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Posted: September 18th, 2024

NURS 6512 Comprehensive Assessment Tina Jones Shadow Health Transcript

Building a Health History: A Patient-Centered Approach to Tina Jones.

Effective communication forms the bedrock of accurate and detailed patient history, a cornerstone of quality healthcare. Advanced practice nurses must remain cognizant of the diverse factors influencing a patient’s health, including age, gender, ethnicity, and environmental setting, tailoring their communication techniques to each individual. This approach not only fosters rapport but also facilitates the gathering of crucial information for comprehensive health risk assessment.

This paper delves into the case of Tina Jones, a 28-year-old African American female presenting for a pre-employment physical examination. We will explore specific communication techniques, a relevant risk assessment instrument, and targeted questions to effectively build her health history.

Understanding Tina Jones: Tailoring Communication Techniques
Tina presents as a young adult starting a new job, potentially indicating a period of both excitement and stress. Employing open-ended questions and active listening will be crucial to creating a safe space for her to share information openly. For instance, instead of directly asking about her stress levels, starting with “How are you feeling about starting your new job?” can elicit a more nuanced understanding of her emotional state.

Given her history of asthma and type 2 diabetes, diagnosed at a young age, it is important to assess her understanding and management of these chronic conditions. Utilizing a conversational, rather than interrogative, tone when discussing her health history can encourage her active participation. Additionally, acknowledging her efforts in managing her conditions, such as her positive lifestyle modifications, can reinforce her agency in her healthcare.

Assessing Health Risks: The Role of the American Diabetes Association (ADA) Risk Test
Considering Tina’s medical history, the ADA Risk Test emerges as a particularly relevant risk assessment instrument (American Diabetes Association, 2023). This tool evaluates an individual’s risk for developing type 2 diabetes based on factors like age, weight, family history, and physical activity levels. Given Tina’s existing diagnosis, the test can be reframed to assess her risk for developing complications related to diabetes.

Targeted Questions: Uncovering Potential Risks and Concerns
Building upon the ADA Risk Test, the following targeted questions can provide valuable insights into Tina’s health risks and guide further investigation:

“You mentioned you’ve made positive lifestyle changes. Can you tell me more about your diet and exercise routine?” (This open-ended question explores her diabetes management and identifies areas for potential intervention).
“Do you have any family history of diabetes-related complications, such as heart disease or eye problems?” (This question assesses her awareness of potential long-term risks associated with diabetes).
“How would you describe your stress levels, and what strategies do you use to manage stress?” (This question explores the potential impact of stress on her diabetes and overall well-being).
“Have you noticed any changes in your vision or experienced any numbness or tingling in your hands or feet?” (This question screens for potential complications related to diabetes, such as retinopathy and neuropathy).
“Do you feel comfortable discussing your sexual health and any concerns you might have?” (This question creates a safe space to address potential risks associated with PCOS and initiate a conversation about contraception and sexually transmitted infections).
Conclusion
Building a comprehensive health history requires a patient-centered approach that prioritizes effective communication and culturally sensitive care. By understanding Tina’s background, utilizing appropriate risk assessment tools like the ADA Risk Test, and asking targeted questions, healthcare providers can empower her to actively participate in her healthcare journey and mitigate potential health risks.

References

American Diabetes Association. (2023). Diabetes risk test. https://www.diabetes.org/risk-test
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at an advanced level. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

===================

Building a Health History.

Effective communication is essential in constructing an accurate and detailed patient history. A patient’s health or illness is influenced by various factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, understanding these factors and tailoring communication techniques accordingly is crucial. This paper explores the methods for building a health history, focusing on a case study involving Tina Jones, a 28-year-old African American woman.

Communication Techniques
When interviewing patients like Tina Jones, employing open-ended questions and active listening is vital. These techniques encourage patients to share detailed information about their health. For instance, asking, “Can you tell me more about your asthma management?” allows the patient to provide comprehensive insights into their condition. Additionally, maintaining eye contact and using empathetic responses, such as “That sounds challenging,” can help build rapport and trust (Ball et al., 2023).

Social Determinants of Health
Social determinants significantly impact health outcomes. For Tina, factors such as her employment status, access to healthcare, and social support systems are crucial. Questions like “How does your job affect your health management?” can uncover potential stressors or barriers to care. Understanding these elements helps tailor interventions that address specific needs (Diamond-Fox, 2021).

Risk Assessment Instruments
Selecting appropriate risk assessment tools is essential for identifying potential health risks. For Tina, the “Timed Up and Go” (TUG) test could be useful in assessing fall risk, given her history of diabetes and potential neuropathy (Chow et al., 2019). This tool is simple, quick, and provides valuable information about mobility and balance.

Targeted Questions
To build a comprehensive health history, the following questions are proposed:

How do you manage your diabetes daily?
What triggers your asthma symptoms, and how do you handle them?
Can you describe any recent changes in your health or medications?
How does your family history influence your health concerns?
What support systems do you rely on for managing your health?
These questions aim to gather detailed information about Tina’s health management strategies, potential triggers, and support systems.

Conclusion
Building a health history requires effective communication, understanding social determinants, and using appropriate risk assessment tools. By employing these strategies, healthcare providers can gather comprehensive information, enabling them to deliver personalized and effective care. For Tina Jones, this approach ensures that her unique health needs are addressed, promoting better health outcomes.

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

Chow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED. The American Journal of Emergency Medicine, 37(3), 457–460. https://doi.org/10.1016/j.ajem.2018.06.015

Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238

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NURS 6512 Comprehensive Assessment Tina Jones Shadow Health Transcript Provided

NURS 6512 Week 1: Discussion
Building A Health History – We Can Reliably Complete This And Related Assignments In This Course, Including All The Required Shadow Health Assessments. These Include Tina Jones Health History, Focused Cough Assessment On Danny Rivera, Focused Assessment – Chest Pain On Brian Foster, And The Comprehensive Health Assessment On Tina Jones.
Effective communication is vital to constructing an accurate and detailed patient history. A patient’s health or illness is influenced by many factors, including age, gender, ethnicity, and environmental setting. As an advanced practice nurse, you must be aware of these factors and tailor your communication techniques accordingly. Doing so will not only help you establish rapport with your patients, but it will also enable you to more effectively gather the information needed to assess your patients’ health risks.

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

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

WEEKLY RESOURCES

To prepare:

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

By Day 1 of this week, you will be assigned a new patient profile by your Instructor for this Discussion. Note: Please see the “Course Announcements” section of the classroom for your new patient profile assignment.
How would your communication and interview techniques for building a health history differ with each patient?
How might you target your questions for building a health history based on the patient’s social determinants of health?
What risk assessment instruments would be appropriate to use with each patient, or what questions would you ask each patient to assess his or her health risks?
Identify any potential health-related risks based upon the patient’s age, gender, ethnicity, or environmental setting that should be taken into consideration.
Select one of the risk assessment instruments presented in Chapter 2 or Chapter 5 of the Seidel’s Guide to Physical Examination text, or another tool with which you are familiar, related to your selected patient.
Develop at least five targeted questions you would ask your selected patient to assess his or her health risks and begin building a health history.
BY DAY 3 OF WEEK 1
Post a summary of the interview and a description of the communication techniques you would use with your assigned patient. Explain why you would use these techniques. Identify the risk assessment instrument you selected, and justify why it would be applicable to the selected patient. Provide at least five targeted questions you would ask the patient.

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

Read a selection of your colleagues’ responses.

BY DAY 6 OF WEEK 1

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

Share additional interview and communication techniques that could be effective with your colleague’s selected patient.
Suggest additional health-related risks that might be considered.
Validate an idea with your own experience and additional research
Learning Resources
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
o Chapter 2, “The History and Interviewing Proce
This chapter explains the process of developing relationships with patients in order to build an effective health history. The authors offer suggestions for adapting the creation of a health history according to age, gender, and disability.

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

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
o Chapter 2, “The Comprehensive History and Physical Exam” (pp. 19–29)

Adly, N. N., Abd-El-Gawad, W. M., & Abou-Hashem, R. M. (2019). Relationship between malnutrition and different fall risk assessment tools in a geriatric in-patient unit. Aging Clinical and Experimental Research, 32(7), 1279–1287. https://doi.org/10.1007/s40520-019-01309-0
Chow, R. B., Lee, A., Kane, B. G., Jacoby, J. L., Barraco, R. D., Dusza, S. W., Meyers, M. C., & Greenberg, M. R. (2019). Effectiveness of the “Timed Up and Go” (TUG) and the Chair test as screening tools for geriatric fall risk assessment in the ED. The American Journal of Emergency Medicine, 37(3), 457–460. https://doi.org/10.1016/j.ajem.2018.06.015
Diamond-Fox, S. (2021). Undertaking consultations and clinical assessments at advanced level. British Journal of Nursing, 30(4), 238–243. https://doi.org/10.12968/bjon.2021.30.4.238
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

Shadow Health. (2021). Welcome to your introduction to Shadow Health. https://link.shadowhealth.com/Student-Orientation-Video
Shadow Health. (n.d.). Shadow Health help deskLinks to an external site. Retrieved from https://support.shadowhealth.com/hc/en-us
Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students. Download Walden University quick start guide: NURS 6512 NP students.
Document: Shadow Health Nursing Documentation Tutorial Download Shadow Health Nursing Documentation Tutorial(Word document)
Required Media
Welcome and General Course Guidelines
Dr. Tara Harris reviews the overall guidelines and the expectations for the course. Consider how you will manage your time as you review your media and Learning Resources throughout the course to better prepare for your Discussions, Case Study Lab Assignments, Digital Clinical Experience (DCE) Assignments, and your Midterm and Final Exams (14m).

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

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

Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw- Hill Medical.
o Chapter 2, “History Taking and the Medical Record” (pp. 1)

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

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

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

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. 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! Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
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
I am sorry about the experience. Empathize
07/22/20 5:52 PM EDT
Thanks. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
It is important to stay away from triggers. Educate
07/22/20 5:54 PM EDT
Thanks for telling me. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
What inhaler do you use? Question
07/22/20 5:59 PM EDT
The daily inhaler is Flovent, and the rescue inhaler is Proventil. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
Are you feeling stressed? Question
07/22/20 7:40 PM EDT
I’m 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 overwhelmed with everything back when I had 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–attending church, especially–is all working well for me. Comprehensive Assessment Tina Jones Shadow Health Transcript
Thanks. Comprehensive Assessment Tina Jones Shadow Health Transcript
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
I’m starting my new job in two weeks, and I’m excited about that. I’m going to be an Accounting Clerk at this nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple of years, I’ll get promoted and be given new responsibilities. I always want to learn new things and improve my job. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
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, about 8 or 9 hours a night.
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; 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 issues? (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 rarely has attacks. (Clarified to if my younger sister has health problems.)
Does your brother 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 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. Comprehensive Assessment Tina Jones Shadow Health Transcript
Have you had any recent illnesses? 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; 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? 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. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Comprehensive Assessment Tina Jones Shadow Health Transcript
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. Exam Action
07/24/20 10:02 AM EDT
Subjective Data Collection: 50 of 50 (100.0%)

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

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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.

HEENT

Fining: Inspected head and neck

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

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

Finding: Head is normocephalic, atraumatic

Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient’s head can identify any indications of trauma.

Finding: Normal scalp hair distribution

Pro Tip: It’s important to inspect your patient’s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.

Finding: Acanthosis nigricans noted on neck

Pro Tip: Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient’s skin, especially in folds around the neck, axilla, and groin.

Finding: Inspected eyebrows and orbital area

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

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

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

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

Finding: Palpated scalp

Finding: No masses

Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.

Finding: Palpated sinuses

Finding: No frontal sinus tenderness

Pro Tip: Palpating the frontal sinuses checks for sinusitis.

Finding: No maxillary sinus tenderness

Pro Tip: Palpating the maxillary sinuses checks for sinusitis.

Finding: Palpated jaw

Finding: No clicks, full ROM

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

Finding: Palpated lymph nodes

Finding: No axillary lymphadenopathy

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

Finding: No supraclavicular lymphadenopathy

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

Finding: Palpated thyroid

Finding: Thyroid smooth without nodules, no goiter

Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.

Finding: Inspected eyelids and conjunctiva

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

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

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

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

Finding: Tested PERRL with penlight

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

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

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

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

Finding: Tested eye movements

Finding: Normal convergence

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

Finding: EOMs intact bilaterally, no nystagmus

Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions.

Finding: Tested peripheral vision

Finding: Peripheral vision intact in both eyes, all fields

Finding: Inspected interior eyes with ophthalmoscope

Finding: Mild retinopathic changes on right

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

Finding: Left fundus with sharp disc margins, no hemorrhages

Finding: Palpated abdomen – deep

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

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

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

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

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

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

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

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

Finding: Palpated organs

Finding: Liver: palpable 1 cm below right costal margin

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

Finding: Spleen: not palpable

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

Finding: Right kidney: not palpable, no masses

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

Finding: Left kidney: not palpable, no masses

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

Musculoskeletal

Finding: Inspected neck

Finding: Neck without swelling, masses, or deformity