Assignment 2: Digital Clinical Experience (DCE): Health History Assessment

NURS 6512 Assignment 2: Digital Clinical Experience (DCE): Health History Assessment


Chief Complaint (CC): “I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now is looking pretty nasty.”

History of Present Illness (HPI): Tina Jones is a 28-year-old African-American woman who visits today with an infected wound on her right foot. Her injury occurred one week ago when she was working on a ladder. She went to the emergency room, where an x-ray was taken. The patient did not have a fracture, and she was given pain medicine. Presently, the foot pain is 7 out of 10. White or yellow pus is presently draining from the wound, but there is no apparent odor. Tina began detecting pus around two days ago and has not stopped since. Tina has been taking care of the wound at home using Neosporin ointment for the last several days.


  • Albuterol inhaler 90micrograms/spray2-3 puffs

    Assignment 2 Digital Clinical Experience (DCE) Health History Assessment
    Assignment 2 Digital Clinical Experience (DCE) Health History Assessment
  • Tramadol 50mg1-2 pills 3 times a day
  • Advil 200mg
  • Tylenol 500mg1-2 tablets


  • Penicillin: rash
  • Cats: difficulty breathing, itchy eyes, sneezing.
  • Dust: asthma attack

Past Medical History (PMH):

  • Asthma
  • Diabetes type 2

Past Surgical History (PSH):

No surgical history.

Sexual/Reproductive History:

  1. Reports she has not been sexually active for 2years. She has had three sexual partners
  2. Heterosexual
  3. Has never been pregnant.
  4. Has a menstrual cycle that is irregular. The last time she had a period was three weeks ago. The cycle is every 6
    Assignment 2 Digital Clinical Experience (DCE) Health History Assessment
    Assignment 2 Digital Clinical Experience (DCE) Health History Assessment

    weeks to 2 months. The menstrual period lasts around 9 days. Her period is heavy for the first 4-5 days, and she needs to replace her tampon every 2-3 hours. She claims that she uses the high-absorbency tampons to reduce the number of tampon changes she has to do each day. Denies having ever had anemia. Takes Advil for cramps during her cycle

  5. She stopped using the contraceptive pill once she no longer had sexual relations with her past sexual partner.
  6. The last time she had a STI test was four years ago. Denies any signs or symptoms of a sexually transmitted infection.

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Personal/Social History:

Denies having ever smoked or chewed tobacco. Acknowledges smoking marijuana on an occasional basis in the past. Admits to use 1-2 alcoholic drinks per week. She is a student pursuing a bachelor’s degree in accounting.  Full-time employee and does not have any financial or transportation hindrances to receiving healthcare. Lives at home with her mother and sister.

Immunization History:

  • Got a tetanus booster one year ago.
  • Has not had annual flu shot.
  • Up to date childhood immunizations.

Health Maintenance:

The last time she visited the dentist was a couple of years ago. Because she does not have dental insurance, she does not see the dentist for an annual cleaning. Two years have passed since her last checkup. No existing primary care provider

Significant Family History:

 Father: died at 58 in a car accident, hypertension diabetes, high cholesterol

 Mother: high cholesterol and hypertension,

  Sister:  History of Asthma

Brother: overweight

Paternal grandmother: still living, age 82, hypertension

Paternal grandfather: Died of colon cancer, history of diabetes

Maternal grandfather: Died of stroke, history of hypertension

Maternal grandmother: died of stroke

Review of Systems:

General: Reports recent weight loss. Denies fatigue

HEENT: headache when reading or reading as a strong, striking feeling behind the eyes. Denies dizziness or head injuries.

 Eyes/ Vision: denies blurred vision becomes blurred when reading and studying. This has only gotten worse in the last few years. She does not wear eyeglasses or contacts. She denies eye pain. There is no history of glaucoma or cataracts in the family. The last visit to the eye doctor or examination is when she was a child.

Ear/Hearing: Denies changes in hearing, crying or balance problems, denies any recent ear infections, denies ear pain, denies any ear surgery.

 Nose/smelling: Denies any changes in the nose. Denies losing the sense of smell, denies nasal pain, denies nosebleeds, or sinus infections.

The mouth / throat: No chewing or swallowing problems, denies changes in taste. She denies reports of dry mouth.

 Neck:  Denies any problems with swallowing, sore throat, lymph nodes, or swollen glands.

Breasts: she denies pain or tenderness only in her period. She denies any discharge from the breasts. She denies lumps on her breasts.

Respiratory: Breathing has been good for the past few days but become short of breath if have asthma attack, denies coughing. The last full attack was in high school. Got an asthma attack three days ago. Asthma started with cats and dust presence. During Asthma attack experience tightness of the chest and throat as well as shortness of breath.

Cardiovascular/Peripheral Vascular: Denies reports of chest pain, denies heartbeat or complaints. There is no swelling of the leg, only under the right foot. Denies HTN history or heart disease. No EKG done.

Gastrointestinal: denies nausea, vomiting or abdominal pain, denies blood in the feces. She had lost an unspecified weight of 10lbs over a month. denies any hemorrhoids, denies constipation or loose stools.

Genitourinary: has periods of urination frequency. Denies hematuria. Takes Advil with stomach cramps.

Musculoskeletal: Denies muscle weakness. no history of arthritis or gout. denies a history of fracture or trauma. There are no problems with various movements other than the right foot due to injury.

Psychiatric: denies hx anxiety. She experienced episodes of depression when father died and part of it was realized as part of the mourning process. Sleep like 6 or 7 hours a night.

Neurological: Negative history of stroke, headache while studying or studying. Denies tremors and fainting.

Skin: A wound on the right foot, reports skin aging on the neck. Concerns about hair on the chin, shin and abdomen otherwise no problems.

Hematologic: denies any harm. denies disruption of clots. denies anemia.

Endocrine: history of type 2 diabetes diagnosed 2 years ago.

Obesity remains one of the most common chronic diseases in the United States. As a leading cause of United States mortality, morbidity, disability, healthcare utilization and healthcare costs, the high prevalence of obesity continues to strain the United States healthcare system (Obesity Society, 2016).  More than one-third (39.8%) of U.S. adults have obesity (CDC, 2018). The estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S. dollars; the medical costs for people who are obese were $1,429 higher than those of normal weight (CDC, 2018).

According to the Centers for Disease Control and Prevention (CDC), the rate of childhood obesity has tripled in the past 30 years, with an estimated 13.7 million children and adolescents considered obese (CDC, 2018). When seeking insights about a patient’s overall health and nutritional state, body measurements can provide a valuable perspective. This is particularly important with pediatric patients. Measurements such as height and weight can provide clues to potential health problems and help predict how children will respond to illness. Nurses need to be proficient at using assessment tools, such as the Body Mass Index (BMI) and growth charts, in order to assess nutrition-related health risks and pediatric development while being sensitive to other factors that may affect these measures. Body Mass Index is also used as a predictor for measurement of adult weight and health.