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Health History Tips & Tricks:
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Student: Hello!
Diana Shadow: Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.

Student: What is the situation?
Diana Shadow: Your patient is Tina Jones:, a 28-year-old African American woman who has just been admitted to Shadow General Hospital for a painful foot wound. Your role in this simulation is that of a healthcare provider who will take Ms. Jones’ health history, a key component of her admission process.

Student: What are my objectives in this assessment?
Diana Shadow: A health history requires you to ask questions related to Ms. Jones’ past and present health, from her current foot wound to her pre-existing conditions. You will also want to review Ms. Jones’ systems, psychosocial history, and family medical history. These assessments together will give you a comprehensive picture of Ms. Jones’ overall health. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. Throughout the conversation, you should educate and empathize with Ms. Jones when appropriate to increase her health literacy and sense of well-being. Regardless of whether you have assessed Ms. Jones previously, ask all questions that are necessary for obtaining a complete health history. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed. After obtaining Ms. Jones’ health history, you will complete an information processing activity. You will identify and prioritize diagnoses, then create a plan to address the identified diagnoses.

Student: What else will this exam involve?
Diana Shadow: You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Besides Subjective Data Collection, and Education and Empathy, there are activities within the simulation that provide valuable practice for their real-world counterparts, but they are not automatically graded by the simulation.

Student: How will I be evaluated?
Diana Shadow: In this assignment, you will be evaluated on your Subjective Data Collection, as well as your Education and Empathy. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. You will also be evaluated on your ability to collect data and form nursing diagnoses in the information processing activity. This assignment takes on average between 90 and 110 minutes. This exam may take longer than in real life, because in this safe simulation, students of all experience levels can take time to hone and review their skills. You can pause and resume the assignment at any time; your work is always saved automatically.

Student: How does this assignment prepare me for the real world?
Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient’s risk of disease, infection, injury, and complications º educate and empathize º reflect on your experience and identify areas to improve º identify and prioritize nursing diagnoses º and develop a plan to address nursing diagnoses.

Diana Shadow: In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Why is it important to obtain a patient’s complete health history?
Student: So that you understand if there are any problems related to their chief complaint. Also, to help treat their current condition.

Diana Shadow: Time to begin.
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Patient Exam – Vital Signs:
Height: 170 cm, Weight: 90 kg, BMI: 31, Random blood glucose: 238, Temperature: 102.4° F, Blood pressure: 138/90 mmHg, Heart rate: 90, Respiratory rate: 18, O2 sat: 98%

Patient Exam – Interview:
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Student: Hello, my name is Catlain, I am your nurse today.
Tina Jones: Hey.

Student: Can you confirm your name?
Tina Jones: Tina Jones:.

Student: Why did you come in today?
Tina Jones: I got this scrape on my foot a while ago, and it got really infected. It’s killing me.

Student: What additional symptoms have you experienced?
Tina Jones: I mean, it’s all red and swollen, and there’s pus, it feels hot, it hurts like hell… It’s got all that going on.

Student: Can you rate your current pain level on a scale of 0 to 10?
Tina Jones: …Like a 7. It hurts a lot, but whatever pain med the ER gave me is helping a little bit.

Student: Please describe the pain.
Tina Jones: It’s throbbing and like, sharp if I try to put weight on it.

Student: How did you hurt your foot?
Tina Jones: I was changing a light bulb, and I had to use our little stepstool to reach it. My foot slid off the bottom step and it got all scraped up. I didn’t realize how sharp the edge was!

Student: Has your foot been draining any liquids?
Tina Jones: Yeah, there’s definitely pus.

Student: What color was the pus?
Tina Jones: It’s… white or maybe off-white.

Student: How have you treated the wound?
Tina Jones: I’ve been taking Advil for my foot for a few days.

Student: What did you do to treat your foot after your accident?
Tina Jones: I made sure to clean it and keep it bandaged. And I put Neosporin on it.

Student: How effective was the Neosporin?
Tina Jones: Well, I’m here, so I guess it didn’t do its job.

Student: Can you walk with your foot being injured?
Tina Jones: No, I can’t. I can’t put any weight on it without like, shooting pain.

Student: What preexisting medical conditions do you have?
Tina Jones: I mean, I have asthma and diabetes, but right I now I just care about my foot!

Student: I understand your foot hurts, but I need to know this information to make sure I take care of the problem correctly.
Tina Jones: Thanks.

Student: When were you diagnosed with diabetes?
Tina Jones: I was diagnosed when I was 24.

Student: What do you do to manage your asthma?
Tina Jones: I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

Student: What medications did you take for your diabetes?
Tina Jones: It was metformin.

Student: Do you currently take medicine for your diabetes?
Tina Jones: No, I don’t take anything for my diabetes anymore.

Student: What made you stop taking medication for your diabetes?
Tina Jones: I guess I just got sick of feeling sick and gassy all the time, and it was overwhelming, remembering to take pills and check my sugar. I feel a lot better now that I’m just eating healthier than I did when I was taking the pills.

Student: Do you monitor your blood glucose?
Tina Jones: I have a monitor at home, but to be honest I don’t really use it that often.

Student: How frequently do you urinate?
Tina Jones: I don’t know. Every hour or two when I’m awake?

Student: What is your current diet?
Tina Jones: It’s pretty good, I think. I’m not a huge health nut or anything.

Student: Have you had any change in appetite?
Tina Jones: Yeah, lately I’ve definitely been much hungrier than usual.

Student: Has your weight changed?
Tina Jones: Yeah, I’ve lost some weight recently.

Student: Do you know why you lost weight?
Tina Jones: I don’t know what caused it, I just lost weight.

Student: How often do you have asthma exacerbations?
Tina Jones: I haven’t had a full attack in years. But my breathing definitely acts up. . .not always. Max twice a week.

Student: What asthma symptoms have you experienced?
Tina Jones: 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.

Student: How many puffs do you take when using your asthma inhaler?
Tina Jones: I usually use two puffs from my inhaler, but sometimes I need three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]

Student: What are some things that trigger your asthma?
Tina Jones: Being around cats is the worst, but dust and running up stairs can make my breathing bad, too.

Student: What allergies do you have?
Tina Jones: I’m allergic to cats.

Student: When did you realize you were allergic to cats?
Tina Jones: For as long as I’ve been around.

Student: How effective was your pain medication at home?
Tina Jones: Whatever pain medication the ER gave me is helping. Before I came in, I was just taking Advil. For the past few days, the Advil wasn’t doing much for me — it would only last a couple of hours.

Student: What medication allergies do you have?
Tina Jones: I’m allergic to penicillin.

Student: What food allergies do you have?
Tina Jones: I don’t have any food allergies that I know of.

Student: Are you allergic to dust, mold, or pollen?
Tina Jones: Well. . . I don’t know if it’s allergies, but sometimes my asthma acts up around dust.

Student: What immunizations have you received?
Tina Jones: 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.

Student: Have you received a flu vaccine?
Tina Jones: No.

Student: Have you had any prior hospitalizations?
Tina Jones: Well, before this I went a bunch of times when I was little, for asthma attacks. This is the first time I’ve been in the hospital since I was probably sixteen, though.

Student: Have you had any gastrointestinal problems?
Tina Jones: No. I’ve never really had stomach or bowel problems.

Student: Do you have a family history of psychiatric illness?
Tina Jones: No. They’re crazy, but nobody’s diagnosed with anything.

Student: Do you have any neck, throat or gland problems?
Tina Jones: No, not that I noticed.

Student: Do you have any problems with your head?
Tina Jones: I don’t think I have any problems. I get headaches sometimes, but that’s all.

Student: Any problems with your ears?
Tina Jones: No.

Student: Any problems with your eyes and vision?
Tina Jones: I’ve actually been noticing problems lately. When I’m reading or studying I’ll notice that things start to get kind of blurry.

Student: Any problems with your nose?
Tina Jones: My nose is fine right now. Sometimes it runs, but not very often.

Student: Do you have problems with your mouth?
Tina Jones: No.

Student: Do you have a history of cardiovascular problems?
Tina Jones: My heart’s fine, thank God!

Student: Any problems with your heart?
Tina Jones: No, my heart’s always been fine.

Student: Have you had any problems with your breasts?
Tina Jones: I haven’t noticed any pain there.

Student: Have you had any reproductive problems?
Tina Jones: I don’t think I have problems in that area. I just get really bad periods, that’s all.

Student: Have you had any neurological problems?
Tina Jones: No, I haven’t.

Student: Have you had any musculoskeletal problems?
Tina Jones: No.

Student: Do you have a history of skin disease?
Tina Jones: Um, I have acne, if that counts.

Student: Does your paternal grandfather have any health problems?
Tina Jones: 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. And high cholesterol like everyone else in my family.

Student: Does your mother have any health problems?
Tina Jones: Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

Student: Does your father have any health problems?
Tina Jones: Well, he passed away. But he had a couple things… Type 2 diabetes, like me, and high cholesterol and blood pressure.

Student: How did your father die?
Tina Jones: He died in a car accident.

Student: Where is your wound located?
Tina Jones: It’s on the ball of my foot.

Student: Do you get thirsty often?
Tina Jones: You know, I did notice lately that I’ve been really thirsty.

Student: What happened with your father’s car accident?
Tina Jones: It was last year… I guess a little over a year ago.

Student: How long ago was your dad’s car accident?
Tina Jones: It was last year… I guess a little over a year ago.

Student: How did you cope with your fathers death?
Tina Jones: 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 kind of depressed. So, I guess at first I just focused on getting things done–groceries, laundry, insurance papers and stuff. Knowing that Mom needed me kind of 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.

Student: What caused your dads accident?
Tina Jones: He was driving to work, and it was raining…and his car hydroplaned. And hit a tree. So, it was really sudden.

Student: How is your paternal grandmother’s health?
Tina Jones: Granny’s doing good. She’s still living on her own. She’s slowing down, but we help her out. She lives down the street from us, and she gets around okay. I think she takes some pills, maybe for blood pressure? She might have high cholesterol too. She seems happy.

Student: How is your paternal grandfather’s health?
Tina Jones: Grandpa Jones passed away when I was really little.

Student: How is your maternal grandfather’s health?
Tina Jones: Well, Poppa died about five years ago.

Student: How is your maternal grandmother’s health?
Tina Jones: Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.

Student: How is your brother’s health?
Tina Jones: He’s a healthy guy. Kind of big like me.

Student: How is your sister’s health?
Tina Jones: She’s pretty healthy. She has asthma too, but she almost never has attacks.

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:
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Chief Complaint
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Finding: Established chief complaint
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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: Do you have any 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.
Example Question: What’s causing your pain?

History of Presenting Illness
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Finding: Asked to rate current pain level on a scale
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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 rate the pain on a scale of 0 to 10?

Finding: Asked for details about the pain
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Finding: Reports pain is throbbing (Found)Pro Tip: Determining how your patient describes the characteristics of the pain can be important data to support the cause of the pain.
Example Question: Can you please describe the pain?

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: What is the pain like when you stand on your foot?

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: How has the pain changed over time?

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: Does the pain radiate anywhere else?

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: Can you bear weight on your foot?

Finding: Asked location of wound
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Finding: Reports right foot is injured (Found)Pro Tip: Confirming which extremity an injury is located is a best practice for your patient’s safety.
Example Question: Which foot is in pain?

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: Where is the wound?

Finding: Asked details of the injury
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Finding: Reports she scraped foot on bottom rung of a step stool (Found)Pro Tip: Discovering how an injury happened helps to assess your patient’s risk factors for injury.
Example Question: How did your injury happen?

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: When did your injury occur?

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: Did you injure anything besides your foot?

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: Were you wearing shoes when you fell?

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: Have you seen a healthcare provider for this injury?

Finding: Asked about drainage from the foot wound
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Finding: Reports that the wound bled a little after sustaining the injury (Available)Pro Tip: Asking about bleeding helps you determine the characteristics of a wound.
Example Question: Did your foot bleed?

Finding: Reports seeing pus draining from wound (Found)Pro Tip: Asking about discharge helps you determine the characteristics of a wound.
Example Question: Did you notice any discharge from the wound?

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: When did you first notice the pus?

Finding: Followed up on drainage
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Finding: Reports pus as white or yellow (Found)Pro Tip: The color of discharge from a wound can provide insight into its severity and characteristics.
Example Question: What color is the drainage from your wound?

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: Does the wound have an odor?

Finding: Asked about home treatment of foot wound
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Finding: Reports wound care regimen of bandaging (Available)Pro Tip: Asking specifically how often a patient changed a bandage will let you know if an infection spread through improper hygiene, or for other reasons such as uncontrolled blood sugar.
Example Question: How often do you change your bandage?

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: How often did you clean 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 you use any ointment on the wound?

Finding: Followed up on effectiveness of ointment
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Finding: Reports bacitracin, neomycin and polymyxin B (Neosporin) was ineffective (Found)Pro Tip: Understanding the effect of a home medication can help you determine the severity of the wound. Tina’s diabetes diagnosis will have a large impact on her body’s healing ability, which should be taken into consideration during your exam.
Example Question: Did the ointment help?

Finding: Asked about other foot wound symptoms
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Finding: Reports swelling around foot wound (Found)Pro Tip: Asking about the presence of swelling helps you gather information about your patient’s complaint, as well as potential related illnesses.
Example Question: Is there 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: How long have you noticed swelling 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: Did you notice any redness around the wound?

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 the wound feel warm?

Finding: Explored impact of patient’s foot injury on activities of daily living
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Finding: Reports pain affects ability to walk (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 walk or not, as a lack of mobility can compromise quality of life.
Example Question: Does your injury impact your ability to walk?

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: Does your foot pain affect your work?

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: Has your injury prevented you from going to class?

Past Medical History
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