NURS 6512 Comprehensive Assessment Tina Jones Shadow Health Transcript ProvidedNURS 6512 Week 1: Dis

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NURS 6512 Comprehensive Assessment Tina Jones Shadow Health Transcript Provided

NURS 6512 Week 1: Discussion

Building A Health History – We Can Reliably Complete This And Related Assignments In This Course, Including All The Required Shadow Health Assessments. These Include Tina Jones Health History, Focused Cough Assessment On Danny Rivera, Focused Assessment – Chest Pain On Brian Foster, And The Comprehensive Health Assessment On Tina Jones.

Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

To prepare:

With the information presented in Chapter 2 of Ball et al. in mind, consider the following:

• By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
• How would your communication and interview techniques for building a health history differ with each patient?
• How might you target your questions for building a health history based on the patient’s social determinants of health?
• What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
• Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
• Select one of the risk assessment instruments presented in Chapter 2 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
• Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

BY DAY 3 OF WEEK 1

Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!   

Read a selection of your colleagues’ responses.

BY DAY 6 OF WEEK 1

Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:

• Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
• Suggest additional health-related risks that might be considered.
• Validate an idea with your own experience and additional research

Learning Resources

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.

o   Chapter 2, “The History and Interviewing Proce
This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

o   Chapter 5, “Recording Information”
This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

• Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

o   Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

• Adly, N. N., Abd-El-Gawad, W. M., & Abou-Hashem, R. M. (2019). Relationship between malnutrition and different fall risk assessment tools in a geriatric in-patient unit. Aging Clinical and Experimental Research, 32(7), 1279–1287. https://doi.org/10.1007/s40520-019-01309-0
• Chow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED. The American Journal of Emergency Medicine, 37(3), 457–460. https://doi.org/10.1016/j.ajem.2018.06.015
• Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

• Shadow Health. (2021). Welcome to your introduction to Shadow Health. https://link.shadowhealth.com/Student-Orientation-Video
• Shadow Health. (n.d.). Shadow Health help deskLinks to an external site. Retrieved from https://support.shadowhealth.com/hc/en-us
• Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. Download Walden University quick start guide: NURS 6512 NP students. 
• Document: Shadow Health Nursing Documentation Tutorial Download Shadow Health Nursing Documentation Tutorial(Word document)

Required Media

Welcome and General Course Guidelines
Dr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m).

Module 1 Introduction
Dr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the registration requirements for your use of Shadow Health for your Digital Clinical Experience (DCE) Assignments as well as the criteria for the DCE Assignments (3m).

Building a Comprehensive Health History – Week 1 (19m)

Optional Resources

• LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw- Hill Medical.

o   Chapter 2, “History Taking and the Medical Record” (pp. 1)

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

This comprehensive shadow health assessment of Tina Jones enables the student to master the art of patient data collection, with head to toe history taking and physical assessment.

The process is highly involving, time-consuming and may require one to complete in different sessions, yet the goal is to be able to assess a patient in one sitting, taking as minimal time as possible. We can help you complete this and other shadow health assessments as and when needed, with excellent scores assured. Comprehensive Assessment Tina Jones Shadow Health Transcript

Transcript

All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394)

Hello, my name is Tammy. I will be conducting an interview and a physical exam.Greet
07/22/20 5:37 PM EDTHey.What is your name?Question
07/22/20 5:37 PM EDTTina Jones.What is your date of birth?Question
07/22/20 5:37 PM EDTFebruary 17th.How old are you?Question
07/22/20 5:43 PM EDTI’m 28.What brings you into the clinic today?Question
07/22/20 5:43 PM EDTI 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 problem?Question
07/22/20 5:44 PM EDTI 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.What is your new job?Question
07/22/20 5:44 PM EDTI’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!Comprehensive Assessment Tina Jones Shadow Health TranscriptThat is great.Empathize
07/22/20 5:45 PM EDTThanks.When was your last physical exam?Question
07/22/20 5:45 PM EDTLet’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.What did your gynecologist say?Question
07/22/20 5:45 PM EDTShe 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.Comprehensive Assessment Tina Jones Shadow Health TranscriptHow often do you take birth control?Question
07/22/20 5:48 PM EDTI take it every morning, with breakfast.What is the name of the birth control pill you took?Question
07/22/20 5:49 PM EDTThey’re called Yaz.Has your menstrual cycle improved since taking Yaz?Question
07/22/20 5:50 PM EDTNow that I’m on the pill I’m getting my period every month.That is great. I am glad you are having your period every month.Empathize
07/22/20 5:50 PM EDTThanks.Comprehensive Assessment Tina Jones Shadow Health TranscriptHow long have you had asthma?Question
07/22/20 5:51 PM EDTI’ve had asthma a long time. . . since I was really little.What age were you diagnosed with asthma?Question
07/22/20 5:51 PM EDTMy 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.Comprehensive Assessment Tina Jones Shadow Health TranscriptI am sorry about the experience.Empathize
07/22/20 5:52 PM EDTThanks.Comprehensive Assessment Tina Jones Shadow Health TranscriptHow do you manage your asthma?Question
07/22/20 5:52 PM EDTI try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.What are your triggers for asthma?Question
07/22/20 5:53 PM EDTBeing 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.Comprehensive Assessment Tina Jones Shadow Health TranscriptIt is important to stay away from triggers.Educate
07/22/20 5:54 PM EDTThanks for telling me.Comprehensive Assessment Tina Jones Shadow Health TranscriptWhat happens when you are around dust?Question
07/22/20 5:54 PM EDTI 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.Comprehensive Assessment Tina Jones Shadow Health TranscriptWhat inhaler do you use?Question
07/22/20 5:59 PM EDTThe daily inhaler is Flovent, and the rescue inhaler is Proventil.Comprehensive Assessment Tina Jones Shadow Health TranscriptHow often do you use Flovent?Question
07/22/20 6:00 PM EDTTwice a day.When did you most recently use the Flovent inhaler?Question
07/22/20 6:01 PM EDTI use my Flovent inhaler two times a day.Comprehensive Assessment Tina Jones Shadow Health TranscriptWhen did you last use your inhaler?Question
07/22/20 6:03 PM EDTI 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.Comprehensive Assessment Tina Jones Shadow Health TranscriptHow much Albuterol do you use?Question
07

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.

What is your relationship like with your family?Question
07/22/20 7:39 PM EDTThings are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along.That is great.Empathize
07/22/20 7:39 PM EDTThanks.Are you involved in church?Question
07/22/20 7:39 PM EDTYeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.Comprehensive Assessment Tina Jones Shadow Health TranscriptAre you feeling stressed?Question
07/22/20 7:40 PM EDTI’m feeling really good lately. . . not stressed at all.How do you cope with stress?Question
07/22/20 7:40 PM EDTI’ve realized that I got overwhelmed with everything back when I had 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–attending church, especially–is all working well for me.Comprehensive Assessment Tina Jones Shadow Health TranscriptThanks.Comprehensive Assessment Tina Jones Shadow Health TranscriptAre you feeling depressed?Question
07/22/20 7:41 PM EDTNo, I’m actually feeling really good these days.How do you feel about your life?Question
07/22/20 7:41 PM EDTI’m starting my new job in two weeks, and I’m excited about that. I’m going to be an Accounting Clerk at this nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple of years, I’ll get promoted and be given new responsibilities. I always want to learn new things and improve my job.Comprehensive Assessment Tina Jones Shadow Health TranscriptAre you feeling anxious?Question
07/22/20 7:41 PM EDTI guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though.Comprehensive Assessment Tina Jones Shadow Health TranscriptDo you have sleeping problems?Question
07/22/20 7:42 PM EDTI’m sleeping a lot better now, which is a relief.Good to hear.Empathize
07/22/20 7:42 PM EDTThanks.How many hours are you sleeping a night?Question
07/22/20 7:42 PM EDTI’m usually asleep by 11:30, and I wake up at 8, about 8 or 9 hours a night.That is great.Empathize
07/22/20 7:42 PM EDTThanks.Have you ever smoked tobacco?Question
07/22/20 7:43 PM EDTNo. I think it’s gross.Have you ever used cocaine?Question
07/22/20 7:43 PM EDTNo way, I have no interest in that. That stuff can mess you up.Have you ever used heroin?Question
07/22/20 7:49 PM EDTUh, no.Have you ever used illegal drugs?Question
07/23/20 3:17 PM EDTWell, I used to smoke pot. . . but I don’t do that anymore.What was the last time you smoked pot?Question
07/23/20 3:17 PM EDTI haven’t smoked pot since I was twenty or twenty-one.Do you have any family history of mental illness?Question
07/23/20 3:18 PM EDTNo. They’re crazy, but nobody’s diagnosed with anything.Have you had suicidal thoughts?Question
07/23/20 3:19 PM EDTNo, I’ve never done that.Any new family medical history report?Question
07/23/20 3:20 PM EDTMy mom has some issues; I think some of my grandparents did, too.How old is your mom?Question
07/23/20 3:21 PM EDTMom is 50.What medical problems does your mum have?Question
07/23/20 3:21 PM EDTMom has high cholesterol and blood pressure, I think. She seems to be doing okay though.What medical problems did your father have?Question
07/23/20 3:22 PM EDTHe had high blood pressure and cholesterol, and diabetes too…the same kind as me.How old is your brother?Question
07/23/20 3:24 PM EDTHe’s almost 27.Does he have any medical issues? (Clarified to Does your younger sister have health problems?.)Question
07/23/20 3:25 PM EDTShe’s pretty healthy. She has asthma too, but she rarely has attacks. (Clarified to if my younger sister has health problems.)Does your brother have health issues? (Clarified to Does your brother have medical problems?.)Question
07/23/20 3:25 PM EDTNo, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.)How old is your maternal grandmother?Question
07/23/20 3:26 PM EDTNana 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 grandfather?Question
07/23/20 3:27 PM EDTPoppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.Any medical history for your paternal grandmother?Question
07/23/20 3:30 PM EDTShe takes some blood pressure pills and has high cholesterol, but Granny’s doing great for 82.Does your dad’s father have health issues?Question
07/23/20 3:30 PM EDTGrandpa 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.Comprehensive Assessment Tina Jones Shadow Health TranscriptHave you had any recent illnesses?Question
07/23/20 3:31 PM EDTNo. . . the last time I was sick was when I was having those heartburn problems a while ago.Any fever?Question
07/23/20 3:32 PM EDTI haven’t had a fever.Any chills?Question
07/23/20 3:32 PM EDTNope, no chills.Any acne?Question
07/23/20 3:32 PM EDTI 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?Question
07/23/20 3:32 PM EDTI think I have a little less body hair than I used to.Do your eyes feel itchy?Question
07/23/20 3:33 PM EDTThey haven’t been itchy lately at all.Are you having any redness in your eyes?Question
07/23/20 3:33 PM EDTMy eyes haven’t been red lately. . . not since I came in with those allergies a while ago.Are your eyes dry?Question
07/23/20 3:34 PM EDTMy eyes don’t feel dry.Do you have any pain in your eyes?Question
07/23/20 3:34 PM EDTI haven’t had any eye problems lately–I went to the eye doctor a few months ago and got these glasses; she checked everything out and said it looked good.Are you having any ear problems?Question
07/23/20 3:34 PM EDTMy ears feel fine.Any changes in your hearing?Question
07/23/20 3:36 PM EDTMy hearing is good.Any ear pain?Question
07/23/20 3:36 PM EDTMy ears feel fine.Ear drainage? (Clarified to Do you have drainage from your ears?.)Question
07/23/20 3:36 PM EDTNothing is coming out of my ears. (Clarified to if I have ear drainage.)Any changes in your sense of smell?Question
07/23/20 3:46 PM EDTNo.Any nose bleeds?Question
07/23/20 3:47 PM EDTNope, my nose isn’t bleeding at all.Any sinus pressures?Question
07/23/20 3:47 PM EDTMy sinuses have been fine.Has your sense of taste changed?Question
07/23/20 3:47 PM EDTNo, I think my sense of taste is fine.Are you having dry mouth?Question
07/23/20 3:48 PM EDTMy mouth hasn’t been dry.ANY pain in your mouth?Question
07/23/20 3:48 PM EDTNo, my mouth feels fine.ANY sore throat?Question
07/23/20 3:49 PM EDTNo, it’s fine.Any issue with your gums?Question
07/23/20 3:49 PM EDTMy gums have been fine.Any issue with your tongue?Question
07/23/20 3:49 PM EDTMy tongue feels fine.Any difficulties when swallowing?Question
07/23/20 3:50 PM EDTI can swallow fine.SORE throat?Question
07/23/20 3:50 PM EDTNo, it’s fine.Any voice changes?Question
07/23/20 3:50 PM EDTMy voice has been fine.Any swollen lymph nodes?Question
07/23/20 3:52 PM EDTMy lymph nodes seem fine.Are you having any nausea?Question
07/23/20 3:52 PM EDTNo, I haven’t been nauseous at all.Any vomiting?Question
07/23/20 3:53 PM EDTNo.ANY pain in the abdomen?Question
07/23/20 3:53 PM EDTI haven’t really had any stomach problems since I came in with them a while ago.Any constipation?Question
07/23/20 3:53 PM EDTI don’t have that problem.Comprehensive Assessment Tina Jones Shadow Health TranscriptAny diarrhea?Question
07/23/20 3:54 PM EDTI haven’t had any problems with diarrhea.Excessive flatulence?Question
07/23/20 3:54 PM EDTI 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.flatulence is one of the side effect of metforminEducate
07/23/20 3:55 PM EDTThanks for telling me.Any food intoleranceQuestion
07/23/20 3:56 PM EDTI can eat just about anything.Any burning sensation when you urinate?Question
07/23/20 3:56 PM EDTNo, it doesn’t burn when I pee.Any blood in your urine?Question
07/23/20 3:57 PM EDTNo! That doesn’t sound like it would be good.Are you having any pain right now?Question
07/23/20 3:57 PM EDTI don’t have any pain anywhere.Any vaginal discharge?Question
07/23/20 3:58 PM EDTMy discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish.Comprehensive Assessment Tina Jones Shadow Health TranscriptAny vaginal itching?Question
07/23/20 3:58 PM EDTNo, it feels normal.Do you have any problem with your breasts?Question
07/23/20 3:59 PM EDTNo, my breasts feel fine.Any pain in the breasts?Question
07/23/20 3:59 PM EDTNo, my breasts feel fine.Are you having any dizziness/Question
07/23/20 3:59 PM EDTI haven’t been getting dizzy at all.Any lightheadedness?Question
07/23/20 4:00 PM EDTNo, I don’t really get lightheaded.Any tingling?Question
07/23/20 4:00 PM EDTNope, no tingling.Comprehensive Assessment Tina Jones Shadow Health TranscriptAny loss of balance?Question
07/23/20 4:00 PM EDTMy balance is fine.Any changes in sensation?Question
07/23/20 4:00 PM EDTI haven’t noticed any changes.Any seizures?Question
07/23/20 4:01 PM EDTNo, I’ve still never had problems with seizures, fortunately.Do you have memory problems?Question
07/23/20 4:01 PM EDTI think my memory has been fine.Any muscle pain?Question
07/23/20 4:01 PM EDTMy muscles have felt great, especially since I started exercising more.Joint pain?Question
07/23/20 4:02 PM EDTMy joints always seem fine.Comprehensive Assessment Tina Jones Shadow Health TranscriptAny muscle weakness?Question
07/23/20 4:02 PM EDTNo, I haven’t felt weak at all.Any swelling?Question
07/23/20 4:03 PM EDTNothing is swollen. Performed pulse oximetryExam Action
07/24/20 10:01 AM EDT Performed spirometryExam Action
07/24/20 10:01 AM EDT Inspected scalpExam Action
07/24/20 10:01 AM EDT Inspected scalpExam Action
07/24/20 10:01 AM EDT Inspected hair on scalpExam Action
07/24/20 10:01 AM EDT Inspected scalpExam Action
07/24/20 10:01 AM EDT Inspected right eyebrow and orbital areaExam Action
07/24/20 10:02 AM EDT Inspected left eyebrow and orbital areaExam Action
07/24/20 10:02 AM EDT Inspected mouth: Oral mucosa moist.Exam Action
07/24/20 10:02 AM EDT

Subjective Data Collection: 50 of 50 (100.0%)

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

Current Health Status

Finding: A confirmed reason for the visit

Finding: Reports needing a pre-employment physical

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: Can I confirm that you are here for a physical?

Finding: Reports no current acute health problems

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 current health problems?

Finding: Asked about last visit to a healthcare provider

Finding: Last visit to a healthcare provider was 4 months ago

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

Example Question: When did you see a healthcare provider?

Finding: Reason for last visit was annual gynecological exam

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.

Example Question: Why did you see a healthcare provider?

Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler

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

Example Question: When was your last physical exam?

Finding: Asked about current prescription medications

Finding: Reports taking diabetes medication

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

Example Question: Have you been taking medication for your diabetes?

Finding: Reports using a daily inhaler

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

Example Question: Do you use a daily inhaler?

Finding: Reports taking prescription birth control pills

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.

Example Question: Are you taking any form of birth control?

Finding: Followed up about diabetes medication

Finding: Medication is metformin

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

Example Question: What is the name of your diabetes medication?

Finding: Started taking metformin 5 months ago

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

Example Question: How long have you been taking metformin?

Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time

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

Example Question: Have you noticed any side effects from the metformin?

Finding: Followed up on metformin frequency and dose

Finding: Reports taking metformin twice daily

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

Example Question: How many times a day do you take metformin?

Finding: Metformin dose is 850 mg

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Comprehensive Assessment Tina Jones Shadow Health Transcript

Example Question: What is the dose of your metformin?

Finding: Asked about asthma medication

Finding: Reports using Flovent inhaler twice daily

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

Example Question: How often do you use your daily inhaler?

Finding: Has a Proventil rescue inhaler

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

Example Question: Do you have a rescue inhaler?

Finding: Last use of Proventil inhaler was three months ago

Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.

Example Question: When did you last use your rescue inhaler?

Finding: Has used Proventil inhaler twice in the last year

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

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