NURS 6512 Comprehensive Assessment Tina Jones Shadow Health Transcript

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NURS 6512 Comprehensive Assessment Tina Jones Shadow Health Transcript Provided

NURS 6512 Week 1: Discussion – ORDER THE INTERVIEW TRANSCRIPT AT A DISCOUNTED PRICE

Building A Health History – We Can Reliably Complete This And Related Assignments In This Course, Including All The Required Shadow Health Assessments. These Include Tina Jones Health History, Focused Cough Assessment On Danny Rivera, Focused Assessment – Chest Pain On Brian Foster, And The Comprehensive Health Assessment On Tina Jones.

Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

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For this Discussion, you will take on the role of a clinician who is building a health history for a particular new patient assigned by your Instructor.

Resources

Be sure to review the Learning Resources before completing this activity.
 Click the weekly resources link to access the resources. 

WEEKLY RESOURCES

To prepare:

With the information presented in Chapter 2 of Ball et al. in mind, consider the following:

  • By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
  • How would your communication and interview techniques for building a health history differ with each patient?
  • How might you target your questions for building a health history based on the patient’s social determinants of health?
  • What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
  • Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
  • Select one of the risk assessment instruments presented in Chapter 2 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
  • Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.

BY DAY 3 OF WEEK 1

Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!   

Read a selection of your colleagues’ responses.

BY DAY 6 OF WEEK 1

Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:

  • Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
  • Suggest additional health-related risks that might be considered.
  • Validate an idea with your own experience and additional research

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Learning Resources

  • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.

o   Chapter 2, “The History and Interviewing Process
 This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

o   Chapter 5, “Recording Information”
 This chapter provides rationale and methods for maintaining clear and accurate records. The authors also explore the legal aspects of patient records.

  • Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

o   Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

Shadow Health Support and Orientation Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Required Media

Welcome and General Course Guidelines
Dr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m).

Module 1 Introduction
Dr. Tara Harris reviews the overall expectations for Module 1. Please pay special attention to the registration requirements for your use of Shadow Health for your Digital Clinical Experience (DCE) Assignments as well as the criteria for the DCE Assignments (3m).

Building a Comprehensive Health History – Week 1 (19m)

Optional Resources

  • LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw- Hill Medical.

o   Chapter 2, “History Taking and the Medical Record” (pp. 1)

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

Comprehensive Assessment Tina Jones Shadow Health Transcript

This comprehensive shadow health assessment of Tina Jones enables the student to master the art of patient data collection, with head to toe history taking and physical assessment.

The process is highly involving, time-consuming and may require one to complete in different sessions, yet the goal is to be able to assess a patient in one sitting, taking as minimal time as possible. We can help you complete this and other shadow health assessments as and when needed, with excellent scores assured. Comprehensive Assessment Tina Jones Shadow Health Transcript

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Transcript

All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394)

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.

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

Current Health Status

Finding: A confirmed reason for the visit

Finding: Reports needing a pre-employment physical

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

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

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

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

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?

Finding: Asked about current prescription medications

Finding: Reports taking diabetes medication

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

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

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

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

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

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

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

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Comprehensive Assessment Tina Jones Shadow Health Transcript

Example Question: What is the dose of your metformin?

Finding: Asked about asthma medication

Finding: Reports using Flovent inhaler twice daily

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 daily inhaler?

Finding: Has a Proventil rescue inhaler

Pro Tip: A patient’s medication 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

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

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 has been treating her symptoms since exacerbation.

Example Question: How often do you use your rescue inhaler?

Finding: Followed up about birth control prescription

Finding: I started taking birth control 4 months ago

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

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)

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.

Example Question: What type of birth control do you use?

Finding: Takes birth control pill daily

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

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

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

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan.

Example Question: Do you take Advil?

Finding: Reports no OTC herbal products

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

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.

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Example Question: Do you take any vitamins?

Finding: Reports no OTC supplements

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

Pro Tip: Discerning what is 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

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

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

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

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 is complied with previous treatment plans.

Example Question: How are you managing your diabetes?

Finding: Asked about blood glucose monitoring

Finding: Reports checking blood sugar once a day

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

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 is complied with previous treatment plans.

Example Question: When do you check your blood glucose?

Findng: Blood sugar number is usually around 90

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’ complied with previous treatment plans.

Example Qestion: 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

Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient’s case.

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HEENT

Fining: Inspected head and neck

Finding: Scattered pustules on face and facial hair on upper lip

Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.

Finding: Head is normocephalic, atraumatic

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.

Finding: Normal scalp hair distribution

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.

Finding: Acanthosis nigricans noted on neck

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.

Finding: Inspected eyebrows and orbital area

Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema

Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.

Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema

Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.

Finding: Palpated scalp

Finding: No masses

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.

Finding: Palpated sinuses

Finding: No frontal sinus tenderness

Pro Tip: Palpating the frontal sinuses checks for sinusitis.

Finding: No maxillary sinus tenderness

Pro Tip: Palpating the maxillary sinuses checks for sinusitis.

Finding: Palpated jaw

Finding: No clicks, full ROM

Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury.

Finding: Palpated lymph nodes

Finding: No axillary lymphadenopathy

Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.

Finding: No supraclavicular lymphadenopathy

Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.

Finding: Palpated thyroid

Finding: Thyroid smooth without nodules, no goiter

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.

Finding: Inspected eyelids and conjunctiva

Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera

Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.

Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera

Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.

Finding: Tested PERRL with penlight

Finding: Right pupil: equal, round, reactive to light

Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.

Finding: Left pupil: equal, round, reactive to light

Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.

Finding: Tested eye movements

Finding: Normal convergence

Pro Tip: This test accommodation assesses the eye’s ability to focus on close objects.

Finding: EOMs intact bilaterally, no nystagmus

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.

Finding: Tested peripheral vision

Finding: Peripheral vision intact in both eyes, all fields

Finding: Inspected interior eyes with ophthalmoscope

Finding: Mild retinopathic changes on right

Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. By visualizing the fundus, you can look for any retinopathic changes.

Finding: Left fundus with sharp disc margins, no hemorrhages

Finding: Palpated abdomen – deep

Finding: Right upper quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Right lower quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Left upper quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Left lower quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Palpated organs

Finding: Liver: palpable 1 cm below right costal margin

Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems.

Finding: Spleen: not palpable

Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions.

Finding: Right kidney: not palpable, no masses

Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.

Finding: Left kidney: not palpable, no masses

Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.

Musculoskeletal

Finding: Inspected neck

Finding: Neck without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Inspected upper extremities

Finding: Right shoulder without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right arm without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right elbow without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right wrist and hand without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left shoulder without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left arm without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left elbow without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left wrist and hand without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Fingernails: no ridges or abnormalities in nails, pink nailbeds

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.

Finding: Inspected hips

Finding: Hips without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Inspected lower extremities

Finding: Right leg without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right knee without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Right ankle without swelling, masses, deformity, or discoloration

Pro Tip: A thorough inspection of your patient’s affected ankle aids in the estimation of the extent of tissue injury and disability.

Finding: Right foot without swelling, masses, or deformity

Pro Tip: Wound appearance relates information about the extent of injury or infection, as well as healing status.

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Finding: Left leg without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left knee without swelling, masses, or deformity

Pro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.

Finding: Left ankle without swelling, masses, or deformity

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.

Finding: Left foot without swelling, masses, or deformity

Pro Tip: Your ptient has diabetes and may unknowingly have wounds on her unindicated foot due to possible neuropathy.

Finding: Toenails: no ridges or abnormalities in nails, pink nailbeds

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.

Finding: Tested ROM for upper extremities

Finding: Right and left shoulders: full ROM

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.

Finding: Right and left elbows: full ROM

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.

Finding: Right and left wrists: full ROM

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.

Finding: Tested ROM for spine

Finding: Rotate left: full ROM

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.

Finding: Rotate right: full ROM

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.

Finding:  Extension: full ROM

Pro Tip: Assessing range of motion of each major joint noting any limitations in mobility, pain, or crepitation can identify joint disease or injury.

Finding:

Flexion: full ROM

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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 oriented 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 workplace

 “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 concerns 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 currently. 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 Allergic 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

 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 dizziness, light-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 bilaterally 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 improved acne due to use of oral contraceptives Facial and body hair improved 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.
Scattered pustules on face Facial hair on upper lip Acanthosis 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.

References on Comprehensive Assessment Tina Jones Shadow Health Transcript

National Institute of Health. https://www.ncbi.nlm.nih.gov/books/NBK493211/

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