Last Updated on April 13, 2024 by Pius

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

Transcript

All 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 & Documentation	Greet 07/22/20 5:37 PM EDT
	Hey.
	What is your name?	Question 07/22/20 5:37 PM EDT
	Tina Jones.
	What is your date of birth?	Question 07/22/20 5:37 PM EDT
	February 17th.
	How old are you?	Question 07/22/20 5:43 PM EDT
	I’m 28.
	What brings you into the clinic today?	Question 07/22/20 5:43 PM EDT
	I 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?	Question 07/22/20 5:44 PM EDT
	I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days.
	What is your new job?	Question 07/22/20 5:44 PM EDT
	I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–I’m really excited!
	That is great.	Empathize 07/22/20 5:45 PM EDT
	Thanks.
	When was your last physical exam?	Question 07/22/20 5:45 PM EDT
	Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.
	What did your gynecologist say?	Question 07/22/20 5:45 PM EDT
	She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things.
	How often do you take birth control?	Question 07/22/20 5:48 PM EDT
	I take it every morning, with breakfast.
	What is the name of the birth control pill you took?	Question 07/22/20 5:49 PM EDT
	They’re called Yaz.
	Has your menstrual cycle improved since taking Yaz?	Question 07/22/20 5:50 PM EDT
	Now 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.	Empathize 07/22/20 5:50 PM EDT
	Thanks.
	How long have you had asthma?	Question 07/22/20 5:51 PM EDT
	I’ve had asthma a long time. . . since I was really little.
	What age were you diagnosed with asthma?	Question 07/22/20 5:51 PM EDT
	My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
	I am sorry about the experience.	Empathize 07/22/20 5:52 PM EDT
	Thanks.
	How do you manage your asthma?	Question 07/22/20 5:52 PM EDT
	I 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?	Question 07/22/20 5:53 PM EDT
	Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though.
	It is important to stay away from triggers.	Educate 07/22/20 5:54 PM EDT
	Thanks for telling me.
	What happens when you are around dust?	Question 07/22/20 5:54 PM EDT
	I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler.
	What inhaler do you use?	Question 07/22/20 5:59 PM EDT
	The daily inhaler is Flovent, and the rescue inhaler is Proventil.
	How often do you use Flovent?	Question 07/22/20 6:00 PM EDT
	Twice a day.
	When did you most recently use the Flovent inhaler?	Question 07/22/20 6:01 PM EDT
	I use my Flovent inhaler two times a day.
	When did you last use your inhaler?	Question 07/22/20 6:03 PM EDT
	I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too.
	How much Albuterol do you use?	Question 07

 

I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church.

 

	What is your relationship like with your family?	Question 07/22/20 7:39 PM EDT
	Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along.
	That is great.	Empathize 07/22/20 7:39 PM EDT
	Thanks.
	Are you involved in church?	Question 07/22/20 7:39 PM EDT
	Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.
	Are you feeling stressed?	Question 07/22/20 7:40 PM EDT
	I’m actually feeling really good lately. . . not stressed at all.
	How do you cope with stress?	Question 07/22/20 7:40 PM EDT
	I’ve realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I’ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me.
	That is good to hear.	Empathize 07/22/20 7:40 PM EDT
	Thanks.
	Are you feeling depressed?	Question 07/22/20 7:41 PM EDT
	No, I’m actually feeling really good these days.
	How do you feel about your life?	Question 07/22/20 7:41 PM EDT
	Well, I’m starting my new job in two weeks, and I’m really excited about that. I’m going to be an Accounting Clerk at this really nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple years, I’ll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job.
	Are you feeling anxious?	Question 07/22/20 7:41 PM EDT
	I 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?	Question 07/22/20 7:42 PM EDT
	I’m sleeping a lot better now, which is a relief.
	Good to hear.	Empathize 07/22/20 7:42 PM EDT
	Thanks.
	How many hours are you sleeping a night?	Question 07/22/20 7:42 PM EDT
	I’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 & Documentation
	That is great.	Empathize 07/22/20 7:42 PM EDT
	Thanks.
	Have you ever smoked tobacco?	Question 07/22/20 7:43 PM EDT
	No. I think it’s gross.
	Have you ever used cocaine?	Question 07/22/20 7:43 PM EDT
	No way, I have no interest in that. That stuff can mess you up.
	Have you ever used heroin?	Question 07/22/20 7:49 PM EDT
	Uh, no.
	Have you ever used illegal drugs?	Question 07/23/20 3:17 PM EDT
	Well, I used to smoke pot. . . but I don’t do that anymore.
	What was the last time you smoked pot?	Question 07/23/20 3:17 PM EDT
	I haven’t smoked pot since I was twenty or twenty-one.
	Do you have any family history of mental illness?	Question 07/23/20 3:18 PM EDT
	No. They’re crazy, but nobody’s diagnosed with anything.
	Have you had suicidal thoughts?	Question 07/23/20 3:19 PM EDT
	No, I’ve never done that.
	Any new family medical history report?	Question 07/23/20 3:20 PM EDT
	My mom has some issues, and I think some of my grandparents did, too.
	How old is your mom?	Question 07/23/20 3:21 PM EDT
	Mom is 50.
	What medical problems does your mum have?	Question 07/23/20 3:21 PM EDT
	Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
	What medical problems did your father have?	Question 07/23/20 3:22 PM EDT
	He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
	How old is your brother?	Question 07/23/20 3:24 PM EDT
	He’s almost 27.
	Does he have any medical issue? (Clarified to Does your younger sister have health problems?.)	Question 07/23/20 3:25 PM EDT
	She’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?.)	Question 07/23/20 3:25 PM EDT
	No, 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?	Question 07/23/20 3:26 PM EDT
	Nana 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?	Question 07/23/20 3:27 PM EDT
	Poppa 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?	Question 07/23/20 3:30 PM EDT
	She 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?	Question 07/23/20 3:30 PM EDT
	Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes.
	Have you had any recent illness?	Question 07/23/20 3:31 PM EDT
	No. . . the last time I was sick was when I was having those heartburn problems a while ago.
	Any fever?	Question 07/23/20 3:32 PM EDT
	I haven’t had a fever.
	Any chills?	Question 07/23/20 3:32 PM EDT
	Nope, no chills.
	Any acne?	Question 07/23/20 3:32 PM EDT
	I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything special. But my zits have gotten better, and I think it’s because I’m on birth control now.
	Has your body hair improved?	Question 07/23/20 3:32 PM EDT
	I think I have a little less body hair than I used to.
	Do your eyes feel itchy?	Question 07/23/20 3:33 PM EDT
	They haven’t been itchy lately at all.
	Are you having any redness in your eyes?	Question 07/23/20 3:33 PM EDT
	My eyes haven’t been red lately. . . not since I came in with those allergies a while ago.
	Are your eyes dry?	Question 07/23/20 3:34 PM EDT
	My eyes don’t feel dry.
	Do you have any pain in your eyes?	Question 07/23/20 3:34 PM EDT
	I haven’t had any eye problems lately–I went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good.
	Are you having any ear problems?	Question 07/23/20 3:34 PM EDT
	My ears feel fine.
	Any changes in your hearing?	Question 07/23/20 3:36 PM EDT
	My hearing is good.
	Any ear pain?	Question 07/23/20 3:36 PM EDT
	My ears feel fine.
	Ear drainage? (Clarified to Do you have drainage from your ears?.)	Question 07/23/20 3:36 PM EDT
	Nothing is coming out of my ears. (Clarified to if I have ear drainage.)
	Any changes in your sense of smell?	Question 07/23/20 3:46 PM EDT
	No.
	Any nose bleeds?	Question 07/23/20 3:47 PM EDT
	Nope, my nose isn’t bleeding at all.
	Any sinus pressures?	Question 07/23/20 3:47 PM EDT
	My sinuses have been fine.
	Has your sense of taste changed?	Question 07/23/20 3:47 PM EDT
	No, I think my sense of taste is fine.
	Are you having dry mouth?	Question 07/23/20 3:48 PM EDT
	My mouth hasn’t been dry.
	ANY pain in your mouth?	Question 07/23/20 3:48 PM EDT
	No, my mouth feels fine.
	ANY sore throat?	Question 07/23/20 3:49 PM EDT
	No, it’s fine.
	Any issue with your gums? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation	Question 07/23/20 3:49 PM EDT
	My gums have been fine.
	Any issue with your tongue?	Question 07/23/20 3:49 PM EDT
	My tongue feels fine.
	Any difficulties when swallowing?	Question 07/23/20 3:50 PM EDT
	I can swallow fine.
	SORE throat?	Question 07/23/20 3:50 PM EDT
	No, it’s fine.
	Any voice changes?	Question 07/23/20 3:50 PM EDT
	My voice has been fine.
	Any swollen lymph nodes?	Question 07/23/20 3:52 PM EDT
	My lymph nodes seem fine.
	Are you having any nausea?	Question 07/23/20 3:52 PM EDT
	No, I haven’t been nauseous at all.
	Any vomiting?	Question 07/23/20 3:53 PM EDT
	No.
	ANY pain in the abdomen?	Question 07/23/20 3:53 PM EDT
	I haven’t really had any stomach problems since I came in with them a while ago.
	Any constipation?	Question 07/23/20 3:53 PM EDT
	I don’t have that problem.
	Any diarrhea?	Question 07/23/20 3:54 PM EDT
	I haven’t had any problems with diarrhea.
	Excessive flatulence?	Question 07/23/20 3:54 PM EDT
	I haven’t been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked.
	flatulence is one of the side effect of metformin	Educate 07/23/20 3:55 PM EDT
	Thanks for telling me.
	Any food intolerance	Question 07/23/20 3:56 PM EDT
	I can eat just about anything.
	Any burning sensation when you urinate?	Question 07/23/20 3:56 PM EDT
	No, it doesn’t burn when I pee.
	Any blood in your urine?	Question 07/23/20 3:57 PM EDT
	No! That doesn’t sound like it would be good.
	Are you having any pain right now?	Question 07/23/20 3:57 PM EDT
	I don’t have any pain anywhere.
	Any vaginal discharge?	Question 07/23/20 3:58 PM EDT
	My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish.
	Any vaginal itching?	Question 07/23/20 3:58 PM EDT
	No, it feels normal.
	Do you have any problem with your breasts?	Question 07/23/20 3:59 PM EDT
	No, my breasts feel fine.
	Any pain in the breasts?	Question 07/23/20 3:59 PM EDT
	No, my breasts feel fine.
	Are you having any dizziness/	Question 07/23/20 3:59 PM EDT
	I haven’t been getting dizzy at all.
	Any lightheadedness?	Question 07/23/20 4:00 PM EDT
	No, I don’t really get lightheaded.
	Any tingling?	Question 07/23/20 4:00 PM EDT
	Nope, no tingling.
	Any loss of balance?	Question 07/23/20 4:00 PM EDT
	My balance is fine.
	Any changes in sensation?	Question 07/23/20 4:00 PM EDT
	I haven’t noticed any changes.
	Any seizures?	Question 07/23/20 4:01 PM EDT
	No, I’ve still never had problems with seizures, fortunately.
	Do you have memory problems?	Question 07/23/20 4:01 PM EDT
	I think my memory has been fine.
	Any muscle pain?	Question 07/23/20 4:01 PM EDT
	My muscles have felt great, especially since I started exercising more.
	Joint pain?	Question 07/23/20 4:02 PM EDT
	My joints always seem fine.
	Any muscle weakness?	Question 07/23/20 4:02 PM EDT
	No, I haven’t felt weak at all.
	Any swelling?	Question 07/23/20 4:03 PM EDT
	Nothing is swollen.
	Performed pulse oximetry	Exam Action 07/24/20 10:01 AM EDT
	Performed spirometry	Exam Action 07/24/20 10:01 AM EDT
	Inspected scalp	Exam Action 07/24/20 10:01 AM EDT
	Inspected scalp	Exam Action 07/24/20 10:01 AM EDT
	Inspected hair on scalp	Exam Action 07/24/20 10:01 AM EDT
	Inspected scalp	Exam Action 07/24/20 10:01 AM EDT
	Inspected right eyebrow and orbital area	Exam Action 07/24/20 10:02 AM EDT
	Inspected left eyebrow and orbital area	Exam Action 07/24/20 10:02 AM EDT
	Inspected mouth: Oral mucosa moist. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation	Exam Action 07/24/20 10:02 AM EDT

 

Subjective Data Collection: 50 of 50 (100.0%)

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Patient Data

Current Health Status

Finding: Confirmed reason for visit

Finding: Reports needing a pre-employment physical

Comprehensive Assessment Tina Jones Shadow Health

 

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

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.

 

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

 

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

Finding: Has a Proventil rescue inhaler

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.

 

Example Question: Do you have a rescue inhaler?

Finding: Last use of Proventil inhaler was three months ago

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. 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 prescription

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

 

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

Finding: Takes birth control pill daily

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.

 

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

 

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

 

Example Question: How are you managing your diabetes?

Finding: Asked about blood glucose monitoring

Finding: Reports checking blood sugar once a day

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

Example Question: When do you check your blood glucose?

 

Finding: 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’s complied with previous treatment plans.

 

Example Question: What is your average blood sugar number?

Finding: Reports having adequate supplies

Objective Data Collection: 70 of 73 (95.9%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips.

Found: Indicates an item that you found.

Available: Indicates an item that is available to be found.

Category

Scored Items

Experts selected these examinations as essential components of objective data collection for this patient.

Patient Data

Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient’s case. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

HEENT

Finding: Inspected head and neck

 

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

 

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

 

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

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

 

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 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.

 

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

 

Finding:    Flexion: full ROM

Documentation / Electronic Health Record

Vitals

Student Documentation	Model Documentation
128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs	• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F

Health History

Student Documentation	Model Documentation
Identifying Data & Reliability   The patient is a 28-year-old female who presented for a pre-employment physical exam. She provided the health information freely during the interview. Ms. Jones’ speech is clear and coherent	Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
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 Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation	Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.

 

Neurological

Student Documentation	Model Documentation
Subjective   Denies any 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.
Objective   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. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Nursing Assignments

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