Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Transcript

Your avatar
Hello, my name is . I will be conducting an interview and later perform a physical exam.

Greet
07/22/20 5:37 PM EDT

Tina Jones
Hey.
Your avatar
What is your name?

Question
07/22/20 5:37 PM EDT

Tina Jones
Tina Jones.
Your avatar
Your date of birth?

Question
07/22/20 5:37 PM EDT

Tina Jones
February 17th.
Your avatar
How old are you?

Question
07/22/20 5:43 PM EDT

Tina Jones
I’m 28.
Your avatar
What brought you into the clinic today?

Question
07/22/20 5:43 PM EDT

Tina Jones
I came in because I’m required to have a recent physical exam for the health insurance at my new job.
Your avatar
Do you have any current health problem?

Question
07/22/20 5:44 PM EDT

Tina Jones
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.
Your avatar
What is your new job? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Question
07/22/20 5:44 PM EDT

Tina Jones
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!
Your avatar
That is great.

Empathize
07/22/20 5:45 PM EDT

Tina Jones
Thanks.
Your avatar
When was your last physical exam?

Question
07/22/20 5:45 PM EDT

Tina Jones
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.
Your avatar
What did your gynecologist say?

Question
07/22/20 5:45 PM EDT

Tina Jones
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.
Your avatar
How often do you take birth control?

Question
07/22/20 5:48 PM EDT

Tina Jones
I take it every morning, with breakfast.
Your avatar
What is the name of the birth control pill you took?

Question
07/22/20 5:49 PM EDT

Tina Jones
They’re called Yaz.
Your avatar
Has your menstrual cycle improved since taking Yaz?

Question
07/22/20 5:50 PM EDT

Tina Jones
Now that I’m on the pill I’m getting my period every month.
Your avatar
That is great. I am glad you are having your period every month.

Empathize
07/22/20 5:50 PM EDT

Tina Jones
Thanks.
Your avatar
How long have you had asthma.

Question
07/22/20 5:51 PM EDT

Tina Jones
I’ve had asthma a long time. . . since I was really little.
Your avatar
What age were you diagnosed with asthma?

Question
07/22/20 5:51 PM EDT

Tina Jones
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.
Your avatar
I am sorry about the experience.

Empathize
07/22/20 5:52 PM EDT

Tina Jones
Thanks.
Your avatar
How do you manage your asthma?

Question
07/22/20 5:52 PM EDT

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.
Your avatar
What are your triggers for asthma?

Question
07/22/20 5:53 PM EDT

Tina Jones
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.
Your avatar
It is important to stay away from triggers.

Educate
07/22/20 5:54 PM EDT

Tina Jones
Thanks for telling me.
Your avatar
What happens when you are around dust?

Question
07/22/20 5:54 PM EDT

Tina Jones
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.
Your avatar
What inhaler do you use?

Question
07/22/20 5:59 PM EDT

Tina Jones
The daily inhaler is Flovent, and the rescue inhaler is Proventil.
Your avatar
How often do you use flovent?

Question
07/22/20 6:00 PM EDT

Tina Jones
Twice a day.
Your avatar
When did you most recently use the flovent inhaler?

Question
07/22/20 6:01 PM EDT

Tina Jones
I use my Flovent inhaler two times a day.
Your avatar
When did you last use your inhaler?

Question
07/22/20 6:03 PM EDT

Tina Jones
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.
Your avatar
How much Albuterol do you use?

Question
07

 

 

 

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.
Your avatar
What is your relationship like with your family?

Question
07/22/20 7:39 PM EDT

Tina Jones
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.
Your avatar
That is great.

Empathize
07/22/20 7:39 PM EDT

Tina Jones
Thanks.
Your avatar
Are you involved in church?

Question
07/22/20 7:39 PM EDT

Tina Jones
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.
Your avatar
Are you feeling stressed?

Question
07/22/20 7:40 PM EDT

Tina Jones
I’m actually feeling really good lately. . . not stressed at all.
Your avatar
How do you cope with stress?

Question
07/22/20 7:40 PM EDT

Tina Jones
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.
Your avatar
That is good to hear.

Empathize
07/22/20 7:40 PM EDT

Tina Jones
Thanks.
Your avatar
Are you feeling depressed?

Question
07/22/20 7:41 PM EDT

Tina Jones
No, I’m actually feeling really good these days.
Your avatar
How do you feel about your life?

Question
07/22/20 7:41 PM EDT

Tina Jones
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.
Your avatar
Are you feeling anxious?

Question
07/22/20 7:41 PM EDT

Tina Jones
I guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though.
Your avatar
Do you have sleeping problems?

Question
07/22/20 7:42 PM EDT

Tina Jones
I’m sleeping a lot better now, which is a relief.
Your avatar
Good to hear.

Empathize
07/22/20 7:42 PM EDT

Tina Jones
Thanks.
Your avatar
How many hours are you sleeping a night?

Question
07/22/20 7:42 PM EDT

Tina Jones
I’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night.
Your avatar
That is great.

Empathize
07/22/20 7:42 PM EDT

Tina Jones
Thanks.
Your avatar
Have you ever smoked tobacco?

Question
07/22/20 7:43 PM EDT

Tina Jones
No. I think it’s gross.
Your avatar
Have you ever used cocaine?

Question
07/22/20 7:43 PM EDT

Tina Jones
No way, I have no interest in that. That stuff can mess you up.
Your avatar
Have you ever used heroin?

Question
07/22/20 7:49 PM EDT

Tina Jones
Uh, no.
Your avatar
Have you ever used illegal drugs?

Question
07/23/20 3:17 PM EDT

Tina Jones
Well, I used to smoke pot. . . but I don’t do that anymore.
Your avatar
What was the last time you smoked pot?

Question
07/23/20 3:17 PM EDT

Tina Jones
I haven’t smoked pot since I was twenty or twenty-one.
Your avatar
Do you have any family history of mental illness?

Question
07/23/20 3:18 PM EDT

Tina Jones
No. They’re crazy, but nobody’s diagnosed with anything.
Your avatar
Have you had suicidal thoughts?

Question
07/23/20 3:19 PM EDT

Tina Jones
No, I’ve never done that.
Your avatar
Any new family medical history report?

Question
07/23/20 3:20 PM EDT

Tina Jones
My mom has some issues, and I think some of my grandparents did, too.
Your avatar
How old is your mom?

Question
07/23/20 3:21 PM EDT

Tina Jones
Mom is 50.
Your avatar
What medical problems does your mum have?

Question
07/23/20 3:21 PM EDT

Tina Jones
Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
Your avatar
What medical problems did your father have?

Question
07/23/20 3:22 PM EDT

Tina Jones
He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
Your avatar
How old is your brother?

Question
07/23/20 3:24 PM EDT

Tina Jones
He’s almost 27.
Your avatar
Does he have any medical issue? (Clarified to Does your younger sister have health problems?.)

Question
07/23/20 3:25 PM EDT

Tina Jones
She’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.)
Your avatar
Does your bother have health issues? (Clarified to Does your brother have medical problems?.)

Question
07/23/20 3:25 PM EDT

Tina Jones
No, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.)
Your avatar
How old is your maternal grandmother?

Question
07/23/20 3:26 PM EDT

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.
Your avatar
How old is your maternal grandfather?

Question
07/23/20 3:27 PM EDT

Tina Jones
Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
Your avatar
Any medical history for your paternal grandmother?

Question
07/23/20 3:30 PM EDT

Tina Jones
She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.
Your avatar
Does your dad’s father have health issues?

Question
07/23/20 3:30 PM EDT

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.
Your avatar
Have you had any recent illness?

Question
07/23/20 3:31 PM EDT

Tina Jones
No. . . the last time I was sick was when I was having those heartburn problems a while ago.
Your avatar
Any fever?

Question
07/23/20 3:32 PM EDT

Tina Jones
I haven’t had a fever.
Your avatar
Any chills?

Question
07/23/20 3:32 PM EDT

Tina Jones
Nope, no chills.
Your avatar
Any acne?

Question
07/23/20 3:32 PM EDT

Tina Jones
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.
Your avatar
Has your body hair improved?

Question
07/23/20 3:32 PM EDT

Tina Jones
I think I have a little less body hair than I used to.
Your avatar
Do your eyes feel itchy?

Question
07/23/20 3:33 PM EDT

Tina Jones
They haven’t been itchy lately at all.
Your avatar
Are you having any redness in your eyes?

Question
07/23/20 3:33 PM EDT

Tina Jones
My eyes haven’t been red lately. . . not since I came in with those allergies a while ago.
Your avatar
Are your eyes dry?

Question
07/23/20 3:34 PM EDT

Tina Jones
My eyes don’t feel dry.
Your avatar
Do you have any pain in your eyes?

Question
07/23/20 3:34 PM EDT

Tina Jones
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.
Your avatar
Are you having any ear problems?

Question
07/23/20 3:34 PM EDT

Tina Jones
My ears feel fine.
Your avatar
Any changes in your hearing?

Question
07/23/20 3:36 PM EDT

Tina Jones
My hearing is good.
Your avatar
Any ear pain?

Question
07/23/20 3:36 PM EDT

Tina Jones
My ears feel fine.
Your avatar
Ear drainage? (Clarified to Do you have drainage from your ears?.)

Question
07/23/20 3:36 PM EDT

Tina Jones
Nothing is coming out of my ears. (Clarified to if I have ear drainage.)
Your avatar
Any changes in your sense of smell?

Question
07/23/20 3:46 PM EDT

Tina Jones
No.
Your avatar
Any nose bleeds?

Question
07/23/20 3:47 PM EDT

Tina Jones
Nope, my nose isn’t bleeding at all.
Your avatar
Any sinus pressure?

Question
07/23/20 3:47 PM EDT

Tina Jones
My sinuses have been fine.
Your avatar
Has your sense of taste changed?

Question
07/23/20 3:47 PM EDT

Tina Jones
No, I think my sense of taste is fine.
Your avatar
Are you having dry mouth?

Question
07/23/20 3:48 PM EDT

Tina Jones
My mouth hasn’t been dry.
Your avatar
ANY pain in your mouth?

Question
07/23/20 3:48 PM EDT

Tina Jones
No, my mouth feels fine.
Your avatar
ANY sore throat?

Question
07/23/20 3:49 PM EDT

Tina Jones
No, it’s fine.
Your avatar
Any issue with your gums?

Question
07/23/20 3:49 PM EDT

Tina Jones
My gums have been fine.
Your avatar
Any issue with your tongue?

Question
07/23/20 3:49 PM EDT

Tina Jones
My tongue feels fine.
Your avatar
Any difficulties when swallowing?

Question
07/23/20 3:50 PM EDT

Tina Jones
I can swallow fine.
Your avatar
SORE throat?

Question
07/23/20 3:50 PM EDT

Tina Jones
No, it’s fine.
Your avatar
Any voice changes?

Question
07/23/20 3:50 PM EDT

Tina Jones
My voice has been fine.
Your avatar
Any swollen lymph nodes?

Question
07/23/20 3:52 PM EDT

Tina Jones
My lymph nodes seem fine.
Your avatar
Are you having any nausea?

Question
07/23/20 3:52 PM EDT

Tina Jones
No, I haven’t been nauseous at all.
Your avatar
Any vomiting?

Question
07/23/20 3:53 PM EDT

Tina Jones
No.
Your avatar
ANY pain in the abdomen?

Question
07/23/20 3:53 PM EDT

Tina Jones
I haven’t really had any stomach problems since I came in with them a while ago.
Your avatar
Any constipation?

Question
07/23/20 3:53 PM EDT

Tina Jones
I don’t have that problem.
Your avatar
Any diarrhea?

Question
07/23/20 3:54 PM EDT

Tina Jones
I haven’t had any problems with diarrhea.
Your avatar
Excessive flatulence?

Question
07/23/20 3:54 PM EDT

Tina Jones
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.
Your avatar
flatulence is one of the side effect of metformin

Educate
07/23/20 3:55 PM EDT

Tina Jones
Thanks for telling me.
Your avatar
Any food intolerance

Question
07/23/20 3:56 PM EDT

Tina Jones
I can eat just about anything.
Your avatar
Any burning sensation when you urinate?

Question
07/23/20 3:56 PM EDT

Tina Jones
No, it doesn’t burn when I pee.
Your avatar
Any blood in your urine?

Question
07/23/20 3:57 PM EDT

Tina Jones
No! That doesn’t sound like it would be good.
Your avatar
Are you having any pain right now?

Question
07/23/20 3:57 PM EDT

Tina Jones
I don’t have any pain anywhere.
Your avatar
Any vaginal discharge?

Question
07/23/20 3:58 PM EDT

Tina Jones
My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish.
Your avatar
Any vaginal itching?

Question
07/23/20 3:58 PM EDT

Tina Jones
No, it feels normal.
Your avatar
Do you have any problem with your breasts?

Question
07/23/20 3:59 PM EDT

Tina Jones
No, my breasts feel fine.
Your avatar
Any pain in the breasts?

Question
07/23/20 3:59 PM EDT

Tina Jones
No, my breasts feel fine.
Your avatar
Are you having any dizziness/

Question
07/23/20 3:59 PM EDT

Tina Jones
I haven’t been getting dizzy at all.
Your avatar
Any lightheadedness?

Question
07/23/20 4:00 PM EDT

Tina Jones
No, I don’t really get lightheaded.
Your avatar
Any tingling?

Question
07/23/20 4:00 PM EDT

Tina Jones
Nope, no tingling.
Your avatar
Any loss of balance?

Question
07/23/20 4:00 PM EDT

Tina Jones
My balance is fine.
Your avatar
Any changes in sensation?

Question
07/23/20 4:00 PM EDT

Tina Jones
I haven’t noticed any changes.
Your avatar
Any seizures?

Question
07/23/20 4:01 PM EDT

Tina Jones
No, I’ve still never had problems with seizures, fortunately.
Your avatar
Do you have memory problems?

Question
07/23/20 4:01 PM EDT

Tina Jones
I think my memory has been fine.
Your avatar
Any muscle pain?

Question
07/23/20 4:01 PM EDT

Tina Jones
My muscles have felt great, especially since I started exercising more.
Your avatar
Joint pain?

Question
07/23/20 4:02 PM EDT

Tina Jones
My joints always seem fine.
Your avatar
Any muscle weakness?

Question
07/23/20 4:02 PM EDT

Tina Jones
No, I haven’t felt weak at all.
Your avatar
Any swelling?

Question
07/23/20 4:03 PM EDT

Tina Jones
Nothing is swollen.
Your avatar
 Performed pulse oximetry

Exam Action
07/24/20 10:01 AM EDT

Your avatar
 Performed spirometry

Exam Action
07/24/20 10:01 AM EDT

Your avatar
 Inspected scalp

Exam Action
07/24/20 10:01 AM EDT

Your avatar
 Inspected scalp

Exam Action
07/24/20 10:01 AM EDT

Your avatar
 Inspected hair on scalp

Exam Action
07/24/20 10:01 AM EDT

Your avatar
 Inspected scalp

Exam Action
07/24/20 10:01 AM EDT

Your avatar
 Inspected right eyebrow and orbital area

Exam Action
07/24/20 10:02 AM EDT

Your avatar
 Inspected left eyebrow and orbital area

Exam Action
07/24/20 10:02 AM EDT

Your avatar
 Inspected mouth: Oral mucosa moist. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Exam Action
07/24/20 10:02 AM EDT

 

 

 

 

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.

  • Found:

    Indicates an item that you found.

  • 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

  • Finding:

    Confirmed reason for visit

  • Finding:

    Reports needing a pre-employment physical

  •  

    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?
  • Finding:

    Asked about last visit to a healthcare provider

  • 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
  • Finding:

    Asked about current prescription medications

  • 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?
  • Finding:

    Followed up about diabetes medication

  • 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?
  • Finding:

    Followed up on metformin frequency and dose

  • 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?
  • Finding:

    Asked about asthma medication

  • 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 & Documentation

    Example 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?
  • Finding:

    Followed up about birth control prescription

  • 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 & Documentation

    Example 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?
  • Finding:

    Asked about current non-prescription medications

  • 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?
  • Finding:

    Asked about allergies

  • 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?
  • Finding:

    Followed up on seasonal allergies

  • 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?
  • Finding:

    Asked about diabetes

  • 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 & Documentation

    Example Question:

    How are you managing your diabetes?
  • Finding:

    Asked about blood glucose monitoring

  • 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.

  • Found:

     Indicates an item that you found.

  • 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 & Documentation

    Example 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 & Documentation

    Example 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 & Documentation

    Example 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 & Documentation

    Example 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 & Reliability

The 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 Survey

Ms. 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 Visit

Ms. 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 Illness

Ms. 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.

Medications

Metformin 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)

Allergies

Allergic 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 History

Diagnosed 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

Subjective

Denies 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.

Objective

Normal 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

Subjective

Reports 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.

Objective

Scattered 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

 

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