Week 9 Assignment: Shadow Health Comprehensive SOAP Note Template

Shadow Health Comprehensive SOAP Note Template

Patient Initials: _____T.J__ Age: __28__ Gender: F

SUBJECTIVE DATA:

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Chief Complaint (CC): “I visited the clinic for a physical examination, which is required for my new job.”

History of Present Illness (HPI): T.J has visited the clinic after securing new employment. The company requires her to present a physical examination report before being issued medical insurance coverage. In today’s clinical interview, T.J denies any acute healthcare problems. The client reports visiting Shadow Health General Clinic for her annual gynecological exam. During the examination, her gynecologist diagnosed her with the polycystic ovarian syndrome (PCOS). She was prescribed an oral contraceptive to treat this condition. The client has type 2 diabetes (T2D), which she manages using metformin, a healthy diet, and exercise. She started managing T2D in the past 5 months. She denies any drug-related side effects. T.J reports feeling healthy, and she is eager to start the new job.

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Medications:

Fluticasone propionate, 110 mcg 2 puffs BID

Drospirenone and Ethinyl estradiol PO

Metformin, 850 mg PO BID

Acetaminophen 500-1000 mg PO

Albuterol 90 mcg/spray MDI 2 puffs

Ibuprofen 600 mg PO

Allergies: The client reports being allergic to cats, penicillin, and dust. She denies latex or food allergy.

Past Medical History (PMH): T. J was diagnosed with asthma at 2.5yo, which she manages using inhalers. She was diagnosed with diabetes at 24 yo. She has been managing it using metformin for the past five months. Additionally, she manages T2D using diet and exercise.

Past Surgical History (PSH): The client denies surgical history.

Sexual/Reproductive History: Denies having children or being pregnant.

Personal/Social History: The client denies having children or being married. She currently lives in a single-family home with her sister and her mother. However, she will move to her apartment next month. She likes attending bible study, reading, and spending time with her family and friends. Being active in the church and spending time with family helps her to cope with stress. She denies tobacco use. Reports using cannabis between the age of 15 and 21 years. Denies using cocaine, heroin, or methamphetamines. She uses alcohol occasionally when she goes out with her friends.

Health Maintenance: The client had a Pap smear in the last four months. She had eye examination in the last 3 months. She reports eating healthy. Her last dental review was over the previous 5 months.

Immunization History: The client reports receiving a tetanus booster currently. She denies her influenza shot being present.

Significant Family History: The client reported that his father died at 58 years and he had been diagnosed with diabetes mellitus, high cholesterol, and high blood pressure. She adds that her mother is alive with high cholesterol and hypertension. Her sister has asthma, while her brother has obesity. She reveals that her maternal grandfather died of a stroke and had been diagnosed with high blood pressure. Similarly, her maternal grandmother died of a stroke. T.J’s paternal grandfather had been diagnosed with diabetes and died of colon cancer.

Review of Systems:

General: Denies night sweats. Reports she has been losing weight recently following lifestyle changes.

HEENT: Denies headache or head injury. Denies dry or itchy eyes. Denies changes in hearing. Denies sneezing or rhinorrhea. Denies changes in taste. Denies any current dental issues. Denies difficulty swallowing. Denies sore throat.

Respiratory: Denies chest pain or wheezing.

Cardiovascular/Peripheral Vascular: Denies palpitations or edema.

Gastrointestinal: Denies food intolerance, nausea, or vomiting.

Genitourinary: Reports testing negative for STIs in the last four months. Reports being diagnosed with PCOS in the past 4 months.

Musculoskeletal: Denies joint pain

Neurological: Denies dizziness or lightheadedness

Psychiatric: Denies sleep difficulties or anxiety.

Skin/hair/nails: Reports reduced acne following prescription of oral contraceptives.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Height: 170 cm, Weight: 84 kg, BMI: 29.0, RR: 15, Blood Glucose: 100, HR: 78, BP: 128 / 82, Pulse Ox: 99%, and Temperature: 99.0 F.

General: The client is neat, presentable, and appropriately dressed for her age and today’s weather. She is alert and oriented to places, people, situations, and events. She is attentive and maintains eye contact throughout the clinical interview. She does not seem to be in acute or mild distress.

HEENT: She has a nomocephalic head. She has eyelids without lesions. She has no discharge on the external ear. Moist nasal mucosa. Tonsils 2+ bilaterally.

Neck: No discoloration on the neck.

Chest/Lungs: Clear lung sound.

Heart/Peripheral Vascular: Regular heart rate with no murmurs.

Abdomen: Normal bowel sound in all quadrants.

Genital/Rectal: Was deferred by the client

Musculoskeletal: No swelling at the joint.

Neurological: Normal bilateral movement

Skin: Acne on the face.

Diagnostic results:

No diagnostics needed

ASSESSMENT:

The following are potential diagnoses for this client;

Diabetes 2 Mellitus: The client reports that she was diagnosed with DT2 at 24 years. She has been managing this condition using lifestyle modifications, including taking a healthy diet and increasing exercise. Additionally, the client has been using Metformin, 850 mg PO BID, for the last 5 months to manage blood sugar.

Asthma: The client reports being diagnosed with asthma at 21/2 years. She has been managing it using Fluticasone propionate, 110 mcg two puffs BID, and Albuterol 90 mcg/spray MDI 2 puffs. However, she denies a recent asthma exacerbation incident.

PCOS: The client was diagnosed with PCOS during an annual gynecological examination five months ago. She has been using Drospirenone and Ethinyl estradiol PO to manage this condition.

Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.

Photo Credit: Getty Images/Hero Images

To Prepare
Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
Also, your Week 9 Assignment 3 should be in the Complete SOAP Note format.
***Below is the transcript to use to create SOAP note***I came in because I’m required to have a recent physical exam for the health insurance at my new job.
Your avatar
Do you have any current health problem?
Question

Tina Jones
I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days.
Your avatar
What is your new job? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
Question
Tina Jones
I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–I’m really excited!
Your avatar
That is great.
Empathize

Tina Jones
Thanks.
Your avatar
When was your last physical exam?
Question
Tina Jones
Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.
Your avatar
What did your gynecologist say?
Question
07/22/20 5:45 PM EDT

Tina Jones
She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things.
Your avatar
How often do you take birth control?
Question
07/22/20 5:48 PM EDT

Tina Jones
I take it every morning, with breakfast.
Your avatar
What is the name of the birth control pill you took?
Question
07/22/20 5:49 PM EDT

Tina Jones
They’re called Yaz.
Your avatar
Has your menstrual cycle improved since taking Yaz?
Question
07/22/20 5:50 PM EDT

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

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

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

Tina Jones
My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.
Your avatar
I am sorry about the experience.
Empathize

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

Tina Jones
I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
Your avatar
What are your triggers for asthma?
Question

Tina Jones
Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though.
Your avatar
It is important to stay away from triggers.
Educate

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

Tina Jones
I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler.
Your avatar
What inhaler do you use?
Question

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

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

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

Tina Jones
I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too.
Your avatar
How much Albuterol do you use?
Question

I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church.
Your avatar
What is your relationship like with your family?
Question

Tina Jones
Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along.
Your avatar
That is great.
Empathize

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

Tina Jones
Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.
Your avatar
Are you feeling stressed?
Question
Tina Jones
I’m actually feeling really good lately. . . not stressed at all.
Your avatar
How do you cope with stress?
Question

Tina Jones
I’ve realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I’ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me.
Your avatar
That is good to hear.
Empathize

Tina Jones
Thanks.
Your avatar
Are you feeling depressed?
Question

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

Tina Jones
Well, I’m starting my new job in two weeks, and I’m really excited about that. I’m going to be an Accounting Clerk at this really nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple years, I’ll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job.
Your avatar
Are you feeling anxious?
Question

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

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

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

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

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

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

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

Tina Jones
Uh, no.
Your avatar
Have you ever used illegal drugs?
Question
07/23/20 3:17 PM EDT

Tina Jones
Well, I used to smoke pot. . . but I don’t do that anymore.
Your avatar
What was the last time you smoked pot?
Question
07/23/20 3:17 PM EDT

Tina Jones
I haven’t smoked pot since I was twenty or twenty-one.
Your avatar
Do you have any family history of mental illness?
Question
07/23/20 3:18 PM EDT

Tina Jones
No. They’re crazy, but nobody’s diagnosed with anything.
Your avatar
Have you had suicidal thoughts?
Question
07/23/20 3:19 PM EDT

Tina Jones
No, I’ve never done that.
Your avatar
Any new family medical history report?
Question
07/23/20 3:20 PM EDT

Tina Jones
My mom has some issues, and I think some of my grandparents did, too.
Your avatar
How old is your mom?
Question
07/23/20 3:21 PM EDT

Tina Jones
Mom is 50.
Your avatar
What medical problems does your mum have?
Question
07/23/20 3:21 PM EDT

Tina Jones
Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.
Your avatar
What medical problems did your father have?
Question
07/23/20 3:22 PM EDT

Tina Jones
He had high blood pressure and cholesterol, and diabetes too…the same kind as me.
Your avatar
How old is your brother?
Question
07/23/20 3:24 PM EDT

Tina Jones
He’s almost 27.
Your avatar
Does he have any medical issue? (Clarified to Does your younger sister have health problems?.)
Question
07/23/20 3:25 PM EDT

Tina Jones
She’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.)
Your avatar
Does your bother have health issues? (Clarified to Does your brother have medical problems?.)
Question
07/23/20 3:25 PM EDT

Tina Jones
No, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.)
Your avatar
How old is your maternal grandmother?
Question
07/23/20 3:26 PM EDT

Tina Jones
Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.
Your avatar
How old is your maternal grandfather?
Question
07/23/20 3:27 PM EDT

Tina Jones
Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.
Your avatar
Any medical history for your paternal grandmother?
Question
07/23/20 3:30 PM EDT

Tina Jones
She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.
Your avatar
Does your dad’s father have health issues?
Question
07/23/20 3:30 PM EDT

Tina Jones
Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes.
Your avatar
Have you had any recent illness?
Question
07/23/20 3:31 PM EDT

Tina Jones
No. . . the last time I was sick was when I was having those heartburn problems a while ago.
Your avatar
Any fever?
Question
07/23/20 3:32 PM EDT

Tina Jones
I haven’t had a fever.
Your avatar
Any chills?
Question
07/23/20 3:32 PM EDT

Tina Jones
Nope, no chills.
Your avatar
Any acne?
Question
07/23/20 3:32 PM EDT

Tina Jones
I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything special. But my zits have gotten better, and I think it’s because I’m on birth control now.
Your avatar
Has your body hair improved?
Question
07/23/20 3:32 PM EDT

Tina Jones
I think I have a little less body hair than I used to.
Your avatar
Do your eyes feel itchy?
Question
07/23/20 3:33 PM EDT

Tina Jones
They haven’t been itchy lately at all.
Your avatar
Are you having any redness in your eyes?
Question
07/23/20 3:33 PM EDT

Tina Jones
My eyes haven’t been red lately. . . not since I came in with those allergies a while ago.
Your avatar
Are your eyes dry?
Question
07/23/20 3:34 PM EDT

Tina Jones
My eyes don’t feel dry.
Your avatar
Do you have any pain in your eyes?
Question
07/23/20 3:34 PM EDT

Tina Jones
I haven’t had any eye problems lately–I went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good.
Your avatar
Are you having any ear problems?
Question
07/23/20 3:34 PM EDT

Tina Jones
My ears feel fine.
Your avatar
Any changes in your hearing?
Question
07/23/20 3:36 PM EDT

Tina Jones
My hearing is good.
Your avatar
Any ear pain?
Question
07/23/20 3:36 PM EDT

Tina Jones
My ears feel fine.
Your avatar
Ear drainage? (Clarified to Do you have drainage from your ears?.)
Question
07/23/20 3:36 PM EDT

Tina Jones
Nothing is coming out of my ears. (Clarified to if I have ear drainage.)
Your avatar
Any changes in your sense of smell?
Question
07/23/20 3:46 PM EDT

Tina Jones
No.
Your avatar
Any nose bleeds?
Question
07/23/20 3:47 PM EDT

Tina Jones
Nope, my nose isn’t bleeding at all.
Your avatar
Any sinus pressure?
Question
07/23/20 3:47 PM EDT

Tina Jones
My sinuses have been fine.
Your avatar
Has your sense of taste changed?
Question
07/23/20 3:47 PM EDT

Tina Jones
No, I think my sense of taste is fine.
Your avatar
Are you having dry mouth?
Question
07/23/20 3:48 PM EDT

Tina Jones
My mouth hasn’t been dry.
Your avatar
ANY pain in your mouth?
Question
07/23/20 3:48 PM EDT

Tina Jones
No, my mouth feels fine.
Your avatar
ANY sore throat?
Question
07/23/20 3:49 PM EDT

Tina Jones
No, it’s fine.
Your avatar
Any issue with your gums?
Question
07/23/20 3:49 PM EDT

Tina Jones
My gums have been fine.
Your avatar
Any issue with your tongue?
Question
07/23/20 3:49 PM EDT

Tina Jones
My tongue feels fine.
Your avatar
Any difficulties when swallowing?
Question
07/23/20 3:50 PM EDT

Tina Jones
I can swallow fine.
Your avatar
SORE throat?
Question
07/23/20 3:50 PM EDT

Tina Jones
No, it’s fine.
Your avatar
Any voice changes?
Question
07/23/20 3:50 PM EDT

Tina Jones
My voice has been fine.
Your avatar
Any swollen lymph nodes?
Question
07/23/20 3:52 PM EDT

Tina Jones
My lymph nodes seem fine.
Your avatar
Are you having any nausea?
Question
07/23/20 3:52 PM EDT

Tina Jones
No, I haven’t been nauseous at all.
Your avatar
Any vomiting?
Question
07/23/20 3:53 PM EDT

Tina Jones
No.
Your avatar
ANY pain in the abdomen?
Question
07/23/20 3:53 PM EDT

Tina Jones
I haven’t really had any stomach problems since I came in with them a while ago.
Your avatar
Any constipation?
Question
07/23/20 3:53 PM EDT

Tina Jones
I don’t have that problem.
Your avatar
Any diarrhea?
Question
07/23/20 3:54 PM EDT

Tina Jones
I haven’t had any problems with diarrhea.
Your avatar
Excessive flatulence?
Question
07/23/20 3:54 PM EDT

Tina Jones
I haven’t been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked.
Your avatar
flatulence is one of the side effect of metformin
Educate
07/23/20 3:55 PM EDT

Tina Jones
Thanks for telling me.
Your avatar
Any food intolerance
Question
07/23/20 3:56 PM EDT

Tina Jones
I can eat just about anything.
Your avatar
Any burning sensation when you urinate?
Question
07/23/20 3:56 PM EDT

Tina Jones
No, it doesn’t burn when I pee.
Your avatar
Any blood in your urine?
Question
07/23/20 3:57 PM EDT

Tina Jones
No! That doesn’t sound like it would be good.
Your avatar
Are you having any pain right now?
Question
07/23/20 3:57 PM EDT

Tina Jones
I don’t have any pain anywhere.
Your avatar
Any vaginal discharge?
Question
07/23/20 3:58 PM EDT

Tina Jones
My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish.
Your avatar
Any vaginal itching?
Question
07/23/20 3:58 PM EDT

Tina Jones
No, it feels normal.
Your avatar
Do you have any problem with your breasts?
Question
07/23/20 3:59 PM EDT

Tina Jones
No, my breasts feel fine.
Your avatar
Any pain in the breasts?
Question
07/23/20 3:59 PM EDT

Tina Jones
No, my breasts feel fine.
Your avatar
Are you having any dizziness/
Question
07/23/20 3:59 PM EDT

Tina Jones
I haven’t been getting dizzy at all.
Your avatar
Any lightheadedness?
Question
07/23/20 4:00 PM EDT

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Tina Jones
No, I don’t really get lightheaded.
Your avatar
Any tingling?
Question
07/23/20 4:00 PM EDT

Tina Jones
Nope, no tingling.
Your avatar
Any loss of balance?
Question
07/23/20 4:00 PM EDT

Tina Jones
My balance is fine.
Your avatar
Any changes in sensation?
Question
07/23/20 4:00 PM EDT

Tina Jones
I haven’t noticed any changes.
Your avatar
Any seizures?
Question
07/23/20 4:01 PM EDT

Tina Jones
No, I’ve still never had problems with seizures, fortunately.
Your avatar
Do you have memory problems?
Question
07/23/20 4:01 PM EDT

Tina Jones
I think my memory has been fine.
Your avatar
Any muscle pain?
Question
07/23/20 4:01 PM EDT

Tina Jones
My muscles have felt great, especially since I started exercising more.
Your avatar
Joint pain?
Question
07/23/20 4:02 PM EDT

Tina Jones
My joints always seem fine.
Your avatar
Any muscle weakness?
Question
07/23/20 4:02 PM EDT

Tina Jones
No, I haven’t felt weak at all.
Your avatar
Any swelling?
Question
07/23/20 4:03 PM EDT

Tina Jones
Nothing is swollen.
Current Health Status
Finding:
Confirmed reason for visit

Finding:
Reports needing a pre-employment physical

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Can I confirm that you are here for a physical?
Finding:
Reports no current acute health problems

(Found)Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.Example Question:Do you have any current health problems?
Finding:
Asked about last visit to a healthcare provider

Finding:
Last visit to a healthcare provider was 4 months ago

(Found)Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.Example Question:When did you see a healthcare provider?
Finding:
Reason for last visit was annual gynecological exam

(Found)Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.Example Question:Why did you see a healthcare provider?
Finding:
Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler

(Found)Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.Example Question:When was your last physical exam? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
Finding:
Asked about current prescription medications

Finding:
Reports taking diabetes medication

(Found)Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.Example Question:Have you been taking medication for your diabetes?
Finding:
Reports using a daily inhaler

(Found)Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.Example Question:Do you use a daily inhaler?
Finding:
Reports taking prescription birth control pills

(Found)Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.Example Question:Are you taking any form of birth control?
Finding:
Followed up about diabetes medication

Finding:
Medication is metformin

(Found)Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history.Example Question:What is the name of your diabetes medication?
Finding:
Started taking metformin 5 months ago

(Found)Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:How long have you been taking metformin?
Finding:
Reports that eating probiotic yogurt helps with side effects and they have abated over time

(Found)Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:Have you noticed any side effects from the metformin?
Finding:
Followed up on metformin frequency and dose

Finding:
Reports taking metformin twice daily

(Found)Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:How many times a day do you take metformin?
Finding:
Metformin dose is 850 mg

(Found)Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.Example Question:What is the dose of your metformin?
Finding:
Asked about asthma medication

Finding:
Reports using Flovent inhaler twice daily

(Found)Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:How often do you use your daily inhaler?
Finding:
Has a Proventil rescue inhaler

(Found)Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it.Example Question:Do you have a rescue inhaler?
Finding:
Last use of Proventil inhaler was three months ago

(Found)Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.Example Question:When did you last use your rescue inhaler?
Finding:
Has used Proventil inhaler twice in the last year

(Available)Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation.Example Question:How often do you use your rescue inhaler?
Finding:
Followed up about birth control prescription

Finding:
Started taking birth control 4 months ago

(Found)Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.Example Question:How long ago did you start taking birth control?
Finding:
Reason for birth control was to manage PCOS symptoms

(Found)Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.Example Question:Why did you decide to start taking birth control?
Finding:
Birth control type is Yaz (drospirenone and ethinyl estradiol)

(Found)Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:What type of birth control do you use?
Finding:
Takes birth control pill daily

(Found)Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.Example Question:How often do you take your birth control pill?
Finding:
Takes birth control pill at the same time every day

(Found)Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.Example Question:Do you take your pill at the same time every day?
Finding:
Reports no skipped days

(Available)Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.Example Question:Have you missed any days of your birth control pill?
Finding:
Asked about current non-prescription medications

Finding:
Reports rare Advil use for cramps

(Found)Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes non prescription drugs will indicate her current treatment plan.Example Question:Do you take Advil?
Finding:
Reports no OTC herbal products

(Found)Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan.Example Question:Do you use any herbal products?
Finding:
Reports no OTC vitamins

(Found)Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan.Example Question:Do you take any vitamins?
Finding:
Reports no OTC supplements

(Found)Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan.Example Question:Do you take any supplements?
Finding:
Asked about allergies

Finding:
Confirms allergies

(Found)Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina’s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina’s health literacy.Example Question:Can you confirm your allergies?
Finding:
Reports no new allergies

(Found)Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.Example Question:Have you noticed any new allergies?
Finding:
Followed up on seasonal allergies

Finding:
Reports no recent seasonal allergy symptoms

(Found)Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.Example Question:Have you been having seasonal allergies?
Finding:
Reports no current medication for allergies
HEENT

Finding:
Inspected head and neck

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

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

Finding:
Head is normocephalic, atraumatic

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

Finding:
Normal scalp hair distribution

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

Finding:
Acanthosis nigricans noted on neck

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

Finding:
Inspected eyebrows and orbital area

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

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

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

Finding:
Palpated scalp

Finding:
No masses

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

Finding:
Palpated sinuses

Finding:
No frontal sinus tenderness

(Found)Pro Tip: Palpating the frontal sinuses checks for sinusitis.Example Question:

Finding:
No maxillary sinus tenderness

(Found)Pro Tip: Palpating the maxillary sinuses checks for sinusitis.Example Question:

Finding:
Palpated jaw

Finding:
No clicks, full ROM

(Found)Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury.Example Question:

Finding:
Palpated lymph nodes

Finding:
No axillary lymphadenopathy

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

Finding:
No supraclavicular lymphadenopathy

(Found)Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:

Finding:
Palpated thyroid

Finding:
Thyroid smooth without nodules, no goiter

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

Finding:
Inspected eyelids and conjunctiva

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

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

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

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

Finding:
Tested PERRL with penlight

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

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

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

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

Finding:
Tested eye movements

Finding:
Normal convergence

(Found)Pro Tip: This test accommodation assesses the eye’s ability to focus on close objects.Example Question:

Finding:
EOMs intact bilaterally, no nystagmus

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

Finding:
Tested peripheral vision

Finding:
Peripheral vision intact in both eyes, all fields

(Found)Pro Tip:Example Question:

Finding:
Inspected interior eyes with ophthalmoscope

Finding:
Mild retinopathic changes on right

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

Finding:
Left fundus with sharp disc margins, no hemorrhages

Finding:
Palpated abdomen – deep

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

(Found)Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.Example Question:

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

(Found)Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & DocumentationExample Question:

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

(Found)Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.Example Question:

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

(Found)Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.Example Question:

Finding:
Palpated organs

Finding:
Liver: palpable 1 cm below right costal margin

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

Finding:
Spleen: not palpable

(Found)Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate a number of serious health conditions.Example Question:

Finding:
Right kidney: not palpable, no masses

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

Finding:
Left kidney: not palpable, no masses

(Found)Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.Example Question:
Musculoskeletal

Finding:
Inspected neck

Finding:
Neck without swelling, masses, or deformity

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

Finding:
Inspected upper extremities

Finding:
Right shoulder without swelling, masses, or deformity