other contributing factors are her family history of diabetes mellitus and a lack of physical exercise. Asking Tina if the hospital treatment has improved her foot wound will clarify the symptoms she is experiencing. We could start you at a low dose, which reduces the side effects. The patients response to questions about this topic may uncover additional problems not discovered during the discussion of the patients chief complaint, such as oral infection or recent trauma. Reports a photograph from years earlier shows darkening skin. Student: I cant even imagine how you feel about losing your father, Tina Jones: Dad was a little stricter than Mom growing up. 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. This record provides necessary information for healthcare professionals who will continue patient care. I personally haven't used Dr. Rose but as a (MLD) Manual Lymphatic Drainage Therapist I had the pleasure to work with one of his patients" more. Bruising easily can be indicative of anemia or a more serious blood disorder. Tina Jones: He was driving to work, and it was rainingand his car hydroplaned. Koilonychia: is a nail disease that can be a sign of hypochromic anemia, especially iron-deficiency anemia. Example Question: How many days have you needed pain medication? Won't go anywhere else. Finding: Denies difficulty swallowing (Available)Pro Tip: Asking if a patient has difficulty swallowing is one possible component of a review of systems interview. Example Question: What did you eat for lunch yesterday? Make sure that the patient feels comfortable asking for your assistance. The vertical axis of your chart should represent current body weight, and the horizontal axis should represent weight after a 3 percent loss. Example Question: Do you have any breast swelling? Example Question: Have you ever smoked marijuana? Finding: Asked about prescription medications. Asking Tina if any of her family members had cancer is essential for understanding her risks. Ask the patient questions about what changes she may be willing to make. Example Question: Have you had a mammogram? Tina Jones: I made sure to clean it and keep it bandaged. Educate Exercise: Educate the patient about the benefits of exercise. This should take about 3 seconds. . Priority High Priority Pro Tip: Poorly managed diabetes and uncontrolled blood glucose complicate wound healing. Finding: Denies family history of headaches (Found)Pro Tip: Asking about trends such as headaches can help you fill in holes in the history that your patient may have missed and can allow you insight into other inherited diseases that affect relatives outside of immediate family. Examples: stasis ulcer, pressure ulcer chancre Finding: Reports family members will be able to help with activities (Available)Pro Tip: Learning about your patients living situation helps develop rapport and gives you a broad picture of her lifestyle. patient. Example Question: How do you manage your asthma? Finding: Reports chest tightness during exacerbation (Found)Pro Tip: Asthma can have a profound impact on health, and it is important to discovered the severity of her condition by asking about symptoms during an exacerbation, such as chest tightness. Tina Jones: I dont think I have problems in that area. Freckles, flat nevi, hypopigmentation, petechiae, measles and scarlet fever Example Question: What are your usual blood sugar levels? As a currently presenting symptom, nocturia could result in a change to the patients care plan. Finding: Denies nail abnormalities (Available)Pro Tip: Nail fungus might cause discoloration and disfigurement of the nails. Came here in the dead of winter - the parking lot to turn into from 800 North (snowing and ice everywhere) is not recommended - you can hit your car's tires on the sidewalk due to it being covered and not being shoveled/maintained! This assignment takes on average between 90 and 110 minutes. I personally haven't used Dr. Rose but as a (MLD) Manual Lymphatic Drainage Therapist I had the pleasure to work with one of his patients post surgery the last two weeks. Finding: Asked about past diabetes medication use. Example Question: Have you ever had a urinary infection? Finding: Asked about family history of thyroid issues. Asking Tina if her skin gets dry solicits important health information. Student: Have you had any neurological problems? Example Question: What pain medication have you been taking? Finding: Denies pain while breathing (Available)Pro Tip: Asking about pain during breathing is one possible component of a review of systems interview. Finding: Reports increased water intake (Available)Pro Tip: Your patients fluid intake can offer insight into underlying medical conditions. Atrophic Scar: the resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Finding: Reports previous medication was prescription metformin (Found)Pro Tip: Asking about a patients medication history for a particular condition, such as Tinas past prescription for metformin, will provide a timeline of her asthma treatment. Student: What are my objectives in this assessment? Example Question: Have you had any head injuries? As a currently presenting symptom, flank pain could result in a change to the patients care plan. Asking Tina when she last saw a doctor about her acne solicits important information about her health history and any treatment plan she was following. I understand your frustration at having your life interrupted by foot pain. her neck hurts, will allow you to compare her symptoms and assess her condition. Asking Tina if her mother had high blood pressure can reveal generational patterns. Tina Jones: Im allergic to cats. Anytime. Tinea pedis (ringworm of the foot) Finding: Reports specific age of diagnosis was 24 (Found)Pro Tip: Learning the diagnosis date of your patients illness is an essential element of the illnesses history. This is the first time Ive been in the hospital since I was probably sixteen, though. The patients response to questions about this topic may uncover additional problems not discovered during the discussion of the patients chief complaint. Example Question: Do you have flank pain? Finding: Reports last asthma attack was in high school (Available)Pro Tip: Discovering the patients most recent asthma attack can provide a timeline of exacerbations and help you better understand the patients condition and effectiveness of any treatments. Ulcer Finding: Reports last exacerbation was three days ago (Available)Pro Tip: Discovering the patients most recent exacerbation can provide a timeline of asthma symptoms and help you better understand the patients condition and effectiveness of any treatments. Pro Tip: Establishing information about the character of Tina's skin, like when she noticed the 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. Finding: Denies current birth control (Available)Pro Tip: A patients use of birth control can impact the care plan, such as which medications are prescribed. Pro Tip: Changes in body hair can indicate a change in hormone levels. Finding: Reports last dental visit was several years ago (Available)Pro Tip: Asking about a patients dental care is one possible component of a review of systems interview. Finding: Reports allergy to cats (Found)Pro Tip: Asking general questions about allergies is the first step to a conversation with a patient about her complete set of allergies. I think she had high blood pressure and cholesterol, too. Student: We are going to take care of everything as quickly as possible. . Distance. Finding: Asked about constitutional health. Reports body hair has been increasing for a long time. Cyst: encapsulated fluid-filled cavity in the dermis or subcutaneous layer, tensely elevating the skin. Example Question: What is the pain like when you stand on your foot? Tina Jones: Mom has high cholesterol and blood pressure, I think. Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will Finding: Reports taking 2 pills each time (Available)Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan. She reports intense pain on a numerical scale and describes pain characteristics. Pro Tip: Specific questions about Tina's wound can help you to assess the care that she will Pro Tip: Changes in skin color can be the symptom of various diseases, disorders, or conditions. Finding: Asked about paternal grandfathers health. Intervene Pain: Administer prescribed analgesics to provide optimal pain relief. Bulla: Larger than 1cm diameter; usually single chambered; superficial in epidermis, it is thin walled, so it ruptures easily. Finding: Reports infrequent eye redness (Available)Pro Tip: Asking about symptoms, such as eye redness, is one possible component of a review of systems interview. Finding: Denies seasonal allergies (Available)Pro Tip: Asking about seasonal allergies can help you understand a patients complete set of allergies over the course of a year. Tina Jones Skin, hair, and nails assessment skin hair nails subjective data collection: 23 of 23 hover to reveal hover over the patient You should assess her needs to determine if providing any addition resources or support is appropriate. The patients response to questions about this topic may uncover additional problems not discovered during the discussion of the patients chief complaint, such as allergic reactions or infection. Scale experiencing. Presence of dizziness could indicate a reaction to medication, an inner ear problem, or changes in blood sugar or blood pressure. Finding: Reports living in a house (Available)Pro Tip: Learning about your patients living situation helps develop rapport and gives you a broad picture of her lifestyle. Finding: Reports occasional headaches (Available)Pro Tip: Asking about headache frequency is one possible component of a review of systems interview. 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