Questions and Answers
Does your family have a history of thyroid issues?
No, I don't think so.
Does your family have a history of substance abuse?
One person in the family, my dad's brother, has an alcohol problem.
Does your family have a history of headaches?
No, not that I know of.
How much alcohol do you drink?
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What is your level of education?
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What are stressors?
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Where do you live?
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What is your belief system?
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Have you experienced abuse?
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Have you used illicit drugs?
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What type of drugs did you use?
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Have you used drugs other than marijuana?
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When did you last use drugs?
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Have you ever smoked cigarettes?
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Have you been around people that are smoking?
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How old were you when your father died?
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Did your father die from any disease?
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What does a health history require you to ask questions about?
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Who is the patient in this simulation?
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What should be the focus of the health history assessment?
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You can return to the instructions at any time during the simulation.
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What percentage of time is the assignment expected to take?
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What should you do if you discover any disease states during the health history?
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What medications did Tina Jones take for her diabetes?
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What allergies does Tina Jones have?
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What is Tina's current pain level on a scale of 0 to 10?
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What is Tina's height?
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What is Tina's weight?
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What does Tina state is making her foot infected?
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What did Tina Jones use to treat her wound?
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How does Tina describe the pain in her foot?
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What type of medical history does Tina Jones have regarding her family?
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Has Tina experienced gastrointestinal problems?
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Study Notes
Health History Overview
- Tina Jones is a 28-year-old African American woman admitted for a painful foot wound.
- Main objectives include obtaining a comprehensive health history covering past and present conditions, psychosocial history, and family medical background.
Patient Description
- Presenting issue: infected scrape on the foot described as red, swollen, with pus, hot to touch, and painful.
- Vital signs: Height 170 cm, Weight 90 kg, BMI 31. Blood glucose 238, Temperature 102.4°F, Blood pressure 138/90 mmHg, Heart rate 90, Respiratory rate 18, O2 saturation 98%.
Medical History
- Pre-existing conditions: asthma and diabetes (diagnosed at age 24).
- Currently not taking diabetes medication; previously managed with metformin.
- Reports increased thirst and hunger recently, along with weight loss.
Asthma Management
- Triggers include cats, dust, and physical exertion.
- Usual management entails using an inhaler, primarily albuterol, with two to three puffs as needed.
- Historical frequency of asthma exacerbations: max twice a week.
Family Medical History
- Grandfather had colon cancer, high blood pressure, and diabetes.
- Mother's health includes high cholesterol and blood pressure issues.
- Father passed away due to a car accident; had type 2 diabetes and high cholesterol.
- Grandmother living independently but has health concerns related to blood pressure and cholesterol.
Psychological and Social Aspects
- Coping with father's death a year ago, supports mother emotionally.
- Currently experiencing stress due to hospital admission impacting education and work.
- Strong faith as a Baptist provides emotional support through tough times.
Health Beliefs and Practices
- Proactive in managing wound initially with cleaning and Neosporin; ultimately deemed ineffective.
- Engages in healthy eating but lacks consistent monitoring of blood glucose levels.
Allergy Information
- Allergies identified: penicillin and cats.
- No known food allergies; occasional asthma symptoms may occur around dust.
Education and Lifestyle
- Currently completing a bachelor's degree.
- Engages socially, drinking alcohol occasionally but in moderation.
Conclusion
- Importance of thorough health history: establishes a comprehensive understanding of the patient's overall health, enabling accurate treatment and care planning.### Drug Use
- Tina Jones previously smoked marijuana but no longer engages in drug use.
- She experimented with pot during her high school years and shortly after, with a cessation around the age of twenty or twenty-one.
- Tina confirms she has not used any drugs other than marijuana.
Smoking Habits
- Tina Jones has never smoked cigarettes and finds the practice unappealing.
- Although she avoids smoking, she is around friends who smoke when they socialize, particularly while drinking.
Family Background
- Tina's father passed away last year when she was 27 years old.
- His death was due to a car accident, not an illness.
Studying That Suits You
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Description
Explore the key elements of health history taking with Tina Jones through these flashcards. Learn important tips and tricks for conducting a health interview effectively. This quiz will enhance your understanding and preparation for clinical assessments.
