Shadow Health Comprehensive Assessment Answer key

Shadow Health Comprehensive Assessment answer keyComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation.Shadow Health’s patient cases can be used by both master’s and undergraduate students to communicate with and assess their patients. Advanced Shadow Health Assessment patient research refers to the evolution of Tina Jones’ single-framework valuations after regular visits to the health institution over the course of a simulated year, which scholars have found useful in planning for their medical assessment.Shadow Health Comprehensive Assessment answer keyFurthermore, this case study allows learners to record their research, which aids in blending the data collected when communicating with their patients.Shadow Health Comprehensive Assessment answer key Tina jones comprehensive assessmentTina Jones Respiratory Shadow Health AssessmentTina had had an asthma attack two days before.During this time, she relied on her albuterol inhaler to treat her asthma; even when the symptoms subsided, the inhaler was never used to treat the condition.Tina noticed she had ten wheezing attacks and was frequently winded since the asthma attack. To conduct an accurate patient assessment, you must answer pertinent questions about the symptoms you are experiencing with your body.This study will aid in the assessment of any lung sounds during the actual medical evaluation.When writing a Shadow Health Assignment, you will analyze the collected data using appropriate medical terminology.Shadow Health Comprehensive Assessment answer keyTina Jones Comprehensive Assessment Shadow HealthTina Jones, a 28-year-old African-American woman, came to our clinic complaining of breathing difficulties and windedness following asthma attacks. Tina claims she went to see her cousin and came across several kittens, which is where her asthma symptoms began. She noticed her wheezing rate was 6/10 and her windedness was 8/10, both of which lasted at least five minutes. Tina, according to her assessment, never experienced any chest pains or hypersensitive side effects. During this time, she dealt with asthma attacks by using her albuterol inhaler, which only helped her manage some symptoms. Ms. Jones discovered that she had ten wheezing episodes and was frequently winded after her asthma attack. She had windedness symptoms at home prior to visiting the health center. Ms. Jones notices that some of her systems are compromised after lying down at a certain angle, which is accompanied by painful coughs. You must include the above information when completing a Shadow Health Respiratory Physical Assessment Research.Shadow Health Comprehensive Assessment answer keyTina gets winded about twice a night while sleeping. Ms. Jones claims that her symptoms are interfering with her daily activities and that her albuterol inhaler may no longer be as effective as it once was. She claims that her breathing has improved since further diagnosis. Ms. Jones was diagnosed with asthma when she was two years old. She has never smoked, has never used a pinnacle stream, has no medical history of pain, and does not own a home vaporizer. According to the medical evaluation of Ms. Jones, she was last hospitalized for asthma at the age of 16 and has never been intubated for her asthma. For a complete assignment on any Shadow Health Case Study, the instructor expects students to include the above information.Shadow Health Comprehensive Assessment answer keyTina jones cardiovascular shadow healthConsulted regarding any heart problems:– Disagrees regarding any heart complicationsHeartbeat rates were discussed:– Accounts for a normal heartbeat– Reports a regular pulse – Disavows palpitations– Refuses to acknowledge arrhythmiaHypertension was discussed.– Hypertension disagreements– Reports her most recent circulatory strain following her diagnosis:– Reports that the last pulse was 140, rather than 80 or 90.– Accounts for a belief that her current pulse is on the high side of normal range.When asked about the heart mumble,– Any heartfelt disagreements are mumbled.When asked about swelling,– Apart from having a foot wound, he disagrees on any swelling.consulted about any blue skin signs– blue skin disagreesI was asked if I wanted to have a heart analysis.– Disagrees on seeing a psychiatrist – Disagrees on any echocardiogram signs– No coronary artery CT X-ray diagnosis was performedConsulted about any heart medical procedures – No heart surgeries were performed – Disagrees about angioplasty or stent – Disagrees about having a pacemakerWhen asked if he had any chest problems,– Disagrees on the possibility of experiencing any chest complications– Disagreements about having anginaIn case of a heart attack or chest tightness, consult a doctor.– Claims to have had chest tightness while being treated for asthma– Does not report having had chest tightness recentlyTina Jones Neurological Shadow HealthConcerning the strike, the following information was requested:– There is no medical history of having had a stroke.– Disagrees on any recent numbness symptomsWhen confronted with quivering:– Disagrees about shiveringIf you have any vision problems, please consult with the following people:– Makes claims about having vision problems– The importance of having vision problems was emphasized.– Following further evaluation, she claims to have had vision problems in recent months. Tina claims to have foggy vision regularly– She claims to have reading vision problems but denies having double eyesight.Consulted about migraines:– Allegations of sporadic cerebral pains– Describes the cerebral pain that has occurred in the last few days.– Disagrees on having recently suffered from migrainesWhen asked if he had any cerebral pain, he said no.– Ms. Jones claims to have regular cerebral pains– claims to have had migraines in the last few hours– claims to have had cerebral pains several times a monthWhen asked about cerebral pain triggers, Ms. Jones says she gets them whenever she anticipates something.When asked if they have any symptoms of cerebral pain– Tina claims that her migraines aren’t life-threatening– She reports having cerebral pains on the sides of her head; she claims to have tight migraines; and she says the cerebral pains have been bothersome.When asked if she had ever received migraine treatment, she stated that she had once used acetaminophen to treat cerebral pains.Shadow Health Comprehensive Assessment answer key– She stated that she had used regular-strength acetaminophen medicine.– When asked if she had ever experienced dizziness, she stated that she had never experienced it.Tina Jones Musculoskeletal Shadow Health. Shadow Health Comprehensive Assessment answer keyAny joint issues were discussed.– Obtained information about her joint pains– Obtained reports on joint swellingquestioned about adaptability– Identifies a history of walking difficulties– Tina claims to have had a wound that caused her walking difficulties.Questioned about whether she felt pain while moving– claims to feel more pain when walking Consulted about her ability to stand– Before she was injured, I gathered information about her position.When asked if he had any muscle pains, he said no. gathered pertinent information about her history of muscle pains– I also gathered information about her recent muscle pain.Shadow Health Comprehensive Assessment answer keyWhen asked if the injury had impacted her work, she stated that it had not.– Is your job hazardous?– Do you move around a lot at work?– What is it that keeps you from doing well at work?– Can you move from a sitting to a standing position?– Do you encounter any difficulties while taking a bath?Tina Jones Abdominal AssessmentWhen asked about distinguishing bowel characteristics,– Do you have bowel movements regularly?-When was the last time you had a bowel movement?Consulted for constipation -Have you recently been constipated? Have you experienced hard stools?– Do you have any difficulties with bowel movements?Screening was performed on the stool sample.-What is the stool’s shape?-Can you tell me what color the stool is?-Is there blood in the stool?When asked about gassiness, she wondered if there was any bloating.Shadow Health Tina Jones Health HistoryA good research paper on Tina Jones’s history should include questions about Tina’s current and past health, from her recent foot wound to any pre-existing disorders. Ms. Jones’s body parts should also be evaluated, as well as her psychosocial history and family health records. This evaluation will assist you in creating detailed health records for Tina Jones. If you discover any illnesses, inquire about the symptoms and how the patient dealt with the diseases as they arose.During the assessment, you will need to educate and empathize with Ms. Jones to develop her sense of well-being. Tina’s comprehensive medical history will require you to ask her pertinent questions. When communicating with the patient in available and formal language, you will need to use medical phrases to obtain accurate information with the assistance of medical recordings, discoveries, and nursing articles. Following completion of the evaluation activities, you will need to go over the findings step by step. You will be required to perform data handling activities to obtain Ms. Jones’ medical history. Finally, you will identify and discuss the evaluation before developing a structured approach to the problematic assessment.Shadow Health Comprehensive Assessment answer keyShadow Health Tina Jones Questions/AnswersWhat criteria will the instructor use to evaluate my work?The instructor will grade your research based on your knowledge of the subject matter, as well as your Education and Understanding. To complete and achieve your Education and Empathy, you must respond to the condition that requires restorative communication as soon as possible. When communicating with your patient, you will think about the format of your questions, which can be therapeutic or definitive. Furthermore, this can be accomplished by conducting extensive and in-depth research on the patient’s health. When handling your research, your instructor will also evaluate your ability to collect data and how you structure your nursing research. It may take 90-110 minutes to gather relevant information for the assessment. As it is a safe restoration, completing the given assignment may take longer than expected; however, every student can have ample time to develop and discover their abilities.How will this assignment help me prepare for the real world?After completing this assignment, you will have acquired skills and information about the structure and content of health history assessments on your patients; as a medical professional, you will be able to:Create appropriate and well-structured questionsGather information about your patient’s medical history.Consider the risks that your patient may face as a result of the disorder or illness.Replicate what you know and identify areas where you need to improve.Identify and have detailed information about the nursing assessment.Concentrate on creating a well-structured nursing assessment.What else would you add to this assignment?To ensure your patient’s health, well-being, and safety, you must answer your nursing questions. You can use the Electronic Health Record as a health practitioner to create a report of your patient’s results. The healthcare practitioners will have relevant information about their patients if these results are recorded. Aside from subject information collection, healthcare professionals can engage in other renovation activities that provide them with pertinent information about their patients.To assess Tina’s spinal levels l2, l3, and l4, which deep tendon reflexes would have to be tested?A patellar profound ligament reflex should have solid and functional nerve strands in the L2, L3, and L4 spinal ranks. The study of rare reflexes aids in distinguishing neurological pathologies of the spine.Tina Jones HeatFinding: The main complaint was established.Tina claims to have a sore throat (Results) Pro Tip: Any protest against a patient will aid in the discovery of any disorder. Achieving any of the outcomes of the demonstration will assist the patient in communicating any emerging side effects.Shadow Health Comprehensive Assessment answer keyExample Question: Does your throat itch? Ms. Jones claims to have had a scratchy throat (Outcomes) Professional Guidance: The main goal of setting up a protest on your patient is to discover any arising disorder. This protest will encourage the patient to discuss any side effects of the disease.Example Question: Does your throat itch?Ms. Jones claims to have itchiness in her eyes as a result of the results (Results) Pro Tip: Performing a protest on your patient will aid in the analysis of any illness or symptoms that may arise. This allows the patient to speak freely about any signs and symptoms.Example Question: Are your eyes itchy?Ms. Jones reports having a runny nose after a few consultations (Outcomes) Recommendation from a Professional: Performing a protest on your patient will aid in the analysis of any illness or symptoms that may arise. The practitioner will be able to communicate with their patients and open up about any symptoms if they are aware of any disorders.Shadow Health Comprehensive Assessment answer keyExample Question: Do you have a runny nose? History of Present IllnessFinding: Consulted about the disorder’s current signs and symptoms.Ms. Jones claims that the sore throat began within the last week (Outcomes) Professional Guidance: Inquiring with your patient about the duration of their most recent illness will help you learn more about the history of their current disorder. Having this data will assist you in detecting any current diseases or symptoms, analyze the area of their pain, or measure the pain she may be experiencing.Question Example: How long have you had a sore throat?Ms. Jones claims that the runny nose started a week ago (Results) Professional Guidance: Inquiring with patients about how long they have been suffering from the current disease provides information about their illness’s history. Gathering information about the current condition will assist you in reevaluating the signs and symptoms of the current disease, such as measuring the pain they may be experiencing.Shadow Health Comprehensive Assessment answer keyQuestion Example: When did your nose start running?Ms. Jones reports that the itching in her eyes began a week ago (Outcomes) Professional Guidance: Inquiring with patients about how long they have been suffering from the current disease provides information about their illness’s history. Gathering information about the current condition will assist you in reevaluating the signs and symptoms of the current disease, such as measuring the pain they may be experiencing.Question Example: When was the last time your eyes itched?Findings: Consulted about the leading causes of throat symptoms.Ms. Jones claims to be suffering from chronic throat pains (Outcomes). Professional Guidance: Collecting information about the time she has been afflicted with the current health disorder will assist you in obtaining relevant information about the current disease. Conducting a current protest allows you to reevaluate the disease’s recent signs and symptoms.Shadow Health Comprehensive Assessment answer keyExample Question: Is it common for you to have throat pain regularly?Ms. Jones claims that her throat pain worsens in the morning (Results) Professional Advice: Gathering information about the patient’s time suffering from the current disorder aids in reanalyzing the past signs and symptoms of the current illness.Example Question: When does your sore throat get worse?Tina claims to have sore throat when she swallows (Outcomes) Professional Guidance: Gathering information about Ms. Jones’s recent illness aids in obtaining relevant information about the history of the current disease. Collecting information about the length of time the patient has been afflicted with the current disorder aids in reanalyzing the past signs and symptoms of the current illness.  Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationTranscriptAll Lines (645) Interview Questions (210) Statements (41) Exam Actions (394)Hello, my name is Tammy. I will be conducting an interview and a physical exam. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationGreet07/22/20 5:37 PM EDTHey.What is your name?ORDER COMPREHENSIVE SOLUTION PAPERS ON Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationQuestion07/22/20 5:37 PM EDTTina Jones.What is your date of birth?Question07/22/20 5:37 PM EDTFebruary 17th.How old are you?Question07/22/20 5:43 PM EDTI’m 28.What brings you into the clinic today?Question07/22/20 5:43 PM EDTI came in because I’m required to have a recent physical exam for the health insurance at my new job.Do you have any current health problem?Question07/22/20 5:44 PM EDTI 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.What is your new job?Question07/22/20 5:44 PM EDTI’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!That is great.Empathize07/22/20 5:45 PM EDTThanks.When was your last physical exam?Question07/22/20 5:45 PM EDTLet’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.What did your gynecologist say?Question07/22/20 5:45 PM EDTShe 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.How often do you take birth control?Question07/22/20 5:48 PM EDTI take it every morning, with breakfast.What is the name of the birth control pill you took?Question07/22/20 5:49 PM EDTThey’re called Yaz.Has your menstrual cycle improved since taking Yaz?Question07/22/20 5:50 PM EDTNow that I’m on the pill I’m getting my period every month.That is great. I am glad you are having your period every month.Empathize07/22/20 5:50 PM EDTThanks.How long have you had asthma?Question07/22/20 5:51 PM EDTI’ve had asthma a long time. . . since I was really little.What age were you diagnosed with asthma?Question07/22/20 5:51 PM EDTMy 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationI am sorry about the experience.Empathize07/22/20 5:52 PM EDTThanks.How do you manage your asthma?Question07/22/20 5:52 PM EDTI try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.What are your triggers for asthma?Question07/22/20 5:53 PM EDTBeing 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.It is important to stay away from triggers.Educate07/22/20 5:54 PM EDTThanks for telling me.What happens when you are around dust?Question07/22/20 5:54 PM EDTI 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.What inhaler do you use?Question07/22/20 5:59 PM EDTThe daily inhaler is Flovent, and the rescue inhaler is Proventil.How often do you use Flovent?Question07/22/20 6:00 PM EDTTwice a day.When did you most recently use the Flovent inhaler?Question07/22/20 6:01 PM EDTI use my Flovent inhaler two times a day.When did you last use your inhaler?Question07/22/20 6:03 PM EDTI 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.How much Albuterol do you use?Question07 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. What is your relationship like with your family?Question07/22/20 7:39 PM EDTThings 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.That is great.Empathize07/22/20 7:39 PM EDTThanks.Are you involved in church?Question07/22/20 7:39 PM EDTYeah. 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.Are you feeling stressed?Question07/22/20 7:40 PM EDTI’m actually feeling really good lately. . . not stressed at all.How do you cope with stress?Question07/22/20 7:40 PM EDTI’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.That is good to hear.Empathize07/22/20 7:40 PM EDTThanks.Are you feeling depressed?Question07/22/20 7:41 PM EDTNo, I’m actually feeling really good these days.How do you feel about your life?Question07/22/20 7:41 PM EDTWell, 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.Are you feeling anxious?Question07/22/20 7:41 PM EDTI guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though.Do you have sleeping problems?Question07/22/20 7:42 PM EDTI’m sleeping a lot better now, which is a relief.Good to hear.Empathize07/22/20 7:42 PM EDTThanks.How many hours are you sleeping a night?Question07/22/20 7:42 PM EDTI’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationThat is great.Empathize07/22/20 7:42 PM EDTThanks.Have you ever smoked tobacco?Question07/22/20 7:43 PM EDTNo. I think it’s gross.Have you ever used cocaine?Question07/22/20 7:43 PM EDTNo way, I have no interest in that. That stuff can mess you up.Have you ever used heroin?Question07/22/20 7:49 PM EDTUh, no.Have you ever used illegal drugs?Question07/23/20 3:17 PM EDTWell, I used to smoke pot. . . but I don’t do that anymore.What was the last time you smoked pot?Question07/23/20 3:17 PM EDTI haven’t smoked pot since I was twenty or twenty-one.Do you have any family history of mental illness?Question07/23/20 3:18 PM EDTNo. They’re crazy, but nobody’s diagnosed with anything.Have you had suicidal thoughts?Question07/23/20 3:19 PM EDTNo, I’ve never done that.Any new family medical history report?Question07/23/20 3:20 PM EDTMy mom has some issues, and I think some of my grandparents did, too.How old is your mom?Question07/23/20 3:21 PM EDTMom is 50.What medical problems does your mum have?Question07/23/20 3:21 PM EDTMom has high cholesterol and blood pressure, I think. She seems to be doing okay though.What medical problems did your father have?Question07/23/20 3:22 PM EDTHe had high blood pressure and cholesterol, and diabetes too…the same kind as me.How old is your brother?Question07/23/20 3:24 PM EDTHe’s almost 27.Does he have any medical issue? (Clarified to Does your younger sister have health problems?.)Question07/23/20 3:25 PM EDTShe’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.)Does your bother have health issues? (Clarified to Does your brother have medical problems?.)Question07/23/20 3:25 PM EDTNo, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.)How old is your maternal grandmother?Question07/23/20 3:26 PM EDTNana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.How old is your maternal grandfather?Question07/23/20 3:27 PM EDTPoppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.Any medical history for your paternal grandmother?Question07/23/20 3:30 PM EDTShe takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.Does your dad’s father have health issues?Question07/23/20 3:30 PM EDTGrandpa 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.Have you had any recent illness?Question07/23/20 3:31 PM EDTNo. . . the last time I was sick was when I was having those heartburn problems a while ago.Any fever?Question07/23/20 3:32 PM EDTI haven’t had a fever.Any chills?Question07/23/20 3:32 PM EDTNope, no chills.Any acne?Question07/23/20 3:32 PM EDTI 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.Has your body hair improved?Question07/23/20 3:32 PM EDTI think I have a little less body hair than I used to.Do your eyes feel itchy?Question07/23/20 3:33 PM EDTThey haven’t been itchy lately at all.Are you having any redness in your eyes?Question07/23/20 3:33 PM EDTMy eyes haven’t been red lately. . . not since I came in with those allergies a while ago.Are your eyes dry?Question07/23/20 3:34 PM EDTMy eyes don’t feel dry.Do you have any pain in your eyes?Question07/23/20 3:34 PM EDTI 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.Are you having any ear problems?Question07/23/20 3:34 PM EDTMy ears feel fine.Any changes in your hearing?Question07/23/20 3:36 PM EDTMy hearing is good.Any ear pain?Question07/23/20 3:36 PM EDTMy ears feel fine.Ear drainage? (Clarified to Do you have drainage from your ears?.)Question07/23/20 3:36 PM EDTNothing is coming out of my ears. (Clarified to if I have ear drainage.)Any changes in your sense of smell?Question07/23/20 3:46 PM EDTNo.Any nose bleeds?Question07/23/20 3:47 PM EDTNope, my nose isn’t bleeding at all.Any sinus pressures?Question07/23/20 3:47 PM EDTMy sinuses have been fine.Has your sense of taste changed?Question07/23/20 3:47 PM EDTNo, I think my sense of taste is fine.Are you having dry mouth?Question07/23/20 3:48 PM EDTMy mouth hasn’t been dry.ANY pain in your mouth?Question07/23/20 3:48 PM EDTNo, my mouth feels fine.ANY sore throat?Question07/23/20 3:49 PM EDTNo, it’s fine.Any issue with your gums? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationQuestion07/23/20 3:49 PM EDTMy gums have been fine.Any issue with your tongue?Question07/23/20 3:49 PM EDTMy tongue feels fine.Any difficulties when swallowing?Question07/23/20 3:50 PM EDTI can swallow fine.SORE throat?Question07/23/20 3:50 PM EDTNo, it’s fine.Any voice changes?Question07/23/20 3:50 PM EDTMy voice has been fine.Any swollen lymph nodes?Question07/23/20 3:52 PM EDTMy lymph nodes seem fine.Are you having any nausea?Question07/23/20 3:52 PM EDTNo, I haven’t been nauseous at all.Any vomiting?Question07/23/20 3:53 PM EDTNo.ANY pain in the abdomen?Question07/23/20 3:53 PM EDTI haven’t really had any stomach problems since I came in with them a while ago.Any constipation?Question07/23/20 3:53 PM EDTI don’t have that problem.Any diarrhea?Question07/23/20 3:54 PM EDTI haven’t had any problems with diarrhea.Excessive flatulence?Question07/23/20 3:54 PM EDTI 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.flatulence is one of the side effect of metforminEducate07/23/20 3:55 PM EDTThanks for telling me.Any food intoleranceQuestion07/23/20 3:56 PM EDTI can eat just about anything.Any burning sensation when you urinate?Question07/23/20 3:56 PM EDTNo, it doesn’t burn when I pee.Any blood in your urine?Question07/23/20 3:57 PM EDTNo! That doesn’t sound like it would be good.Are you having any pain right now?Question07/23/20 3:57 PM EDTI don’t have any pain anywhere.Any vaginal discharge?Question07/23/20 3:58 PM EDTMy discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish.Any vaginal itching?Question07/23/20 3:58 PM EDTNo, it feels normal.Do you have any problem with your breasts?Question07/23/20 3:59 PM EDTNo, my breasts feel fine.Any pain in the breasts?Question07/23/20 3:59 PM EDTNo, my breasts feel fine.Are you having any dizziness/Question07/23/20 3:59 PM EDTI haven’t been getting dizzy at all.Any lightheadedness?Question07/23/20 4:00 PM EDTNo, I don’t really get lightheaded.Any tingling?Question07/23/20 4:00 PM EDTNope, no tingling.Any loss of balance?Question07/23/20 4:00 PM EDTMy balance is fine.Any changes in sensation?Question07/23/20 4:00 PM EDTI haven’t noticed any changes.Any seizures?Question07/23/20 4:01 PM EDTNo, I’ve still never had problems with seizures, fortunately.Do you have memory problems?Question07/23/20 4:01 PM EDTI think my memory has been fine.Any muscle pain?Question07/23/20 4:01 PM EDTMy muscles have felt great, especially since I started exercising more.Joint pain?Question07/23/20 4:02 PM EDTMy joints always seem fine.Any muscle weakness?Question07/23/20 4:02 PM EDTNo, I haven’t felt weak at all.Any swelling?Question07/23/20 4:03 PM EDTNothing is swollen. Performed pulse oximetryExam Action07/24/20 10:01 AM EDT Performed spirometryExam Action07/24/20 10:01 AM EDT Inspected scalpExam Action07/24/20 10:01 AM EDT Inspected scalpExam Action07/24/20 10:01 AM EDT Inspected hair on scalpExam Action07/24/20 10:01 AM EDT Inspected scalpExam Action07/24/20 10:01 AM EDT Inspected right eyebrow and orbital areaExam Action07/24/20 10:02 AM EDT Inspected left eyebrow and orbital areaExam Action07/24/20 10:02 AM EDT Inspected mouth: Oral mucosa moist. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExam Action07/24/20 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.Indicates an item that you found.Indicates an item that is available to be found.CategoryScored ItemsExperts selected these topics as essential components of a strong, thorough interview with this patient.Patient DataCurrent Health StatusFinding: Confirmed reason for visitFinding: Reports needing a pre-employment physicalComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation 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 problemsPro 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 providerFinding: Last visit to a healthcare provider was 4 months agoPro 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 examPro 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? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationFinding: Asked about current prescription medicationsFinding: Reports taking diabetes medicationPro 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 inhalerPro 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 pillsPro 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 medicationFinding: Medication is metforminPro 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 agoPro 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 timePro 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 doseFinding: Reports taking metformin twice dailyPro 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 mgPro 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 medicationFinding: Reports using Flovent inhaler twice dailyPro 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 inhalerPro 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 agoPro 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 yearPro 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Example Question: How often do you use your rescue inhaler?Finding: Followed up about birth control prescriptionFinding: Started taking birth control 4 months agoPro 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 symptomsPro 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. 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 dailyPro 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 dayPro 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 daysPro 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 medicationsFinding: Reports rare Advil use for crampsPro 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 productsPro 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 vitaminsPro 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 supplementsPro 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.Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Example Question: Do you take any supplements?Finding: Asked about allergiesFinding: Confirms allergiesPro 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 allergiesPro 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 allergiesFinding: Reports no recent seasonal allergy symptomsPro 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 allergiesPro 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 diabetesFinding: Reports managing diabetes with diet and exercise in addition to medicationPro 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation Example Question: How are you managing your diabetes?Finding: Asked about blood glucose monitoringFinding: Reports checking blood sugar once a dayPro 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 morningPro 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question: When do you check your blood glucose? Finding: Blood sugar number is usually around 90Pro 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 suppliesObjective 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.CategoryScored ItemsExperts selected these examinations as essential components of objective data collection for this patient.Patient DataThorough 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 & DocumentationHEENTFinding: 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, atraumaticPro 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 distributionPro 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.Shadow Health Comprehensive Assessment answer key Finding: Acanthosis nigricans noted on neckPro 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 areaFinding: 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 edemaPro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions. Finding: Palpated scalpFinding: 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.Shadow Health Comprehensive Assessment answer key Finding: Palpated sinusesFinding: No frontal sinus tenderness Pro Tip: Palpating the frontal sinuses checks for sinusitis. Finding: No maxillary sinus tendernessPro Tip: Palpating the maxillary sinuses checks for sinusitis. Finding: Palpated jawFinding: No clicks, full ROM Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury. Finding: Palpated lymph nodesFinding: No axillary lymphadenopathyPro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Finding: No supraclavicular lymphadenopathyPro 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 Finding: Palpated thyroidFinding: 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 conjunctivaFinding: 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 scleraPro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.Shadow Health Comprehensive Assessment answer key Finding: Tested PERRL with penlightFinding: 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 lightPro 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 movementsFinding: Normal convergence Pro Tip: This test accommodation assesses the eye’s ability to focus on close objects. Finding: EOMs intact bilaterally, no nystagmusPro 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 visionFinding: Peripheral vision intact in both eyes, all fields Finding: Inspected interior eyes with ophthalmoscopeComprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationFinding: 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 – deepFinding: Right upper quadrant: no masses, guarding or reboundPro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Finding: Right lower quadrant: no masses, guarding or reboundPro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation 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 organsFinding: 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 massesPro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.Shadow Health Comprehensive Assessment answer key 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. MusculoskeletalFinding: Inspected neckFinding: 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 extremitiesFinding: Right shoulder without swelling, masses, or deformityPro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Shadow Health Comprehensive Assessment answer key Finding: Right arm without swelling, masses, or deformityPro 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 deformityPro 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 deformityPro 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.Shadow Health Comprehensive Assessment answer key Finding: Left arm without swelling, masses, or deformityPro 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 deformityPro 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation. Shadow Health Comprehensive Assessment answer key 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation 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 deformityPro Tip: A comprehensive musculoskeletal exam includes the inspection of all joints and muscle groups for swelling, masses, discoloration, and deformity.Shadow Health Comprehensive Assessment answer key Finding: Right ankle without swelling, masses, deformity, or discolorationPro 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. Finding: Left leg without swelling, masses, or deformityPro 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 deformityPro 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 patient 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 extremitiesFinding: 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 spineFinding: Rotate left: full ROMPro 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 ROMPro 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 ROMPro 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 & DocumentationFinding:    Flexion: full ROMDocumentation / Electronic Health RecordVitalsStudent DocumentationModel Documentation128/82 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 FHealth HistoryStudent DocumentationModel DocumentationIdentifying Data & ReliabilityThe patient is a 28-year-old female who presented for a pre-employment physical exam. She provided the health information freely during the interview. Ms. Jones’ speech is clear and coherentMs. 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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationGeneral SurveyMs. Jones appears alert and oriented She is appropriately dressed She appears to be in good healthMs. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.Reason for VisitMs. Jones visited to have a physical exam for the health insurance at her new 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 IllnessMs. Jones reported that she recently got a job at a new place and she is required to obtain a physical examination. She does not have any acute concerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modificationsMs. 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.MedicationsMetformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)AllergiesAllergic to cats and dust 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 HistoryDiagnosed with asthma at 2 1/2 years Diagnosed with diabetes at age 24 years Last asthma exacerbation 3 months ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationAsthma 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. NeurologicalStudent DocumentationModel DocumentationSubjectiveDenies any dizziness, light-headedness, loss of sensation, tingling, numbness Denies any seizures or sense of disequilibriumReports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.ObjectiveNormal 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 surfacesNormal 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 & NailsStudent DocumentationModel DocumentationSubjectiveReports improved acne due to use of oral contraceptives Facial and body hair improved Denies any nail or hair changesReports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.ObjectiveScattered pustules on face Facial hair on upper lip Acanthosis nigricans on posterior neck Nails free of any abnormalities or ridgesScattered 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 Why is it important to obtain a patient’s complete health history Shadow health?The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient’s family so that the health care team and the patient can collaboratively create a plan that will promote health, address acute health problems, and minimize chronic health conditions.Shadow Health Comprehensive Assessment answer key What should I ask for past medical history?The Rest of the HistoryPast Medical History: Start by asking the patient if they have any medical problems. …Past Surgical History: Were they ever operated on, even as a child? …Medications: Do they take any prescription medicines? …Allergies/Reactions: Have they experienced any adverse reactions to medications?How old is Tina Jones in Shadow health?Tina Jones is a pleasant, 28-year-old African American woman who presented to the emergency department for evaluation of a right foot injury and is admitted for IV antibiotics.What questions do I ask in shadow health?“What brings you here today?” o When did it start / how long has it been going on? o Is this a new problem / first time having this problem? o Intermittent or constant? o What makes it worse • Any other symptoms that you have? What are the 7 parts of the health history?Terms in this set (7)Identifying data, source of hx, reliability.Chief concern.Present illness.Past history.Family History.P/S H. Persona/Social History.Review of Systems.What physical exam findings would indicate the presence of neuropathy Shadow Health?In physical examination of the skin of patients with peripheral neuropathy these finding may be present: skin dryness, calluses, bruises, skin color changes. Shadow Health Comprehensive Assessment answer key  

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