Tina Jones Health History Simulation Part 2
Flashcards summarizing the full patient health history interview with Tina Jones during her hospital admission—covers medical background, symptoms, medications, and communication techniques for nursing assessments.
Student: Does your family have a history of obesity?
Tina Jones: 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.
Key Terms
Student: Does your family have a history of obesity?
Tina Jones: 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.
Student: Does your family have a history thyroid issue?
Tina Jones: No, I don't think so.
Student: Does your family have a history of substance abuse?
Tina Jones: One person in the family, my dad's brother, has an alcohol problem, but we never see him.
Student: Does your family have a history of headaches?
Tina Jones: No, not that I know of.
Student: How much alcohol do you drink?
Tina Jones: I only have a few drinks when I go out.
Student: What is your level of education?
Tina Jones: Well, I'm finishing up my bachelor's degree right now.
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| Term | Definition |
|---|---|
Student: Does your family have a history of obesity? | Tina Jones: 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. |
Student: Does your family have a history thyroid issue? | Tina Jones: No, I don't think so. |
Student: Does your family have a history of substance abuse? | Tina Jones: One person in the family, my dad's brother, has an alcohol problem, but we never see him. |
Student: Does your family have a history of headaches? | Tina Jones: No, not that I know of. |
Student: How much alcohol do you drink? | Tina Jones: I only have a few drinks when I go out. |
Student: What is your level of education? | Tina Jones: Well, I'm finishing up my bachelor's degree right now. |
Student: What are stressors? | Tina Jones: I feel really stressed out right now! Honestly, I didn't realize that I'd be admitted to the hospital for my foot. I don't want to miss work or school but now it looks like I'll have to. And I want my foot to stop hurting. I know I need sleep, too. |
Student: We are going to take care of everything as quickly as possible. | Tina Jones: Thanks. |
Student: Where do you live? | Tina Jones: Right now, I'm living at my mom's place, which is out in the suburbs a bit. It's like a half hour from here. |
Student: What is your belief system? | Tina Jones: 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. |
Student: Have you experienced abuse? | Tina Jones: I've never had been in any kind of situation like that... It's scary to think about. |
Student: Have you used illicit drugs? | Tina Jones: Well, I used to smoke pot. . . but I don't do that anymore. |
Student: What type of drugs did you use? | Tina Jones: Um...I've smoked pot before. In high school, and after high school... I definitely don't anymore, though. |
Student: Have you used drugs other than marijuana? | Tina Jones: No. |
Student: When did you last use drugs? | Tina Jones: I haven't smoked pot since I was twenty or twenty-one. |
Student: Have you ever smoked cigarettes? | Tina Jones: No. I think it's gross. |
Student: Have you been around people that are smoking? | Tina Jones: Some of my friend's smoke when we go out drinking. But I don't smoke, and nobody at home smokes. |
Student: How old were you when your father died? | Tina Jones: He died last year, so I was 27. |
Student: Did your father die from any disease? | Tina Jones: He died in a car accident. |
Student: Can you tell me about your father's health? | Tina Jones: He had high blood pressure and cholesterol. And diabetes -- we have diabetes in common. |
Student: I can't even imagine how you feel about losing your father | Tina Jones: Thanks. |
Student: Tell me about your father. | Tina Jones: Dad was a little stricter than Mom growing up. . . he would sometimes get kind of mad at us when we did something wrong. But he never hit us or anything. He would just get really calm and quiet and tell us to go to our rooms without supper, or that we were grounded when we were older. Or like, he'd make us rake the yard or wash his car or something. It's pretty sad to |
Student: How old was your father when he died? | Tina Jones: Last year when Dad passed, he was only 58. |
Subjective Data Collection - Checklist: | Chief Complaint |
Example Question: Do you have any pain? | Finding: Reports pain (Found)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: What's causing your pain? | Finding: Reports foot wound (Found)Pro Tip: If a patient mentions pain, it's important to determine what specifically is causing her pain, if she knows. |
Finding: Asked to rate current pain level on a scale | History of Presenting Illness |
Example Question: Can you rate the pain on a scale of 0 to 10? | Finding: Reports current pain is 7/10 (Found)Pro Tip: Asking your patient to rate her pain on a scale of 0 to 10 is important to gauge how it ebbs and flows while she is in your care. |
Example Question: Can you please describe the pain? | Finding: Asked for details about the pain |
Example Question: What is the pain like when you stand on your foot? | Finding: Reports pain is sharp when she attempts to stand (Found)Pro Tip: Determining what physical activities and movements exacerbate the patient's pain can help you better understand the problems and assess treatment needs. This can also alert you if a patient's activities of daily living are hindered. |
Example Question: How has the pain changed over time? | Finding: Reports pain has increased in the past 2 days (Available)Pro Tip:Finding out how the patient's pain has changed will give you insight into the acceleration of infection. |
Example Question: Does the pain radiate anywhere else? | Finding: Reports feeling pain radiating into ankle (Available)Pro Tip: Asking about where else the patient's pain radiates can help determine the progression of infection. |
Example Question: Can you bear weight on your foot? | Finding: Reports pain prevents bearing weight on foot (Found)Pro Tip: Determining if your patient can bear weight on an injury is important to determine their risk for falls while in your care. |
Example Question: Which foot is in pain? | Finding: Asked location of wound |
Example Question: Where is the wound? | Finding: Reports wound is on the plantar surface of her foot (Found)Pro Tip: Confirming where a wound is located ensures you are aware of your patient's biggest complaint. |
Example Question: How did your injury happen? | Finding: Asked details of the injury |
Example Question: When did your injury occur? | Finding: Reports injury occurred 1 week ago (Available)Pro Tip: Discovering how long ago the pain began is the first step in understanding whether the pain is chronic or acute. |
Example Question: Did you injure anything besides your foot? | Finding: Denies other injuries besides foot wound (Available)Pro Tip: Discovering additional injuries can reveal more information about the circumstances that caused the presenting injury. |
Example Question: Were you wearing shoes when you fell? | Finding: Reports being barefoot at the time of injury (Available)Pro Tip: Asking about clothing, footwear, and other protective elements being worn at the time of injury helps you discover the totality of the circumstances. |
Example Question: Have you seen a healthcare provider for this injury? | Finding: Denies seeing a healthcare provider for the injury until now (Available)Pro Tip: It's crucial to ask whether your patient has seen another provider for the injury, because any previous medical intervention will help you understand the progression of the wound. |
Example Question: Did your foot bleed? | Finding: Asked about drainage from the foot wound |
Example Question: Did you notice any discharge from the wound? | Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound. |
Example Question: When did you first notice the pus? | Finding: Reports noticing pus 2 days ago (Available)Pro Tip: Pinpointing exactly when the patient noticed the arrival of pus gives you an important data point for when an active infection began. |
Example Question: What color is the drainage from your wound? | Finding: Followed up on drainage |
Example Question: Does the wound have an odor? | Finding: Denies odor from the wound (Available)Pro Tip: The odor of discharge from a wound can provide insight into its severity and characteristics. |
Example Question: How often do you change your bandage? | Finding: Asked about home treatment of foot wound |
Example Question: How often did you clean the wound? | Finding: Reports cleaning wound twice a day (Available)Pro Tip: Asking specifically how often a patient cleaned a wound will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar. |
Example Question: Did you use any ointment on the wound? | Finding: Reports applying bacitracin, neomycin and polymyxin B (Neosporin) (Found)Pro Tip: Determining what products a patient used to sterilize or treat a wound establishes home care routines and health literacy. |
Example Question: Did the ointment help? | Finding: Followed up on effectiveness of ointment |
Example Question: Is there swelling around the wound? | Finding: Asked about other foot wound symptoms |
Example Question: How long have you noticed swelling around the wound? | Finding: Reports swelling worsened in the past 2 days (Available)Pro Tip:Finding out how long swelling appeared will help you understand the timeline for the infection progression. |
Example Question: Did you notice any redness around the wound? | Finding: Reports redness around the wound (Found)Pro Tip: Asking about redness will help you understand the timeline for the infection progression. |
Example Question: Does the wound feel warm? | Finding: Reports that the wound feels warm (Found)Pro Tip: Asking about warmth will help you understand the timeline for the infection progression. |
Example Question: Does your injury impact your ability to walk? | Finding: Explored impact of patient's foot injury on activities of daily living |
Example Question: Does your foot pain affect your work? | Finding: Reports pain affects ability to stand at work for long periods of time (Available)Pro Tip: Understanding the impact of your patient's wound on daily activities helps inform your plan for care. With a foot wound, it is imperative to discern if a patient can stand or not, as this can compromise quality of life and impact job performance. |
Example Question: Has your injury prevented you from going to class? | Finding: Reports pain prevented her from being able to walk to class (Available)Pro Tip: For patients who are also students, you can find out what schoolwork they are missing, and help them make accommodations so they don't fall behind. |
Example Question: Do you have any existing conditions? | Past Medical History |
Example Question: Do you have any other conditions? | Finding: Reports asthma (Found)Pro Tip: It is important to identify any existing medical conditions, such as Tina's asthma, because that information is an integral part of her health history. Existing conditions can also inform your treatment and understanding of the patient's current health issues. |
Example Question: At what age were you diagnosed with diabetes? | Finding: Followed up on diabetes diagnosis |
Example Question: Do you know what type of diabetes you have? | Finding: Reports that her diabetes is Type 2 (Available)Pro Tip: The type of diabetes your patient has will drastically affect how you care for her. |
Example Question: Tell me more about any sugars you consume. | Finding: Asked about diabetes management through lifestyle changes |
Example Question: Do you drink sugary drinks? | Finding: Reports drinking diet coke instead of regular (Available)Pro Tip: Particularly for diabetic patients, asking about intake of drinks that contain sugar can reveal additional sources of carbohydrates that the patient may not consider. |
Example Question: Do you take prescribed medication for your diabetes? | Finding: Asked about current diabetes medication use |
Example Question: Have you ever taken medication for your diabetes? | Finding: Asked about past diabetes medication use |
Example Question: Do you remember what you were prescribed for diabetes? | Finding: Reports previous medication was prescription metformin (Found)Pro Tip: Asking about a patient's medication history for a particular condition, such as Tina's past prescription for metformin, will provide a timeline of her asthma treatment. You will be able to see what has been effective and ineffective in the past, which will allow you to make a more informed decision about current treatment. |
Example Question: When was the last time you took your diabetes medication on a regular basis? | Finding: Reports last use of medication was 3 years ago (Available)Pro Tip: It important to discover when Tina stopped taking any medications and what caused her to stop. Discovering her reason for noncompliance will allow you to make a more informed decision about current treatment. |
Example Question: Did the metformin cause any side effects? | Finding: Followed up on stopping diabetes regimen |
Example Question: What's preventing you from taking your diabetes medication? | Finding: Reports that she didn't like checking sugar and taking daily pills (Found)Pro Tip: Asking reasons for noncompliance can reveal information about your patient's health literacy, side effects, financial situation, and more. |
Example Question: Tell me about your blood sugar monitoring. | Finding: Asked about blood glucose monitoring |
Example Question: How often do you check your blood sugar? | Finding: Reports she last checked blood sugar a month ago (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. |
Example Question: What are your usual blood sugar levels? | Finding: Reports confusion about what the numbers mean (Available)Pro Tip: Your patient's blood sugar monitoring habits are an important part of her health literacy and home treatment. If you find gaps in the patient's literacy, that is your opportunity to provide education. |
Example Question: Have you been more thirsty lately? | Finding: Asked about thirst |
Example Question: Are you drinking more water than normal? | Finding: Reports increased water intake (Available)Pro Tip: Your patient's fluid intake can offer insight into underlying medical conditions. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. |
Example Question: Have you been urinating more often than usual? | Finding: Asked about frequency of urination |
Example Question: How often do you urinate during the day? | Finding: Reports urinating every hour or two during the day (Found)Pro Tip: Your patient's urination habits can offer insight into underlying medical conditions and general health. Knowing that Tina is diabetic, you will want to explore this classic symptom of the condition. |
Example Question: How often do you wake up at night to urinate? | Finding: Reports urinating 2 to 3 times during the night (Available)Pro Tip: Discovering if Tina has nocturia can offer insight into underlying medical conditions and general health. |
Example Question: What did you eat for breakfast yesterday? | Finding: Asked about diet |
Example Question: What did you eat for lunch yesterday? | Finding: Reports eating mac and cheese for lunch yesterday (Available)Pro Tip: In a health history, it is important to get an idea of a patient's typical dietary patterns. This can be achieved by asking for a 24-hour diet recall. |
Example Question: What did you eat for your last meal? | Finding: Reports eating chicken and roll for dinner yesterday (Available)Pro Tip:Finding out the foods a patient last ate can provide evidence for any current stomach upset and for their current level of hunger and blood sugar status and can affect medications given while in your care. |
Example Question: Have you noticed an increase in appetite? | Finding: Asked about change in appetite |