NURS 6512 Discussion: Building a Health History Instructions and Example Solution Provided
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.
Photo Credit: Getty Images/Caiaimage
To prepare:
With the information presented in Chapter 1 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. Patient Profile to Use: 40-year-old black recent immigrant from Africa without health insurance
- 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 1 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 “Post to Discussion Question” link, and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
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.
Resource List
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 1, “The History and Interviewing Process”
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.
- 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.
Deckx, L., van den Akker, M., Daniels, L., De Jonge, E. T., Bulens, P., Tjan-Heijnen, V. C. G., … Buntinx, F. (2015). Geriatric screening tools are of limited value to predict decline in functional status and quality of life: Results of a cohort study. BMC Family Practice, 16, 1–12. https://doi-org.ezp.waldenulibrary.org/10.1186/s12875-015-0241- x
Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family health history: Barriers and benefits. Postgraduate Medical Journal, (1079), 508–513.
Lushniak, B. D. (2015). Surgeon general’s perspectives: Family health history: Using the past to improve future health. Public Health Reports, (1), 3.
NURS 6512 Discussion: Building a Health History Example Solution
The scenario I was given for this week is an 80-year-old white male with angina who lives on a farm 80 miles from a healthcare center.
According to the National Institute on Aging (NIA), 25% of seniors aged 65 to 70 have hearing loss, while 50% of those over 75 have debilitating hearing loss. Talking clearly and slowly, looking at the patient directly, and reducing background noise are all ways of dealing with hearing loss (National Institute on Aging, n.d.-b).
Background noise could distract patients from listening to what you are trying to communicate with the patient. Sit facing the patient, employ active listening techniques, ask open-ended questions that might elicit a more thorough response, inquire about their functional status, and, if possible, request medical records from another provider before the appointment so that you can gather additional information that the patient may not provide to obtain an accurate medical history via interview (National Institute on Aging, n.d.-a).
When there is excellent communication between the practitioner and the patient, health assessment questions can be answered to the best of one’s ability. For the patient to grasp what you are asking or saying, the National Institute on Aging (n.d.-b) advises avoiding medical terms and adopting straightforward language and expressions.
The cardiovascular risk calculator from the ACC/AHA is the risk assessment tool I selected to employ for this patient. The patient’s angina complaint was why I decided on this tool. To ascertain the likelihood of a stroke, heart attack, or death from cardiovascular illness within the next ten years, persons should have a cardiovascular risk assessment (UpToDate, n.d.). To use this tool efficiently, this patient would require simple laboratory tests to determine his total cholesterol and HDL cholesterol. His medical history for diabetes, the drugs he is on now, his social history for smoking, and his current medications would all need to be evaluated by the healthcare professional (UpToDate, n.d.).
Age, race, and gender of the patient are all potential health hazards that should be taken into account. According to the Centers for Disease Control and Prevention, approximately 1 in every 4 American male fatalities are attributable to heart disease in 2021, and 7.7% of white males, or 1 in 13, had coronary artery disease. Diabetes history, a poor diet, being overweight, being inactive physically, and drinking too much alcohol are all potential risk factors for heart disease (Centers for Disease Control and Prevention, 2021). When beginning new drug management, this information should be carefully reviewed and may be obtained during the patient interview.
A few questions I would ask the patient are:
- What medications are you now taking? Can I see them, please?
- What do you consume in the morning? Lunch? Dinner?
- Do you have any dietary or medicine allergies? What responses did you get?
- Do you find it easy to stand up and move around or feel out of breath?
- Do you experience breathing issues while lying on your back?
- Any issues using the restroom?
- Are there any aches or weakened muscles?
- How does this pain feel when it is present? Does it extend to your arm, neck, or jaw?
- Does it hurt or feel like someone is stabbing you?
- How long does this discomfort linger before it stops?
- Is there anything you do that affects it positively or negatively?
- Do you consume alcohol, illegal substances, or smoke?
- What procedures have you previously undergone?
- How do you feel today?
- Do you get enough rest at night?
References
Ball, J., Dains, J., Flynn, J., Soloman, B., & Stewart, R. (2021). Seidel’s guide to physical examination 9th edition 2018 (9th ed.). Elsevier.
Centers for Disease Control and Prevention. (2021, February 3). Men and heart disease. https://www.cdc.gov/heartdisease/men.htm
National Institute on Aging. (n.d.-a). Obtaining an Older Patient’s Medical History. https://www.nia.nih.gov/health/obtaining-older-patients-medical-history
National Institute on Aging. (n.d.-b). Tips for improving communication with older patients. https://www.nia.nih.gov/health/tips-improving-communication-older-patients#: %7E:text=Talk%20slowly%20and%20clearly%20in,or%20pick%20up%20visual %20clues.
UpToDate. (n.d.). Calculator: Cardiovascular risk assessment in adults (10-year, ACC/AHA 2013) (patient education). https://www.uptodate.com/contents/calculator-cardiovascularrisk-assessment-in-adults-10-year-acc-aha-2013-patient-education
NURS 6512 Week 2: Functional Assessments and Cultural and Diversity Awareness in Health Assessment
DIVERSITY AND HEALTH ASSESSMENTS
May 2012, Alice Randall wrote an article for The New York Times on the cultural factors that encouraged black women to maintain a weight above what is considered healthy. Randall explained—from her observations and her personal experience as a black woman—that many African-American communities and cultures consider women who are overweight to be more beautiful and desirable than women at a healthier weight. As she put it, “Many black women are fat because we want to be” (Randall, 2012).
Randall’s statements sparked a great deal of controversy and debate; however, they emphasize an underlying reality in the healthcare field: different populations, cultures, and groups have diverse beliefs and practices that impact their health. Nurses and healthcare professionals should be aware of this reality and adapt their health assessment techniques and recommendations to accommodate diversity.
In this Discussion, you will consider different socioeconomic, spiritual, lifestyle, and other cultural factors that should be taken into considerations when building a health history for patients with diverse backgrounds. Your Instructor will assign a case study to you for this Discussion.
To prepare:
- Reflect on your experiences as a nurse and on the information provided in this week’s Learning Resources on diversity issues in health assessments.
- By Day 1 of this week, you will be assigned a case study by your Instructor. Note: Please see the “Course Announcements” section of the classroom for your case study assignment.
- Reflect on the specific socioeconomic, spiritual, lifestyle, and other cultural factors related to the health of the patient assigned to you.
- Consider how you would build a health history for the patient. What questions would you ask, and how would you frame them to be sensitive to the patient’s background, lifestyle, and culture? Develop five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
- Think about the challenges associated with communicating with patients from a variety of specific populations. What strategies can you as a nurse employ to be sensitive to different cultural factors while gathering the pertinent information?
BY DAY 3 OF WEEK 2
Post an explanation of the specific socioeconomic, spiritual, lifestyle, and other cultural factors associated with the patient you were assigned. Explain the issues that you would need to be sensitive to when interacting with the patient, and why. Provide at least five targeted questions you would ask the patient to build his or her health history and to assess his or her health risks.
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!
Required Readings
- 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.
- Chapter 1, “Cultural Competency”
This chapter highlights the importance of cultural awareness when conducting health assessments. The authors explore the impact of culture on health beliefs and practices.
- Chapter 1, “Cultural Competency”
- Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. - Centers for Disease Control and Prevention. (2020, October 21). Cultural competence in health and human services
- . Retrieved from https://npin.cdc.gov/pages/cultural-competence
This website discusses cultural competence as defined by the Centers for Disease Control and Prevention (CDC). Understanding the difference between cultural competence, awareness, and sensitivity can be obtained on this website. - United States Department of Human & Health Services. Office of Minority Health. (n.d.). A physician’s practical guide to culturally competent care. Retrieved June 10, 2019, from https://cccm.thinkculturalhealth.hhs.gov/
From the Office of Minority Health, this website offers CME and CEU credit and equips healthcare professionals with awareness, knowledge, and skills to better treat the increasingly diverse U.S. population they serve. - Coleman, D. E. (2019). Evidence based nursing practice: The challenges of health care and cultural diversity. Journal of Hospital Librarianship, 19(4), 330–338. https://doi.org/10.1080/15323269.2019.1661734
- Young, S., & Guo, K. L. (2016). Cultural diversity training. The Health Care Manager, 35(2), 94–102. https://doi.org/10.1097/hcm.0000000000000100
NURS 6512 Week 3: Assessment of Nutrition in Children
Week 3: Assignment 1 Case Study Assignment: Assessment of Nutrition in Children
When seeking to identify a patient’s health condition, advanced practice nurses can use a diverse selection of diagnostic tests and assessment tools; however, different factors affect the validity and reliability of the results produced by these tests or tools. Nurses must be aware of these factors in order to select the most appropriate test or tool and to accurately interpret the results.
Not only do these diagnostic tests affect adults, body measurements can provide a general picture of whether a child is receiving adequate nutrition or is at risk for health issues. These data, however, are just one aspect to be considered. Lifestyle, family history, and culture—among other factors—are also relevant. That said, gathering and communicating this information can be a delicate process.
For this Assignment, you will consider examples of children with various weight issues. You will explore how you could effectively gather information and encourage parents and caregivers to be proactive about their children’s health and weight.
To Prepare:
- Review this week’s Learning Resources and consider factors that impact the validity and reliability of various assessment tools and diagnostic tests. You also will review examples of pediatric patients and their families as it relates to BMI.
- Based on the risks you might identify consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
- Consider how you could encourage parents or caregivers to be proactive toward the child’s health.
THE ASSIGNMENT
Assignment (3–4 pages, not including title and reference pages):
Assignment: Child Health Case:
Include the following:
- An explanation of the health issues and risks that are relevant to the child you were assigned.
- Describe additional information you would need in order to further assess his or her weight-related health.
- Identify and describe any risks and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion.
- Taking into account the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information.
- Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight.
Required Readings
- 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.
- Chapter 3, “Examination Techniques and Equipment”
This chapter explains the physical examination techniques of inspection, palpation, percussion, and auscultation. This chapter also explores special issues and equipment relevant to the physical exam process. - Chapter 8, “Growth and Nutrition”
In this chapter, the authors explain examinations for growth, gestational age, and pubertal development. The authors also differentiate growth among the organ systems.
- Chapter 3, “Examination Techniques and Equipment”
- Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Student checklist: Health history guide
- Download Student checklist: Health history guide. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. - Centers for Disease Control and Prevention. (2021, April 9). Childhood overweight & obesity. http://www.cdc.gov/obesity/childhood/
This website provides information about overweight and obese children. Additionally, the website provides basic facts about obesity and strategies to counteracting obesity. - Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.- Chapter 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom Analysis”
This chapter introduces the diagnostic process, which includes performing an analysis of the symptoms and then formulating and testing a hypothesis. The authors discuss how becoming an expert clinician takes time and practice in developing clinical judgment.
- Chapter 1, “Clinical Reasoning, Evidence-Based Practice, and Symptom Analysis”
- Nyante, S. J., Benefield, T. S., Kuzmiak, C. M., Earnhardt, K., Pritchard, M., & Henderson, L. M. (2021). Population‐level impact of coronavirus disease 2019 on breast cancer screening and diagnostic procedures. Cancer, 127(12), 2111–2121. https://doi.org/10.1002/cncr.33460
- Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). History subjective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center. - Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Week 1)
- Chapter 5, “Pediatric Preventative Care Visits” (pp. 91 101)
NURS_6512_Week_3_Assignment_1_Rubric
| Criteria | Ratings | Pts | |
| This criterion is linked to a Learning Outcome In 3–4 pages, address the following: An explanation of the health issues and risks that are relevant to the child you were assigned. | 25 to >24.0 pts Excellent The response clearly, accurately, and in detail explains the relevant health issues and risks for the assigned child. 24 to >23.0 pts Good The response accurately explains the relevant health issues and risks for the assigned child. 23 to >17.0 pts Fair The response vaguely and with some inaccuracy explains the relevant health issues and risks for the assigned child. 17 to >0 pts Poor The response is inaccurate and/or missing explanations of the relevant health issues and risks for the assigned child. | 25 pts | |
| This criterion is linked to a Learning Outcome Describe additional information you would need in order to further assess his or her weight-related health. | 25 to >24.0 pts Excellent The response clearly and accurately describes detailed additional information needed to further assess the child’s weight-related health. 24 to >23.0 pts Good The response accurately describes additional information needed to further assess the child’s weight-related health. 23 to >17.0 pts Fair The response vaguely and with some inaccuracy describes additional information needed to further assess the child’s weight-related health. 17 to >0 pts Poor The response is inaccurate and/or missing a description of additional information needed to further assess the child’s weight-related health. | 25 pts | |
| This criterion is linked to a Learning Outcome Identify and describe any risks, and consider what further information you would need to gain a full understanding of the child’s health. Think about how you could gather this information in a sensitive fashion. | 20 to >17.0 pts Excellent The response clearly and accurately identifies and describes in detail any risks to the child’s health. The response clearly and accurately identifies and describes in detail further information needed to gain a full understanding of the child’s health, with a detailed explanation of how to gather that information in a way that is sensitive to the child. 17 to >14.0 pts Good The response accurately identifies and describes any risks to the child’s health. The response accurately identifies and describes further information needed to gain a full understanding of the child’s health, with a clear explanation of how to gather that information in a way that is sensitive to the child.1 4 to >13.0 pts Fair The response vaguely and with some inaccuracy identifies and describes any risks to the child’s health. The response vaguely identifies and describes further information needed to gain a full understanding of the child’s health, with a vague explanation of how to gather that information in a way that is sensitive to the child. 13 to >0 pts Poor The response identifies inaccurately and/or is missing descriptions of any risks to the child’s health. The response identifies inaccurately and/or is missing descriptions of further information needed to gain a full understanding of the child’s health, with an inadequate or missing explanation of how to gather that information in a way that is sensitive to the child. | 20 pts | |
| This criterion is linked to a Learning Outcome Taking into account the parents’ and caregivers’ potential sensitivities, list at least three specific questions you would ask about the child to gather more information. | 10 to >9.0 pts Excellent The response clearly and accurately lists three or more specific questions that would gather more information about the child. Specific questions are carefully worded to clearly demonstrate sensitivity to the parent(s) or caregiver(s) of the child. 9 to >8.0 pts Good The response lists three specific questions that would gather more information about the child. Specific questions are worded to demonstrate sensitivity to the parent(s) or caregiver(s) of the child. 8 to >7.0 pts Fair The response lists three questions with wording that is vague and lacking specificity for gathering more information about the child. Some wording of the questions lacks sensitivity to the parent(s) or caregiver(s) of the child. 7 to >0 pts Poor The response lists two or fewer confusing or inadequate questions, or is missing questions, for gathering more information about the child. Wording of questions provided lacks sensitivity to the parent(s) or caregiver(s) of the child. | 10 pts | |
| This criterion is linked to a Learning Outcome Provide at least two strategies you could employ to encourage the parents or caregivers to be proactive about their child’s health and weight. | 5 to >4.0 pts Excellent The response clearly describes two or more detailed strategies to encourage the parent(s) or caregiver(s) to be proactive about the child’s health and weight. 4 to >3.0 pts Good The response describes at least two strategies to encourage the parent(s) or caregiver(s) to be proactive about the child’s health and weight. 3 to >2.0 pts Fair The response vaguely describes two strategies to encourage the parent(s) or caregiver(s) to be proactive about the child’s health and weight. 2 to >0 pts Poor The response inadequately describes one strategy or is missing strategies to encourage the parent(s) or caregiver(s) to be proactive about the child’s health and weight. | 5 pts | |
| This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. | 5 to >4.0 pts Excellent Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.0 pts Good Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 to >2.0 pts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 2 to >0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. | 5 pts | |
| This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation | 5 to >4.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 to >2.0 pts Fair Contains several (3 or 4) grammar, spelling, and punctuation errors. 2 to >0 pts Poor Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. | 5 pts | |
| This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. | 5 to >4.0 pts Excellent Uses correct APA format with no errors. 4 to >3.0 pts Good Contains a few (1 or 2) APA format errors. 3 to >2.0 pts Fair Contains several (3 or 4) APA format errors. 2 to >0 pts Poor Contains many (≥ 5) APA format errors. | 5 pts | |
| Total Points: 100 | |||
Week 3: Assignment 2 Digital Clinical Experience (DCE): Health History Assessment
A comprehensive health history is essential to providing quality care for patients across the lifespan, as it helps to properly identify health risks, diagnose patients, and develop individualized treatment plans. To effectively collect these heath histories, you must not only have strong communication skills, but also the ability to quickly establish trust and confidence with your patients. For this DCE Assignment, you begin building your communication and assessment skills as you collect a health history from a volunteer “patient.”
To Prepare
- Review this week’s Learning Resources as well as the Taking a Health History media program, and consider how you might incorporate these strategies. Download and review the Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment.
- Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
- Review the Shadow Health Student Orientation media program and the Useful Tips and Tricks document provided in the week’s Learning Resources to guide you through Shadow Health.
- Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
DCE Health History Assessment:
Complete the following in Shadow Health:
Orientation (Required, you will not be able to access the Health History without completing the requirements).
- DCE Orientation (15 minutes)
- Conversation Concept Lab (50 minutes, Required)
Health History
- Health History of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve total score of 80% or better(includes BOTH DCE and Documentation), but you must take all attempts by the Week 4 Day 7 deadline.
Tina Jones Health History Transcript
Started: Sep 18, 2023 | Total Time: 292 min
All Lines (330)
Interview Questions (280)
Statements (38)
Exam Actions (12)
 | Weight: 90 kg | Exam Action09/18/23 12:20 AM EDT |
 | BMI: 31 | Exam Action09/18/23 12:20 AM EDT |
 | Random blood glucose: 238 | Exam Action09/18/23 12:20 AM EDT |
 | Blood pressure: 142/82 | Exam Action09/18/23 12:20 AM EDT |
 | Respiratory rate: 19 | Exam Action09/18/23 12:20 AM EDT |
 | O2 sat: 99% | Exam Action09/18/23 12:20 AM EDT |
 | Heart rate: 86 | Exam Action09/18/23 12:20 AM EDT |
 | Height: 170.2 cm | Exam Action09/18/23 12:20 AM EDT |
 | Temperature: 38.4 °C | Exam Action09/18/23 12:20 AM EDT |
 | Hello… My Name is Orlando and I will be assessing you today | Greet09/18/23 12:20 AM EDT |
 | Hey. | |
 | What is your name? | Question09/18/23 12:20 AM EDT |
 | Tina Jones. | |
 | How old are you Miss Jones | Question09/18/23 12:20 AM EDT |
 | I’m 28. | |
 | What brings you in today | Question09/18/23 12:21 AM EDT |
 | I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me! | |
 | I am so sorry to hear that you are in so much pain. I will do everything to reduce the pain for you. | Empathize09/18/23 12:21 AM EDT |
 | Thanks for understanding. | |
 | On a scale of 1 to 10, how would you rate the pain | Question09/18/23 12:22 AM EDT |
 | I’d say a 7. It hurts a lot, and the pain pills haven’t kicked in yet. | |
 | I am sorry to hear that | Empathize09/18/23 12:22 AM EDT |
 | I appreciate you telling me that. | |
 | How would you describe the pain | Question09/18/23 12:22 AM EDT |
 | It’s throbbing and like, sharp if I try to put weight on it. | |
 | Has the pain increased over the last few days | Question09/18/23 12:23 AM EDT |
 | Yeah, it got a lot worse two days ago. It was noticeably more painful. | |
 | Does the pain radiate | Question09/18/23 12:23 AM EDT |
 | The pain’s worse in my foot, but I feel it moving up into my ankle, too. | |
 | Does the pain interfere with your balance (Clarified to Has the pain affected your usual activities?.) | Question09/18/23 12:23 AM EDT |
 | I mean, the last two days I couldn’t walk on my foot, so it’s gotten in the way of everything — I had to basically stay home and off my foot. I didn’t think it could get to the point where it caused so many problems. (Clarified to if my pain has affected my activities.) | |
 | Where is the wound located | Question09/18/23 12:24 AM EDT |
 | It’s on the ball of my foot. | |
 | KIndly chow me the wound (No matching questions found.) | Question09/18/23 12:25 AM EDT |
 | How did the wound occur | Question09/18/23 12:25 AM EDT |
 | I was going down the back steps, and I tripped. . . I caught the railing, but I guess I kind of turned my ankle a little bit. And I scraped up my foot on the edge of the step. | |
 | Am sorry to hear | Empathize09/18/23 12:26 AM EDT |
 | Thanks. | |
 | When did the injury occur | Question09/18/23 12:26 AM EDT |
 | Well, I got the scrape a week ago, but the scrape and the pain got a lot worse in the last few days. | |
 | Were you wearing shoes at the time the injury occurred | Question09/18/23 12:26 AM EDT |
 | No, I was barefoot. | |
 | Did you sustain any other injuries (Clarified to Did you hurt anything else during the fall?.) | Question09/18/23 12:27 AM EDT |
 | Well, at first I thought my ankle was sprained because it hurt a lot right after I fell. But, I mean, I guess I was over-estimating it, because the ankle felt pretty okay the next day and it wasn’t a problem all week. (Clarified to if I hurt anything else during the fall.) | |
 | Did you seek medical attention after the injury | Question09/18/23 12:27 AM EDT |
 | Yeah, right after it happened, I worried I might’ve sprained my ankle so mom drove me to the ER. | |
 | That was a good decision. It is always advisable to seek medical help whenever someone gets an accident, however minor. | Educate09/18/23 12:28 AM EDT |
 | Alright, thanks for letting me know. | |
 | Did the wound bleed soon after the injury | Question09/18/23 12:28 AM EDT |
 | It didn’t bleed much. I think it stopped in just a few minutes. I just wrapped it up in a paper towel and put it up, and the bleeding stopped. | |
 | Is there any drainage from the wound right now | Question09/18/23 12:29 AM EDT |
 | Yeah, there’s definitely pus. | |
 | When did you first notice the pus | Question09/18/23 12:29 AM EDT |
 | Two days ago. | |
 | How have you been managing the wound (Clarified to How have you cared for the scrape?.) | Question09/18/23 12:29 AM EDT |
 | I made sure to clean it and just keep it bandaged. And I put Neosporin on it. (Clarified to how I have been taking care of the scrape.) | |
 | Do you clean the wound often | Question09/18/23 12:30 AM EDT |
 | Twice a day — every morning and every night. | |
 | Have you used any medication for the wound (No matching questions found.) | Question09/18/23 12:30 AM EDT |
 | What home remedies do you use for the wound | Question09/18/23 12:31 AM EDT |
 | I made sure to clean it and just keep it bandaged. And I put Neosporin on it. | |
 | What color is the pus | Question09/18/23 12:31 AM EDT |
 | It’s… white or maybe off-white. | |
 | Does the wound have any odor | Question09/18/23 12:31 AM EDT |
 | Um, no, not that I know of… That sounds gross. | |
 | Has the neosporin been effective (No matching questions found.) | Question09/18/23 12:32 AM EDT |
 | Is the wound swollen (Clarified to Is it swollen around the wound?.) | Question09/18/23 12:32 AM EDT |
 | Yeah, it looks swollen around the scrape. (Clarified to if it is swollen around the wound.) | |
 | Has the swelling changed in the last few days | Question09/18/23 12:32 AM EDT |
 | Yeah, it’s been steadily getting worse. | |
 | What color is the wound | Question09/18/23 12:33 AM EDT |
 | It’s… white or maybe off-white. | |
 | Is there redness around the wound | Question09/18/23 12:33 AM EDT |
 | Yeah, it’s red all around the scrape. | |
 | does the wound feel warm | Question09/18/23 12:33 AM EDT |
 | Yeah, it feels pretty warm. | |
 | has the pain affected your daily activities | Question09/18/23 12:34 AM EDT |
 | I mean, the last two days I couldn’t walk on my foot, so it’s gotten in the way of everything — I had to basically stay home and off my foot. I didn’t think it could get to the point where it caused so many problems. | |
 | Am sorry to hear that. I will make sure you get better soonest possible. | Empathize09/18/23 12:34 AM EDT |
 | I appreciate you saying that. | |
 | Do you have any existing medical conditions | Question09/18/23 12:35 AM EDT |
 | Yeah. . . I have asthma and diabetes. | |
 | When were you first diagnosed with diabetes | Question09/18/23 12:35 AM EDT |
| I was diagnosed when I was 24. | ||
 | Which type of diabetes is it (Clarified to What type of diabetes do you have?.) | Question09/18/23 12:35 AM EDT |
 | It’s type 2. (Clarified to what type of diabetes I have.) | |
 | How do you manage your diabetes | Question09/18/23 12:36 AM EDT |
 | I just watch what I eat and try to stay away from sweets. | |
 | Do you drink soda | Question09/18/23 12:36 AM EDT |
 | Yeah, I drink diet Coke. | |
 | It is advisable that you avoid any sugary foods and drinks going forward to help manage your diabetes | Educate09/18/23 12:37 AM EDT |
 | That makes sense. | |
 | Do you currently take any medication for your diabetes | Question09/18/23 12:37 AM EDT |
 | I don’t take anything for my diabetes anymore. | |
 | Did you take any diabetes medication before (No matching questions found.) | Question09/18/23 12:38 AM EDT |
 | Have you ever taken any diabetes medication | Question09/18/23 12:38 AM EDT |
 | Yeah, when I was diagnosed they gave me a medicine to try. | |
 | What was the previous diabetes medication you were given | Question09/18/23 12:39 AM EDT |
 | It was Metformin. | |
| When did you last use metformin for your diabetes (Clarified to When was the last time you took medicine for your diabetes?.) | Question09/18/23 12:39 AM EDT |
 | I haven’t taken it in about three years, honestly. (Clarified to when the last time I took my diabetes medication was.) | |
 | what made you stop taking diabetes medication | Question09/18/23 12:39 AM EDT |
| 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. | |
| While metformin may always have some side effects, especially on the stomach, it is advisable for one to take them, alongside yoghurt. Others have reported relief | Educate09/18/23 12:41 AM EDT |
| Sure, I think I understand what you mean. | |
| Also, checking your blood sugar regularly is important to avoid any emergencies. I will show you have to do that without much strain. | Educate09/18/23 12:41 AM EDT |
| OK, I understand. | |
| Do you monitor your blood glucose | Question09/18/23 12:42 AM EDT |
 | I have a monitor at home, but to be honest I don’t really use it that often. It’s such a hassle to check my blood sugar, and my diabetes is under control right now so I don’t really need to. | |
| When did you last check your blood sugar | Question09/18/23 12:42 AM EDT |
 | I don’t check it very often, honestly. . . I think the last time was about a month ago. | |
 | It is advisable for you to check your blood sugar regularly to help avoid any emergencies | Educate09/18/23 12:43 AM EDT |
| Thanks for telling me. | |
| What made you stop checking your blood sugar (Clarified to Why don’t you check your sugar often?.) | Question09/18/23 12:43 AM EDT |
| I just have a lot going on in my life, and I only have space in my mind for so much, you know? It’s a lot easier to stay away from sweets than it is to remember to test my sugar and be pricking my finger all the time and all of that. Anyway, the numbers were always so all over the place, and I wasn’t sure what they meant. (Clarified to why I do not check my sugar often.) | |
| I will explain to you how to read the numbers, and how to take your readings without much hassle | Educate09/18/23 12:44 AM EDT |
| OK, I understand. | |
| Do you often feel thirsty | Question09/18/23 12:44 AM EDT |
| You know, I did notice lately that I’ve been really thirsty. | |
| Do you drink a lot of water | Question09/18/23 12:44 AM EDT |
| Yeah, I’ve been drinking tons of water lately. | |
| How often do you urinate | Question09/18/23 12:45 AM EDT |
| I don’t know. Every hour or two when I’m awake? | |
| Do you wake up at night to urinate | Question09/18/23 12:45 AM EDT |
| Yeah, I definitely get up more than once during the night. | |
| How many times do you wake up at night to urinate | Question09/18/23 12:45 AM EDT |
| I probably have to get up two or three times a night. | |
| Tell me about your diet (Clarified to What is your diet like?.) | Question09/18/23 12:45 AM EDT |
| It’s pretty good, I think. I’m not a huge health nut or anything. (Clarified to what my diet is like.) | ||
| What did you take for breakfast yesterday | Question09/18/23 12:46 AM EDT |
| Mom brought me a muffin from the coffee shop. | |
| What did you take for lunch yesterday | Question09/18/23 12:46 AM EDT | |
| Yesterday I hopped to the kitchen and made a PB&J for lunch. | ||
| What did you take for dinner yesterday | Question09/18/23 12:46 AM EDT | |
| Mom made baked chicken and mashed potatoes. | ||
| I can see your diet yesterday had little fruits and vegetables included. Kindly start taking a lot more vegetables and fruits. | Educate09/18/23 12:47 AM EDT | |
| Thanks for telling me. | ||
| How is your appetite lately (Clarified to How is your appetite?.) | Question09/18/23 12:47 AM EDT | |
 | My appetite’s been huge lately. . . I feel like I’m hungry all the time. (Clarified to how my appetite is.) | |
| When did you first notice your change in appetite | Question09/18/23 12:48 AM EDT |
| I guess I started being starving all the time about a month ago. No matter how much I eat, I’m still hungry. | |
| Have you noticed any change in your weight | Question09/18/23 12:48 AM EDT |
 | Yeah, I’ve lost some weight recently. | |
 | When did this weight loss occur (No matching questions found.) | Question09/18/23 12:49 AM EDT |
 | When did you notice this weight loss | Question09/18/23 12:49 AM EDT |
 | Yeah, I’ve lost some weight recently. | |
 | How much weight have you lost | Question09/18/23 12:49 AM EDT |
 | It was about ten pounds in a little over a month, actually. | |
 | Was the weight loss intentional | Question09/18/23 12:50 AM EDT |
| I’ve never tried to lose weight. I’ve always accepted my body as it was–I have a lot more important things to worry about than dieting or the way I look. | |
| Unintentional weight loss can be a result of different factors. I will try and establish what might have caused it. | Educate09/18/23 12:50 AM EDT | |
| Alright, thanks for letting me know. | ||
| When were you first diagnosed with Asthma | Question09/18/23 12:51 AM EDT |
| 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. | |
 | Am sorry to hear that | Empathize09/18/23 12:51 AM EDT |
| Thanks for saying that. | ||
| When did you last experience an asthma attack (Clarified to When was your last asthma attack?.) | Question09/18/23 12:51 AM EDT |
| It’s really rare for me to have an attack now. Three days ago I had some breathing problems, but I guess probably my last full attack was in high school. (Clarified to when my last asthma attack was.) | ||
| Tell me about your asthma symptoms | Question09/18/23 12:52 AM EDT | |
| My chest and throat get tight, and I start to wheeze. It feels like I can’t take in air, like I can’t get enough air into my lungs. | ||
| Have you been hospitalized before with asthma (Clarified to Have you ever been hospitalized for your asthma?.) | Question09/18/23 12:52 AM EDT | |
| I went a bunch of times when I was little, for asthma attacks. (Clarified to if I have been hospitalized for asthma.) | ||
| When were you last hospitalized with asthma | Question09/18/23 12:53 AM EDT | |
 | I haven’t gone to the hospital for asthma since I was sixteen. | |
 | How many times have you been hospitalized for asthma | Question09/18/23 12:53 AM EDT |
| The last time was years ago, but I think I’ve been to the hospital maybe five times total. . . all for asthma. | ||
| Have you used a nebulizer before | Question09/18/23 12:54 AM EDT | |
| Yeah, they put me on a nebulizer at the hospital a couple times when I went in for asthma. | ||
| How do you manage your asthma | Question09/18/23 12:54 AM EDT | |
| I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. | ||
| Which inhaler do you use | Question09/18/23 12:54 AM EDT | |
| It’s just a regular Proventil inhaler. | ||
| When last did you use the inhaler | Question09/18/23 12:54 AM EDT | |
| I had to use my inhaler three days ago when I was at my cousin’s house. | ||
| Were you exposed to any allergens when at your cousin’s house | Question09/18/23 12:55 AM EDT | |
| Three days ago, at my cousin’s house. She has three cats. | ||
| How often do you use the inhaler | Question09/18/23 12:55 AM EDT | |
| Not often. Maybe two or three times a week. | ||
 | It is advisable that you try and avoid things that trigger your asthma, such as being around cats | Educate09/18/23 12:56 AM EDT |
 | That makes sense. | |
| What is the recommended dose for the asthma inhaler (Clarified to What dosage of albuterol do you take?.) | Question09/18/23 12:56 AM EDT | |
 | I usually use two puffs from my albuterol inhaler — it’s 90 micgrograms a spray — but lately sometimes I need three puffs. [AUDIO COMING SOON] (Clarified to what dose of albuterol I take.) | |
 | What triggers your asthma | Question09/18/23 12:57 AM EDT |
| Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. | ||
| Try and avoid cats as much as possible | Educate09/18/23 12:57 AM EDT | |
| Sure, I think I understand what you mean. | ||
| Does dust also trigger your asthma | Question09/18/23 12:57 AM EDT | |
| Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. | ||
| Do you have any seasonal triggers (Clarified to Do you have seasonal asthma triggers?.) | Question09/18/23 12:57 AM EDT | |
| No, not really. (Clarified to if I have seasonal asthma triggers.) | ||
| Do you have any allergies | Question09/18/23 12:58 AM EDT | |
| Yeah, I’m allergic to cats. | ||
 | What are your cat allergy symptoms | Question09/18/23 12:58 AM EDT |
 | Whenever I’m around cats, I start sneezing, my eyes get itchy. . . and my asthma starts to act up. | |
 | Do you have latex allergy | Question09/18/23 12:58 AM EDT |
| Nope. | ||
 | Are you allergic to any medication | Question09/18/23 12:59 AM EDT |
| Yeah, I’m allergic to penicillin. | ||
| What are the symptoms of your penicillin allergy | Question09/18/23 12:59 AM EDT | |
| I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that. | ||
 | I am sorry to hear that | Empathize09/18/23 12:59 AM EDT |
 | Thanks for understanding. | |
 | Do you have any food allergies | Question09/18/23 1:00 AM EDT |
 | Nope, no food allergies that I know of. | |
 | Are you allergic to dust | Question09/18/23 1:00 AM EDT |
 | Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust. | |
 | Are you allergic to pollen | Question09/18/23 1:00 AM EDT |
 | Not that I’ve noticed. | |
 | Are you allergic to mould (No matching questions found.) | Question09/18/23 1:00 AM EDT |
 | Do you have mould allergies | Question09/18/23 1:00 AM EDT |
 | I’m allergic to cats. | |
 | Do you have any seasonal allergies | Question09/18/23 1:01 AM EDT |
 | No, not really. | |
 | Tell me about your immunization status | Question09/18/23 1:01 AM EDT |
 | I got a tetanus booster for work about a year ago. For the other kinds, I got all the required ones when I was a kid, and for college…I’m sure I have a record somewhere at home. | |
 | have you received the measles vaccine | Question09/18/23 1:02 AM EDT |
 | Yeah, when I was a kid. I’m pretty sure, anyway. | |
 | Did you get the polio vaccine | Question09/18/23 1:02 AM EDT |
 | I’m pretty sure I got that one as a kid. | |
 | Did you get the varicella vaccine | Question09/18/23 1:02 AM EDT |
| No, I had the chicken pox when I was a kid so I didn’t need one. | ||
| Have you been immunized against Hepatitis A and B (Clarified to Have you been vaccinated for hep a or b?.) | Question09/18/23 1:02 AM EDT | |
| I think I got one, but maybe not the other. I got whichever one you get as a kid. (Clarified to if I have been vaccinated for Hep A or B.) | ||
 | Did you get your meningococcal vaccine | Question09/18/23 1:03 AM EDT |
| I got one when I first went to college…I was 19. | ||
| Have you received your HPV vaccine (Clarified to Did you get vaccinated for HPV?.) | Question09/18/23 1:03 AM EDT | |
| No, I didn’t know there was a vaccine for that. (Clarified to if I have gotten vaccinated for HPV.) | ||
| There is HPV vaccine right now. I will refer you to your GP for further information regarding the HPV | Educate09/18/23 1:04 AM EDT | |
| That makes sense. | ||
 | Have you received your annual flu shot (Clarified to Have you been vaccinated for the seasonal flu?.) | Question09/18/23 1:04 AM EDT |
| No. (Clarified to if I have had a flu shot.) | ||
 | When last did you get a tetanus vaccine | Question09/18/23 1:05 AM EDT |
 | I got a tetanus booster about a year ago. | |
 | Do you use any pain medication | Question09/18/23 1:05 AM EDT |
 | Yeah, I had to start taking pain medication. | |
 | Which pain medication do you use (Clarified to Which pain pills are you taking for your foot?.) | Question09/18/23 1:06 AM EDT |
 | It’s called tramadol. (Clarified to what pain pills I am taking for my foot.) | |
 | What dose of tramadol do you take | Question09/18/23 1:07 AM EDT |
 | I’m not 100% sure, but I think they’re 50 milligrams. | |
 | How many times a day do you take the tramadol | Question09/18/23 1:07 AM EDT |
 | They said I could take two pills at a time, up to three times a day. | |
| Do you take any other pain medication | Question09/18/23 1:07 AM EDT | |
| No, just the tramadol. | ||
| What other prescription medication do you take | Question09/18/23 1:08 AM EDT | |
| I’ve been taking some pain medication. Other than that, I have my inhaler. | ||
| Are there OTC medications that you use (Clarified to Do you take other over the counter medications?.) | Question09/18/23 1:08 AM EDT | |
| No, I only take Advil when my cramps get bad, and sometimes Tylenol for headaches. Lately I’ve been taking Advil for my foot, too. (Clarified to if I take other over the counter medications.) | ||
| What dosage of Advil do you always take (Clarified to What dosage of ibuprofen do you take?.) | Question09/18/23 1:09 AM EDT | |
 | I just take the regular kind I think — 200 mg. It’s not extra strength or anything. [AUDIO COMING SOON] (Clarified to what dosage of ibuprofen I take.) | |
 | Do you take any supplements | Question09/18/23 1:09 AM EDT |
| I don’t take vitamins or supplements. | ||
 | Do you take any herbals | Question09/18/23 1:09 AM EDT |
| No, I don’t take anything herbal. | ||
| Do you experience headaches | Question09/18/23 1:10 AM EDT | |
| Yeah, I get them a lot when I’m studying. | ||
| What medications do you use for headache | Question09/18/23 1:10 AM EDT | |
| I just take some acetaminophen. The gel kind, 500 mg. [AUDIO COMING SOON] | ||
| How often do you take the pain medication | Question09/18/23 1:12 AM EDT | |
| I’ve been taking the Tramadol morning, noon, and night. [AUDIO COMING SOON] | ||
| Does the pain medication offer relief | Question09/18/23 1:12 AM EDT | |
| Yeah, the pain pills help, but only for a few hours. | ||
| Do you have any problem affording medications | Question09/18/23 1:13 AM EDT | |
 | I haven’t had trouble affording medication . . . Cost wasn’t really the issue with the metformin. I just got really sick of having to take it, and I hated the side effects. [AUDIO COMING SOON] | |
| It is advisable that one takes medication, however bad they are, and try and find ways of mitigating any side effects. I will help you through this | Educate09/18/23 1:14 AM EDT | |
| Alright, thanks for letting me know. | ||
| tell me about your living situation | Question09/18/23 1:14 AM EDT | |
| I live at home with my mom and my sister — we’re a pretty tight-knit family. They’ve been helping me out. | ||
| That’s great. Family support is always crucial for good health | Educate09/18/23 1:15 AM EDT | |
 | OK, I understand. | |
 | What is your level of education | Question09/18/23 1:15 AM EDT |
 | Well, I’m finishing up my Bachelor’s degree right now. | |
 | What are you studying for your bachelor’s (Clarified to What’s your major in school?.) | Question09/18/23 1:16 AM EDT |
 | I’m going to get my bachelor’s in accounting. (Clarified to what my major is.) | |
| Tell me about your social life | Question09/18/23 1:16 AM EDT | |
 | I’ve known most of my girlfriends since high school. We’ve been a pretty tight group for a long time. I am really close to people at church too, especially the ones in my bible study group. I sometimes get drinks with the other shift-supervisors at work, but we’re not super close. | |
 | Do you feel stressed sometimes | Question09/18/23 1:17 AM EDT |
 | I don’t get stressed out much, but sometimes having such a hectic schedule can be a lot. Right now, though, I’m mostly worried about my foot. | |
 | Does your family help at home | Question09/18/23 1:18 AM EDT |
 | I like helping my family. Family is such an important part of my life and it feels good to be able to help. | |
 | what is your belief system like (Clarified to What is your religious affiliation?.) | Question09/18/23 1:18 AM EDT |
 | I’m Baptist. My faith is a big part of my life–when things get hard like they’ve been this past year, I know I can trust that God’s looking out for me. I’ve been going to the same church since I was a kid, too, so the people at church are practically part of my family. (Clarified to what religion I am.) | |
 | I agree. Church can be a strong social support system | Educate09/18/23 1:19 AM EDT |
 | Sure, I think I understand what you mean. | |
 | Have you experienced abuse before | Question09/18/23 1:19 AM EDT |
 | No, no way. I’ve never been hurt or anything in the way that you’re talking about. | |
 | Do you drink alcohol | Question09/18/23 1:20 AM EDT |
 | I do sometimes, yeah, when I go out with my friends. | |
 | How often do you go out to drink (Clarified to How often do you go to the bar with friends?.) | Question09/18/23 1:20 AM EDT |
 | Not much. I go out for drinks with friends maybe a couple times a month. (Clarified to how often I go to the bar with friends.) | |
 | How much alcohol do you take in one sitting | Question09/18/23 1:21 AM EDT |
 | 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. | |
 | When last did you drink alcohol (Clarified to When did you last drink alcohol?.) | Question09/18/23 1:21 AM EDT |
 | I haven’t had any alcohol in at least three weeks. (Clarified to when I last drank alcohol.) | |
 | Alcohol intake is not good for your health. Try and eliminate it from your diet | Educate09/18/23 1:22 AM EDT |
 | Thanks for telling me. | |
 | Do you use any other illegal substances | Question09/18/23 1:22 AM EDT |
 | Well, I used to smoke pot. . . but I don’t do that anymore. | |
 | When was the last time you smoked pot | Question09/18/23 1:22 AM EDT |
 | I haven’t smoked pot since I was twenty or twenty-one. | |
 | What made you stop using pot | Question09/18/23 1:22 AM EDT |
 | I guess I started smoking it because my friends were, and there was a while there when it could be pretty fun. | |
 | Why did you stop smoking marijuana | Question09/18/23 1:23 AM EDT |
 | It just wasn’t that fun anymore, plus it started to bother my asthma. | |
 | Do you smoke tobacco | Question09/18/23 1:23 AM EDT |
 | No. I think it’s gross. | |
 | Are you exposed to second hand tobacco smoke | Question09/18/23 1:24 AM EDT |
 | Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes. | |
 | it is advisable that you stay a distance from your friends whenever they are smoking. Tobacco is not good for your health, given as you have asthma. | Educate09/18/23 1:24 AM EDT |
 | Sure, I think I understand what you mean. | |
 | Do you use e-cigarettes | Question09/18/23 1:25 AM EDT |
 | No. I think it’s gross. | |
 | Do you take fast foods (No matching questions found.) | Question09/18/23 1:28 AM EDT |
 | Do you eat fast foods | Question09/18/23 1:28 AM EDT |
 | I probably have fast food a few times a week, usually when I’m on campus. Sometimes I don’t bring a lunch, and I get so starving I have to get something from one of the places around campus. | |
 | Do you exercise | Question09/18/23 1:30 AM EDT |
| I don’t have the energy to go to a gym or anything after work…I’m pretty exhausted by the end of the day. But I’m on my feet all the time at work so I feel like that’s a little bit of exercise most days at least. | ||
 | Exercise is good for the body. You do not have to go to the gym to exercise. Simple things such as walking are enough exercise when done correctly. | Educate09/18/23 1:31 AM EDT |
| OK, I understand. | ||
 | Are you sexually active | Question09/18/23 1:31 AM EDT |
 | Um, not right now. | |
 | Tell me about your mother’s health? | Question09/18/23 1:33 AM EDT |
 | Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. | |
 | Tell me about your father’s health | Question09/18/23 1:33 AM EDT |
 | He had high blood pressure and cholesterol, and diabetes too. | |
 | Is your father deceased | Question09/18/23 1:34 AM EDT |
 | He passed last year. | |
 | Am sorry to hear that. | Empathize09/18/23 1:34 AM EDT |
| Thanks. | ||
 | What was your father’s cause of death | Question09/18/23 1:34 AM EDT |
| He died in a car accident. | ||
 | That was really tragic. | Empathize09/18/23 1:34 AM EDT |
 | I appreciate you saying that. | |
 | How old was he at the time of his death | Question09/18/23 1:34 AM EDT |
 | My mom is still alive, thank God! | |
 | How old was your father when he died | Question09/18/23 1:35 AM EDT |
 | Last year when Dad passed, he was only 58. | |
 | How do you cope with your father’s death | Question09/18/23 1:35 AM EDT |
 | Well, right after he died, after the funeral and everything, I just tried to get through that. Mom was having such a hard time, crying a lot, everything made her sad, she was kinda depressed. So I guess at first I just focused on getting things done–groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kinda helped me get through day by day. There was about a month where it was hard for us to get to church. Even getting up and ready for church was too overwhelming. But our church family helped us out, and gave us rides to church and brought meals and all that, so they really helped build us back up. Things were only hard like that for a few months. | |
 | Am sorry you and your family had to go through all that. It is good you are now managing well. | Empathize09/18/23 1:36 AM EDT |
 | I appreciate you telling me that. | |
 | Tell me about your paternal grandfather’s health | Question09/18/23 1:37 AM EDT |
| 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. | ||
| Am so sorry to hear that you lost Grandpa Jones to colon cancer. It must have been a difficult time for you and your family (No matching questions found.) | Question09/18/23 1:38 AM EDT | |
| Am so sorry to hear that you lost Grandpa Jones to colon cancer. It must have been a difficult time for you and your family | Empathize09/18/23 1:38 AM EDT | |
| Thanks for saying that. | ||
| How old was Grandpa Jones when he died | Question09/18/23 1:38 AM EDT | |
| Let me think. He died when I was really little… I think he was in his mid-sixties. He died of colon cancer. | ||
| Tell me about your paternal grandmother’s health | Question09/18/23 1:39 AM EDT | |
| Granny is my only grandparent who’s still alive. . . she’s my dad’s mom. She’s 82. She has high blood pressure and cholesterol, but otherwise she’s doing pretty well. | ||
| Tell me about your maternal grandfather’s health | Question09/18/23 1:39 AM EDT | |
| Well, Poppa died about five years ago. | ||
 | Did Poppa have any health issues | Question09/18/23 1:40 AM EDT |
| Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too. | ||
| Am sorry to hear that | Empathize09/18/23 1:40 AM EDT | |
| Thanks for understanding. | ||
| Tell me about your maternal grandmother’s health | Question09/18/23 1:40 AM EDT | |
| Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. | ||
| Am sorry you had to lose Nana to stroke. That must be a difficult moment in your lives | Empathize09/18/23 1:41 AM EDT | |
| I appreciate you telling me that. | ||
| Tell me about your brother’s health | Question09/18/23 1:41 AM EDT | |
| He’s a healthy guy. Kinda big like me. | ||
| Tell me about your sister’s health | Question09/18/23 1:42 AM EDT | |
| She’s pretty healthy. She has asthma too, but she almost never has attacks. | ||
| Is there a history of obesity in your family | Question09/18/23 1:42 AM EDT | |
| No, I don’t think so. My brother and my dad are kind of big, but I wouldn’t say they were obese or anything. | ||
| Does your family have a history of thyroid issues | Question09/18/23 1:43 AM EDT | |
| No, I don’t think so. | ||
| Does your family have a history of substance abuse | Question09/18/23 1:43 AM EDT | |
| No, no drugs in my family. The only thing like that is that one of my uncles is an alcoholic. | ||
| Does your family have a history of headache problems | Question09/18/23 1:43 AM EDT | |
| No, not that I know of. | ||
| Do you often feel tired or fatigued | Question09/18/23 1:44 AM EDT | |
| Most days I feel pretty exhausted by the end of the day…I’m tired now, too, but I think that’s just because I slept terribly. | ||
 | Am sorry to hear that | Empathize09/18/23 1:45 AM EDT |
 | I appreciate you saying that. | |
 | feeling tired or fatigued for most part of the day could be a result of different factors. I will help you establish any, then work towards mitigating it. | Educate09/18/23 1:45 AM EDT |
 | Alright, thanks for letting me know. | |
| Tell me about your sleep pattern | Question09/18/23 1:46 AM EDT | |
| I try to be in bed by eleven or midnight, and I get up at seven or eight. | ||
 | It is advisable that one gets a minimum of 7 to 8 hours of sleep every night. | Educate09/18/23 1:46 AM EDT |
 | That makes sense. | |
 | Do you have any trouble falling asleep | Question09/18/23 1:47 AM EDT |
 | I usually sleep pretty well, but the last couple nights the pain has made it hard to get good sleep. | |
 | Do you have a fever | Question09/18/23 1:47 AM EDT |
 | I don’t feel feverish right now, but last night I had a high temperature. | |
 | Do you experience chills | Question09/18/23 1:47 AM EDT |
 | I got some chills last night, before my fever really kicked in. | |
 | Do you sweat at night | Question09/18/23 1:47 AM EDT |
 | I don’t get sweaty, but sometimes I wake up hot and have to kick off my sheets. | |
 | Tell me about your mental health status (Clarified to How is your mental status?.) | Question09/18/23 1:47 AM EDT |
 | My mental status? I’m not crazy! (Clarified to how my mental status is.) | |
 | Do you feel depressed sometimes | Question09/18/23 1:48 AM EDT |
 | No, I don’t tend to feel depressed. | |
 | Do you ever feel like you want to commit suicide | Question09/18/23 1:48 AM EDT |
 | No, no. I don’t have feelings like that. God never gives you more than you can bear, you know? | |
 | Do you experience headaches | Question09/18/23 1:48 AM EDT |
 | Yeah, I get them a lot when I’m studying. | |
 | Do you currently have a headache | Question09/18/23 1:49 AM EDT |
 | No, I’m fine right now. | |
 | Have you ever had a head injury | Question09/18/23 1:49 AM EDT |
 | No. | |
 | Have you noticed any recent change in your hearing (Clarified to Have you had changes in your hearing?.) | Question09/18/23 1:49 AM EDT |
 | No. (Clarified to if I have had changes in my hearing.) | |
 | Does your ears ring | Question09/18/23 1:50 AM EDT |
 | No, I haven’t heard anything like that. | |
 | Do you experience ear pain | Question09/18/23 1:50 AM EDT |
| No. | ||
 | Do you have any discharge from your ears. | Question09/18/23 1:50 AM EDT |
 | No. | |
 | Have you had any issues with your eyesight | Question09/18/23 1:50 AM EDT |
 | I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry. | |
 | Am sorry to hear that. I will make sure we find a solution’ | Empathize09/18/23 1:51 AM EDT |
 | Thanks. | |
 | Do you wear corrective lenses | Question09/18/23 1:51 AM EDT |
| I don’t wear contacts or glasses, no. | ||
| Does your eyes feel itchy at times | Question09/18/23 1:51 AM EDT | |
| No. That only happens around cats or dust. | ||
| Do you experience eye redness (Clarified to Do you have eye redness?.) | Question09/18/23 1:52 AM EDT | |
 | No. I only really have that problem around cats. . . or sometimes dust. (Clarified to if my eyes get red.) | |
| Does your eyes have frequent discharge or wateriness | Question09/18/23 1:52 AM EDT | |
 | No. Well, unless I’m around cats. Then they get a little watery. | |
| Any eye pain | Question09/18/23 1:52 AM EDT | |
| I guess it’s not eye pain exactly, but when I read for too long I’ll start to get a headache. | ||
| Does your eyes feel dry sometimes | Question09/18/23 1:53 AM EDT | |
 | No. | |
 | Do you have any problems with your nose | Question09/18/23 1:54 AM EDT |
 | My nose is fine right now. Sometimes it runs, but not very often. | |
 | Do you experience sinus problems (No matching questions found.) | Question09/18/23 1:54 AM EDT |
| Do you have sinus problems | Question09/18/23 1:54 AM EDT | |
| Not really. Just a runny nose sometimes around cats. | ||
| Do you nosebleed | Question09/18/23 1:54 AM EDT | |
| No. | ||
| have you noticed any recent change in your sense of smell (Clarified to Has your sense of smell changed?.) | Question09/18/23 1:55 AM EDT | |
| No. (Clarified to if my sense of smell has changed.) | ||
 | Do you have any mouth issues | Question09/18/23 1:55 AM EDT |
| No. | ||
| Any dental problems | Question09/18/23 1:55 AM EDT | |
| Nope, no problems. | ||
| Any recent change in your sense of taste | Question09/18/23 1:56 AM EDT | |
| No, I think my sense of taste is fine. | ||
| Does your mouth fee dry sometimes | Question09/18/23 1:56 AM EDT | |
| No. | ||
| Do you have mouth sores | Question09/18/23 1:56 AM EDT | |
 | Nope. | |
 | Any gum problems | Question09/18/23 1:56 AM EDT |
 | No. | |
 | Any tongue problems | Question09/18/23 1:56 AM EDT |
 | Nope. | |
| Any problems with your jaw | Question09/18/23 1:57 AM EDT | |
| Nope. | ||
| Do you have any issues with your neck | Question09/18/23 1:57 AM EDT | |
 | Sometimes I get a crick in it when I’m reading, but nothing serious. | |
 | Any difficulty swallowing | Question09/18/23 1:58 AM EDT |
 | Nope. | |
 | Any problems with your lymph nodes | Question09/18/23 1:58 AM EDT |
 | No. | |
| Do you get frequent sore throats | Question09/18/23 1:58 AM EDT | |
 | No, I haven’t had a sore throat in awhile. | |
 | Do you have any swollen glands | Question09/18/23 1:58 AM EDT |
 | No, not that I noticed. | |
 | Any recent changes in your voice (Clarified to Have you had changes in your voice?.) | Question09/18/23 1:58 AM EDT |
 | No. (Clarified to if I have had changes in my voice.) | |
 | Tell me about your breast health (Clarified to How are your breasts?.) | Question09/18/23 1:59 AM EDT |
 | Fine, I’m sure. (Clarified to how my breasts are.) | |
 | Do you occasionally self examine your breasts (Clarified to Do you perform breast self-exams?.) | Question09/18/23 1:59 AM EDT |
 | Uh, I guess I tried a couple of times, but I didn’t really know what I was looking for. (Clarified to if I perform breast self exams.) | |
 | Self breast exam involves touching your breasts to feel for lumps, changes in the shape and size of the nipple, or even if there is an unusual discharge. | Educate09/18/23 2:01 AM EDT |
| Thanks for telling me. | ||
 | Any swelling in your breasts | Question09/18/23 2:01 AM EDT |
| No, no problems in that area. | ||
 | Any rashes in your breasts | Question09/18/23 2:01 AM EDT |
 | I don’t have any rashes. | |
 | Any discharge from the nipples | Question09/18/23 2:01 AM EDT |
 | Uh, no, definitely not. | |
| Have you ever had a mammogram | Question09/18/23 2:02 AM EDT | |
| I haven’t had a mammogram. I’ve just had the exam where the doctor felt around for lumps. | ||
 | Do you have a history of breast cancer | Question09/18/23 2:02 AM EDT |
| No, never. Thank God! | ||
| Do you have any breathing problem currently | Question09/18/23 2:03 AM EDT | |
 | No, my breathing is fine right now. | |
| Any wheezing currently | Question09/18/23 2:04 AM EDT | |
| Not right now. | ||
| Any current chest tightness (Clarified to Does your chest feel tight?.) | Question09/18/23 2:04 AM EDT | |
| Not right now. . . my chest gets tight, like I can’t take in air, when I have asthma problems, though. (Clarified to if I have tightness in my chest.) | ||
| Do you feel any pain when breathing (Clarified to Do you have pain when you breathe?.) | Question09/18/23 2:04 AM EDT | |
| No. (Clarified to if it hurts to breathe.) | ||
| Do you have frequent coughs | Question09/18/23 2:04 AM EDT | |
 | I wouldn’t say that. | |
| Do you current have any chest pain or discomfort | Question09/18/23 2:05 AM EDT | |
| No, my chest feels tight when I have breathing problems, but it doesn’t hurt. | ||
| Any palpitations | Question09/18/23 2:06 AM EDT | |
 | No, I haven’t had those. | |
 | Do you have irregular heartbeat | Question09/18/23 2:06 AM EDT |
 | I think my heart’s fine. I don’t really notice how it beats. | |
 | Do you bruise easily | Question09/18/23 2:06 AM EDT |
 | I don’t think so, no… I don’t hurt myself very often. | |
 | Any edema | Question09/18/23 2:06 AM EDT |
 | Yeah, it looks swollen around the scrape. | |
 | Any circulation problems | Question09/18/23 2:07 AM EDT |
 | I don’t think I have any circulation problems. |