Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
Transcript
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Hello, my name is . I will be conducting an interview and later perform a physical exam.
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Greet |
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Hey.
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What is your name?
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Question |
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Tina Jones.
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Your date of birth?
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February 17th.
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How old are you?
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I’m 28.
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What brought you into the clinic today?
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I came in because I’m required to have a recent physical exam for the health insurance at my new job.
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Do you have any current health problem?
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I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days.
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What is your new job? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
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I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–I’m really excited!
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That is great.
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Empathize |
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Thanks.
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When was your last physical exam?
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Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.
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What did your gynecologist say?
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She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things.
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How often do you take birth control?
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I take it every morning, with breakfast.
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What is the name of the birth control pill you took?
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They’re called Yaz.
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Has your menstrual cycle improved since taking Yaz?
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Now that I’m on the pill I’m getting my period every month.
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That is great. I am glad you are having your period every month.
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Empathize |
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Thanks.
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How long have you had asthma.
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I’ve had asthma a long time. . . since I was really little.
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What age were you diagnosed with asthma?
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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.
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I am sorry about the experience.
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Empathize |
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Thanks.
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How do you manage your asthma?
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I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
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What are your triggers for asthma?
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Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though.
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It is important to stay away from triggers.
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Educate |
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Thanks for telling me.
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What happens when you are around dust?
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I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler.
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What inhaler do you use?
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The daily inhaler is Flovent, and the rescue inhaler is Proventil.
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How often do you use flovent?
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Twice a day.
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When did you most recently use the flovent inhaler?
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I use my Flovent inhaler two times a day.
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When did you last use your inhaler?
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I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too.
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How much Albuterol do you use?
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I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church.
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What is your relationship like with your family?
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Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along.
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That is great.
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Empathize |
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Thanks.
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Are you involved in church?
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Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.
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Are you feeling stressed?
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I’m actually feeling really good lately. . . not stressed at all.
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How do you cope with stress?
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I’ve realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I’ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me.
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That is good to hear.
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Empathize |
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Thanks.
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Are you feeling depressed?
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No, I’m actually feeling really good these days.
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How do you feel about your life?
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Well, I’m starting my new job in two weeks, and I’m really excited about that. I’m going to be an Accounting Clerk at this really nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple years, I’ll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job.
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Are you feeling anxious?
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I guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though.
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Do you have sleeping problems?
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I’m sleeping a lot better now, which is a relief.
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Good to hear.
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Empathize |
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Thanks.
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How many hours are you sleeping a night?
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I’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night.
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That is great.
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Empathize |
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Thanks.
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Have you ever smoked tobacco?
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No. I think it’s gross.
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Have you ever used cocaine?
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No way, I have no interest in that. That stuff can mess you up.
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Have you ever used heroin?
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Uh, no.
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Have you ever used illegal drugs?
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Well, I used to smoke pot. . . but I don’t do that anymore.
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What was the last time you smoked pot?
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I haven’t smoked pot since I was twenty or twenty-one.
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Do you have any family history of mental illness?
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No. They’re crazy, but nobody’s diagnosed with anything.
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Have you had suicidal thoughts?
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No, I’ve never done that.
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Any new family medical history report?
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My mom has some issues, and I think some of my grandparents did, too.
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How old is your mom?
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Mom is 50.
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What medical problems does your mum have?
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Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
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What medical problems did your father have?
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He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
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How old is your brother?
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He’s almost 27.
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Does he have any medical issue? (Clarified to Does your younger sister have health problems?.)
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She’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.)
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Does your bother have health issues? (Clarified to Does your brother have medical problems?.)
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No, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.)
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How old is your maternal grandmother?
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Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.
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How old is your maternal grandfather?
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Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
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Any medical history for your paternal grandmother?
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She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.
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Does your dad’s father have health issues?
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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.
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Have you had any recent illness?
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No. . . the last time I was sick was when I was having those heartburn problems a while ago.
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Any fever?
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I haven’t had a fever.
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Any chills?
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Nope, no chills.
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Any acne?
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I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything special. But my zits have gotten better, and I think it’s because I’m on birth control now.
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Has your body hair improved?
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I think I have a little less body hair than I used to.
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Do your eyes feel itchy?
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They haven’t been itchy lately at all.
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Are you having any redness in your eyes?
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My eyes haven’t been red lately. . . not since I came in with those allergies a while ago.
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Are your eyes dry?
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My eyes don’t feel dry.
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Do you have any pain in your eyes?
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I haven’t had any eye problems lately–I went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good.
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Are you having any ear problems?
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My ears feel fine.
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Any changes in your hearing?
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My hearing is good.
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Any ear pain?
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My ears feel fine.
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Ear drainage? (Clarified to Do you have drainage from your ears?.)
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Nothing is coming out of my ears. (Clarified to if I have ear drainage.)
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Any changes in your sense of smell?
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No.
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Any nose bleeds?
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Nope, my nose isn’t bleeding at all.
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Any sinus pressure?
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My sinuses have been fine.
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Has your sense of taste changed?
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No, I think my sense of taste is fine.
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Are you having dry mouth?
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My mouth hasn’t been dry.
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ANY pain in your mouth?
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No, my mouth feels fine.
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ANY sore throat?
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No, it’s fine.
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Any issue with your gums?
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My gums have been fine.
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Any issue with your tongue?
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My tongue feels fine.
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Any difficulties when swallowing?
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I can swallow fine.
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SORE throat?
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No, it’s fine.
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Any voice changes?
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My voice has been fine.
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Any swollen lymph nodes?
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My lymph nodes seem fine.
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Are you having any nausea?
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No, I haven’t been nauseous at all.
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Any vomiting?
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No.
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ANY pain in the abdomen?
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I haven’t really had any stomach problems since I came in with them a while ago.
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Any constipation?
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I don’t have that problem.
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Any diarrhea?
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I haven’t had any problems with diarrhea.
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Excessive flatulence?
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I haven’t been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked.
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flatulence is one of the side effect of metformin
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Educate |
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Thanks for telling me.
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Any food intolerance
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I can eat just about anything.
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Any burning sensation when you urinate?
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No, it doesn’t burn when I pee.
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Any blood in your urine?
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No! That doesn’t sound like it would be good.
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Are you having any pain right now?
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I don’t have any pain anywhere.
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Any vaginal discharge?
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My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish.
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Any vaginal itching?
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No, it feels normal.
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Do you have any problem with your breasts?
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No, my breasts feel fine.
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Any pain in the breasts?
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No, my breasts feel fine.
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Are you having any dizziness/
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I haven’t been getting dizzy at all.
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Any lightheadedness?
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No, I don’t really get lightheaded.
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Any tingling?
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Nope, no tingling.
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Any loss of balance?
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My balance is fine.
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Any changes in sensation?
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I haven’t noticed any changes.
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Any seizures?
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No, I’ve still never had problems with seizures, fortunately.
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Do you have memory problems?
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I think my memory has been fine.
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Any muscle pain?
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My muscles have felt great, especially since I started exercising more.
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Joint pain?
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My joints always seem fine.
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Any muscle weakness?
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No, I haven’t felt weak at all.
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Any swelling?
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Nothing is swollen.
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Performed pulse oximetry
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Exam Action |
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Performed spirometry
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Exam Action |
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Inspected scalp
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Exam Action |
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Inspected scalp
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Exam Action |
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Inspected hair on scalp
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Exam Action |
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Inspected scalp
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Exam Action |
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Inspected right eyebrow and orbital area
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Exam Action |
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Inspected left eyebrow and orbital area
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Exam Action |
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Inspected mouth: Oral mucosa moist. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
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Exam Action |
Subjective Data Collection: 50 of 50 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Found:
Indicates an item that you found.
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Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Current Health Status
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Finding:
Confirmed reason for visit
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Finding:
Reports needing a pre-employment physical
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Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(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:
Can I confirm that you are here for a physical? -
Finding:
Reports no current acute health problems
(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 current health problems?
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Finding:
Asked about last visit to a healthcare provider
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Finding:
Last visit to a healthcare provider was 4 months ago
(Found)
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.Example Question:
When did you see a healthcare provider? -
Finding:
Reason for last visit was annual gynecological exam
(Found)
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.Example Question:
Why did you see a healthcare provider? -
Finding:
Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler
(Found)
Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.Example Question:
When was your last physical exam? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
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Finding:
Asked about current prescription medications
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Finding:
Reports taking diabetes medication
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.Example Question:
Have you been taking medication for your diabetes? -
Finding:
Reports using a daily inhaler
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.Example Question:
Do you use a daily inhaler? -
Finding:
Reports taking prescription birth control pills
(Found)
Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.Example Question:
Are you taking any form of birth control?
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Finding:
Followed up about diabetes medication
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Finding:
Medication is metformin
(Found)
Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history.Example Question:
What is the name of your diabetes medication? -
Finding:
Started taking metformin 5 months ago
(Found)
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:
How long have you been taking metformin? -
Finding:
Reports that eating probiotic yogurt helps with side effects and they have abated over time
(Found)
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:
Have you noticed any side effects from the metformin?
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Finding:
Followed up on metformin frequency and dose
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Finding:
Reports taking metformin twice daily
(Found)
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:
How many times a day do you take metformin? -
Finding:
Metformin dose is 850 mg
(Found)
Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:
What is the dose of your metformin?
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Finding:
Asked about asthma medication
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Finding:
Reports using Flovent inhaler twice daily
(Found)
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
How often do you use your daily inhaler? -
Finding:
Has a Proventil rescue inhaler
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.Example Question:
Do you have a rescue inhaler? -
Finding:
Last use of Proventil inhaler was three months ago
(Found)
Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.Example Question:
When did you last use your rescue inhaler? -
Finding:
Has used Proventil inhaler twice in the last year
(Available)
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.Example Question:
How often do you use your rescue inhaler?
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Finding:
Followed up about birth control prescription
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Finding:
Started taking birth control 4 months ago
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.Example Question:
How long ago did you start taking birth control? -
Finding:
Reason for birth control was to manage PCOS symptoms
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.Example Question:
Why did you decide to start taking birth control? -
Finding:
Birth control type is Yaz (drospirenone and ethinyl estradiol)
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
What type of birth control do you use? -
Finding:
Takes birth control pill daily
(Found)
Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.Example Question:
How often do you take your birth control pill? -
Finding:
Takes birth control pill at the same time every day
(Found)
Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.Example Question:
Do you take your pill at the same time every day? -
Finding:
Reports no skipped days
(Available)
Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.Example Question:
Have you missed any days of your birth control pill?
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Finding:
Asked about current non-prescription medications
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Finding:
Reports rare Advil use for cramps
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes non prescription drugs will indicate her current treatment plan.Example Question:
Do you take Advil? -
Finding:
Reports no OTC herbal products
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan.Example Question:
Do you use any herbal products? -
Finding:
Reports no OTC vitamins
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan.Example Question:
Do you take any vitamins? -
Finding:
Reports no OTC supplements
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan.Example Question:
Do you take any supplements?
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Finding:
Asked about allergies
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Finding:
Confirms allergies
(Found)
Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina’s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina’s health literacy.Example Question:
Can you confirm your allergies? -
Finding:
Reports no new allergies
(Found)
Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.Example Question:
Have you noticed any new allergies?
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Finding:
Followed up on seasonal allergies
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Finding:
Reports no recent seasonal allergy symptoms
(Found)
Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.Example Question:
Have you been having seasonal allergies? -
Finding:
Reports no current medication for allergies
(Found)
Pro Tip: Tina’s response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.Example Question:
Are you taking any medication for your allergies?
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Finding:
Asked about diabetes
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Finding:
Reports managing diabetes with diet and exercise in addition to medication
(Found)
Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
How are you managing your diabetes?
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Finding:
Asked about blood glucose monitoring
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Finding:
Reports checking blood sugar once a day
(Found)
Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.Example Question:
How often do you monitor your blood glucose? -
Finding:
Checks sugar in the morning
(Found)
Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.Example Question:
When do you check your blood glucose? -
Finding:
Blood sugar number is usually around 90
(Found)
Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.Example Question:
What is your average blood sugar number? -
Finding:
Reports having adequate supplies
Objective Data Collection: 70 of 73 (95.9%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips.
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Found:
Indicates an item that you found.
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Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these examinations as essential components of objective data collection for this patient.
Patient Data
Not Scored
Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient’s case. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
HEENT
Finding:
Inspected head and neck
Finding:
Scattered pustules on face and facial hair on upper lip
(Found)
Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.Example Question:
Finding:
Head is normocephalic, atraumatic
(Found)
Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient’s head can identify any indications of trauma.Example Question:
Finding:
Normal scalp hair distribution
(Found)
Pro Tip: It’s important to inspect your patient’s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.Example Question:
Finding:
Acanthosis nigricans noted on neck
(Available)
Pro Tip: Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient’s skin, especially in folds around the neck, axilla, and groin.Example Question:
Finding:
Inspected eyebrows and orbital area
Finding:
Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema
(Found)
Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.Example Question:
Finding:
Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema
(Found)
Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.Example Question:
Finding:
Palpated scalp
Finding:
No masses
(Found)
Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.Example Question:
Finding:
Palpated sinuses
Finding:
No frontal sinus tenderness
(Found)
Pro Tip: Palpating the frontal sinuses checks for sinusitis.Example Question:
Finding:
No maxillary sinus tenderness
(Found)
Pro Tip: Palpating the maxillary sinuses checks for sinusitis.Example Question:
Finding:
Palpated jaw
Finding:
No clicks, full ROM
(Found)
Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury.Example Question:
Finding:
Palpated lymph nodes
Finding:
No axillary lymphadenopathy
(Found)
Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.Example Question:
Finding:
No supraclavicular lymphadenopathy
(Found)
Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
Finding:
Palpated thyroid
Finding:
Thyroid smooth without nodules, no goiter
(Found)
Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.Example Question:
Finding:
Inspected eyelids and conjunctiva
Finding:
Upper eyelids: conjunctiva pink, no lesions, white sclera
(Found)
Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.Example Question:
Finding:
Lower eyelids: conjunctiva pink, no lesions, white sclera
(Found)
Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.Example Question:
Finding:
Tested PERRL with penlight
Finding:
Right pupil: equal, round, reactive to light
(Found)
Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.Example Question:
Finding:
Left pupil: equal, round, reactive to light
(Found)
Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.Example Question:
Finding:
Tested eye movements
Finding:
Normal convergence
(Found)
Pro Tip: This test accommodation assesses the eye’s ability to focus on close objects.Example Question:
Finding:
EOMs intact bilaterally, no nystagmus
(Found)
Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions.Example Question:
Finding:
Tested peripheral vision
Finding:
Peripheral vision intact in both eyes, all fields
(Found)
Pro Tip:Example Question:
Finding:
Inspected interior eyes with ophthalmoscope
Finding:
Mild retinopathic changes on right
(Found)
Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. By visualizing the fundus, you can look for any retinopathic changes.Example Question:
Finding:
Left fundus with sharp disc margins, no hemorrhages
Finding:
Palpated abdomen – deep
Finding:
Right upper quadrant: no masses, guarding or rebound
(Found)
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.Example Question:
Finding:
Right lower quadrant: no masses, guarding or rebound
(Found)
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
Finding:
Left upper quadrant: no masses, guarding or rebound
(Found)
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.Example Question:
Finding:
Left lower quadrant: no masses, guarding or rebound
(Found)
Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.Example Question:
Finding:
Palpated organs
Finding:
Liver: palpable 1 cm below right costal margin
(Found)
Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems.Example Question:
Finding:
Spleen: not palpable
(Found)
Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate a number of serious health conditions.Example Question:
Finding:
Right kidney: not palpable, no masses
(Found)
Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.Example Question:
Finding:
Left kidney: not palpable, no masses
(Found)
Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.Example Question:
Musculoskeletal
Finding:
Inspected neck
Finding:
Neck without swelling, masses, or deformity
(Available)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Inspected upper extremities
Finding:
Right shoulder without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right arm without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right elbow without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right wrist and hand without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left shoulder without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left arm without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left elbow without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left wrist and hand without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Fingernails: no ridges or abnormalities in nails, pink nailbeds
(Found)
Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
Finding:
Inspected hips
Finding:
Hips without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Inspected lower extremities
Finding:
Right leg without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right knee without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Right ankle without swelling, masses, deformity, or discoloration
(Found)
Pro Tip: A thorough inspection of your patient’s affected ankle aids in the estimation of the extent of tissue injury and disability.Example Question:
Finding:
Right foot without swelling, masses, or deformity
(Found)
Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status.Example Question:
Finding:
Left leg without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left knee without swelling, masses, or deformity
(Found)
Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Example Question:
Finding:
Left ankle without swelling, masses, or deformity
(Found)
Pro Tip: The inspection of your patient’s unaffected ankle provides a comparison to the affected side and aids in the assessment for possible unknown injury inflicted during the fall.Example Question:
Finding:
Left foot without swelling, masses, or deformity
(Found)
Pro Tip: Your patient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy.Example Question:
Finding:
Toenails: no ridges or abnormalities in nails, pink nailbeds
(Found)
Pro Tip: Nail appearance suggests the status of respiratory and vascular function and the presence of nutrient deficiencies or diseases. This is especially important to assess in your patient because diabetics are at risk for peripheral vascular disease.Example Question:
Finding:
Tested ROM for upper extremities
Finding:
Right and left shoulders: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
Finding:
Right and left elbows: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
Finding:
Right and left wrists: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
-
Finding:
Tested ROM for spine
-
Finding:
Rotate left: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
-
Finding:
Rotate right: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. The assessment should also include the comparison of bilateral sides.Example Question:
-
Finding:
Extension: full ROM
(Found)
Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:
-
Finding:
Flexion: full ROM
Documentation / Electronic Health Record
Vitals
| Student Documentation | Model Documentation |
|---|---|
|
128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs |
• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F |
Health History
| Student Documentation | Model Documentation |
|---|---|
Identifying Data & ReliabilityThe patient is a 28-year-old female who presented for a pre-employment physical exam. She provided the health information freely during the interview. Ms. Jones’ speech is clear and coherent |
Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. |
General SurveyMs. Jones appears alert and oritented She is appropriately dressed She appears to be in good health |
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene. |
Reason for VisitMs. Jones visited to have a physical exam for the health insurance at her new workplae |
“I came in because I’m required to have a recent physical exam for the health insurance at my new job.” |
History of Present IllnessMs. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. She does not have any acute cincerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications |
Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job. |
MedicationsMetformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD |
• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago) |
AllergiesAllergic to cats and dust Allergiic to penicillin Denies any food or latex allergy |
• Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms. |
Medical HistoryDiagnosed with asthma at 2 1/2 years DIagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation |
Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago. |
Neurological
| Student Documentation | Model Documentation |
|---|---|
SubjectiveDenies any dizinness, ligh-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibrium |
Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. |
ObjectiveNormal graphesthesia, stereognosis and rapid alternating movements bilaterallly Tests of cerebellar function normal DRTs and equal bilaterally in upper and lower extremities Reduced sensation to monofilament in bilateral plantar surfaces |
Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces. |
Skin, Hair & Nails
| Student Documentation | Model Documentation |
|---|---|
SubjectiveReports imporved acne due to use of oral contraceptives Facial and body hair imporved Denies any nail or hair changes |
Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes. |
ObjectiveScattered pustules on face Facial hair on upper lip Acanthos nigricans on posterior neck Nails free of any abnormalities or ridges |
Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation |
