Tina Jones shadow health
Please use the patient information provided below for this paper.
This assignment assesses intended course outcome(s)
#4 Use information found in patients’ health histories, genograms, and assessments to formulate an individualized plan of nursing care that focuses on the patient’s individual health promotion and disease prevention needs
Students will use the information found in Tina’s history, physical exam, and problem list to formulate an individualized health promotion and disease prevention plan of care. Recommendations should be evidence-based and from credible sources. The readings in module eight contains some suggested sources for obtaining health and screening recommendations for your patient. Tina Jones shadow health.
The plan for addressing the health promotion and disease prevention needs for your patient should include:
Demographics:
– Age, gender and race of patient
ORDER SHADOW HEALTH ASSESSMENT HELP HERE
WE WILL SCORE ABOVE 95% AND HANDLE THE SOAP NOTE
DON’T STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW.
– Education level (health literacy)
– Access to health care
Insurance/Financial status
– Is the patient able to afford medications and health diet, and other out-of-pocket expenses?
Screening/Risk Assessment
– Identified health concerns based on screening assessments and demographic information
Nutrition/Activity
BRIAN FOSTER CHEST PAIN SHADOW HEALTH ASSESSMENT
– What is the patients activity level, is the environment where the patient lives safe for activity
– Nutrition recommendations based on age, race gender and pre-existing medical conditions
– Activity recommendations
Social Support
– Support systems, family members, community resources
Health Maintenance
– Recommended health screening based on age, race, gender and pre-existing medical conditions
Patient Education:
– Identified knowledge deficit areas/patient education needs (medication teaching etc).
– Self-care needs/ Activities of daily living
* The paper should be written and referenced in APA format and be no longer than 4 pages (excluding cover page and references).
Your paper will be evaluated based on the following criteria:
Criteria
Level 3
Level 2
Level 1
Demographics
(5%)
Includes age, race and gender of patient
Missing one data item
Missing 2 or more data items
Insurance/Financial status
(10%)
Includes information regarding patient’s insurance status and ability to afford medications and other out-of-pocket expenses
Missing some information regarding insurance status and ability to pay for medications and other out-of-pocket expenses.
Missing information regarding the patients insurance status, ability to pay of medications and other out-of-pocket expenses
Screening /risk assessment
(10%)
Identifies health concerns based on screening assessments and demographic information.
Missing some information regarding health concerns, by excluding information from screening assessments and demographics
Health concerns are not identified due to information missing from screening assessments and demographics
Nutrition/activity
(20%)
Completely asses patient’s nutrition and activity levels and makes recommendations based on age, race, gender and pre-existing medical conditions
Missing some information regarding the patients nutrition and activity levels, make recommendations based on age, race, gender and pre-existing medical conditions
Most of the information regarding the patient’s nutrition and activity levels are missing, recommendations are missing or not based on the patient’s age, race, gender and pre-existing medical conditions
Social support
(10%)
Identifies support systems such as family members and community resources
Missing some information regarding support systems such as family members and/or community resources
Little to no information regarding social support Tina Jones shadow health
Health Maintenance
(20%)
Overall health maintenance recommendations made based on age, race, gender and pre-existing medical conditions
Missing some recommendations, mostly based on age, race, gender and pre-existing medical conditions
Missing many recommendations, loosely related to age, race, gender and pre-existing medical conditions
Patient Education
(20%)
Identified knowledge deficit areas/patient education needs including self-care needs and activities of daily living
Missing one or more areas of knowledge deficit/patient education needs including self-care and activities of daily living
Lacks identification of knowledge deficit areas/patient education needs. Does not consider self-care needs or activities of daily living.
Organization, spelling and grammar, APA
(5%)
Organized, easy to read, no spelling or grammar mistakes, appropriate use of APA
Organized and easy to read, few spelling or grammar mistakes, few errors in APA
Tina Jones shadow health
Disorganized, difficult to read, many spelling and grammar errors mistakes. Does not use APA
Overall score
Points
(60-100)
Points
(24-59)
Points
( 0-23)
Health History
Student Documentation
Model Documentation
Identifying Data & Reliability
Ms Jones is xxxx
Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
General Survey
Tina Jones is Alert and xxxx
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
Presents to xxx
“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
The patient is a xxx
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 at this time. 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
XXX twice daily XXXX
• Fluticasone propionate, XXX(last use: this morning) • Drospirenone and XXXX (last use: this morning) • XXXX (last use: three months ago) • XXX) • IXXXX (menstrual cramps: last taken 6 weeks ago)
Allergies
XXXX No Known XXX
• XXXX • Denies food and latex allergies • XXXXX. When she is exposed to allergens she states that she has XXXXX, and increased asthma symptoms.
Medical History
Diabetes Type 2 – diagnosed xxx
XXXdiagnosed at age 2 1/2. She uses her XXXwhen she is around cats. Her last aXXXXX in high school. Never intubated. XXXX. She began XXX months ago and initially had some gastrointestinal side effects which have since dissipated. XXXXXXXX. 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 XXX. For the past four months (after initiatingXXXX) 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 XXX four months ago.
Health Maintenance
Ms Jones has xxx
Last xxx 4 months ago. Last xxx three months ago. Last xxx months ago. xxx2 years ago. xxx: xxx was received within the past year, xxx is not current, and xxx has not been received. She reports that she believes she is up to date on xxx and received the xxxx for xxx. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sx. xx, having belonged to her dad, are in the home, locked in parent’s room.
Family History
-Her Mother is still alive. She has xxx
• Mother: age xxxx• Father: deceased in car accident one year ago at age 58, xxx, and xxx • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a xx, history of xxx, xxx • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of xxxx • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems
Social History
Has never been pregnant xxx.
Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.
Mental Health History
Denies any problems with xxxx
Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports sore throat
(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:
Is your throat sore?
Finding:
Reports itchy throat
(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:
Is your throat itchy?
Finding:
Reports itchy eyes
(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:
Are your eyes itchy?
Finding:
Reports runny nose
(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 a runny nose?
History of Present Illness
Finding:
Asked about onset of symptoms
Finding:
Reports sore throat began “about a week ago”
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s throat has been sore will also aid in treating her sore throat.
Example Question:
How long has your throat been sore?
Finding:
Reports runny nose began “about a week ago”
(Available)
Pro Tip: Establishing a timeline for how long Tina’s nose has been running will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
When did your nose start running?
Finding:
Reports itchy eyes began “about a week ago”
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s eyes have been itching will also aid in treating her itchy eyes.
Example Question:
When did your eyes start itching?
Finding:
Asked about aggravating factors for throat symptoms
Finding:
Reports throat pain is constant
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s throat has been sore will also aid in treating her sore throat.
Example Question:
Is the throat pain constant?
Finding:
Reports throat pain is worse in the morning
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Establishing a timeline for how long Tina’s throat has been sore will also aid in treating her sore throat.
Example Question:
When does your sore throat feel the worst?
Finding:
Reports some soreness with swallowing
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Does it hurt when you swallow?
Finding:
Asked severity of throat discomfort
Finding:
Describes sore throat as mild to moderate
(Found)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.
Example Question:
Can you rate your sore throat on a scale of 0 to 10?
Finding:
Asked about frequency and duration of runny nose
Finding:
Reports nose is runny “pretty much all day”
(Available)
Pro Tip: Establishing a timeline for how long Tina’s nose has been running will illustrate how long she has been suffering these particular symptoms, when the symptoms are worst, and possible triggers.
Example Question:
How often does your nose run?
Finding:
Asked about character of nasal symptoms
Finding:
Denies itchy nose
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Does your nose itch?
Finding:
Denies sinus pain
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Do you feel any sinus pain?
Finding:
Denies sinus pressure
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Do you feel any sinus pressure?
Finding:
Denies sneezing
(Available)
Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems.
Example Question:
Have you been sneezing?
Finding:
Followed up about character of nasal discharge
Finding:
Reports clear discharge
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
What color is your mucus?
Finding:
Reports thin discharge
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Is the mucus thick?
Finding:
Denies purulent discharge
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Does your mucus have pus in it?
Finding:
Asked about eye symptoms
Finding:
Reports eye itching is constant
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Determining when Tina’s eyes most itch will also aid in treating her itchy eyes.
Example Question:
Do your eyes constantly itch?
Finding:
Reports eye redness
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Are your eyes red?
Finding:
Asked related respiratory symptoms
Finding:
Reports breathing isn’t affected
(Found)
Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns or conditions.
Example Question:
Have you had any changes in your breathing?
Finding:
Denies cough
(Available)
Pro Tip: A shallow history of a patient’s condition can provide a comparative baseline for juxtaposing an attack, exacerbation, and more regular breathing. Soliciting this information from Tina allows her to explain any recent developments with her asthma.
Example Question:
Do you have a cough?
Finding:
Denies chest tightness
(Available)
Pro Tip: For many patients with asthma, exacerbation often results in chest tightness. Asking Tina if her chest feels tight might point to possible asthma symptoms.
Example Question:
Does your chest feel tight?
Finding:
Asked about related asthma symptoms
Finding:
Denies recent wheezing
(Available)
Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and thus might not volunteer this information. Asking Tina whether she has been wheezing illustrates how her asthma is presenting.
Example Question:
Have you been wheezing?
Finding:
Denies increase in recent asthma symptoms
(Available)
Pro Tip: Discerning what’s 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:
Has your asthma been worse lately?
Finding:
Asked about exposure to allergens
Finding:
Reports no exposure to cats
(Found)
Pro Tip: Tina’s symptoms are consistent with being exposed to allergens. Asking Tina if she’s recently been exposed to allergens could explain what’s triggering her symptoms.
Example Question:
Have you been recently exposed to any allergens?
Finding:
Reports no exposure to mold or mildew
(Available)
Pro Tip: Exposure to mold can result in painful ear, nose, or throat symptoms. Asking Tina if she has mold in her house might indicate a possible trigger that she has been exposed to.
Example Question:
Do you have mold in your house?
Finding:
Reports no exposure to dust
(Available)
Pro Tip: Exposure to dust can result in painful ear, nose, or throat symptoms. Asking Tina if she has dust in her house might indicate a possible trigger that she has been exposed to.
Example Question:
Do you have dust in your house?
Finding:
Reports no known exposure to irritants in work environment
(Available)
Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation.
Example Question:
Are you allergic to anything at work?
Finding:
Reports changing bedding “once a week”
(Available)
Pro Tip: Bedding provides the perfect environment for dust mites and other allergens. By asking Tina if she regularly changes her bedding, you’re soliciting information about environmental factors that might exacerbate her condition.
Example Question:
How often do you change your bedding?
Finding:
Asked about perceived cause of symptoms
Finding:
Describes symptoms as similar to allergies
(Found)
Pro Tip: Questions about what factors might have caused certain symptoms can point to a patient’s environmental stressors, habits, and general wellbeing. Asking Tina what caused her asthma might indicate her health literacy and understanding of what factors impact her breathing.
Example Question:
Do you know what’s causing your symptoms?
Finding:
Reports that the symptoms don’t seem like a common cold
(Found)
Pro Tip: A patient is an expert on her body. Asking Tina if she thinks she has a cold will give Tina the opportunity to compare her current symptoms with cold symptoms she’s historically had and describe if her current symptoms differ from those she experiences when she has a cold.
Example Question:
Do you think you have a cold?
ORDER SHADOW HEALTH ASSESSMENT HELP HERE
WE WILL SCORE ABOVE 95% AND HANDLE THE SOAP NOTE
DON’T STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW.
Finding:
Describes similarity to her sister’s hay fever symptoms
(Available)
Pro Tip: A patient is an expert on her body. Asking Tina if she thinks she is having an allergic reaction will give Tina the opportunity to compare her current symptoms with symptoms she’s historically had during an allergic reaction.
Example Question:
Do you think you are having an allergic reaction?
Finding:
Reports no history of cigarette smoking
(Available)
Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she has recently smoked can help you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.
Example Question:
Have you smoked cigarettes recently?
Finding:
Reports no recent exposure to secondhand smoke
(Available)
Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking whether Tina has been exposed to secondhand smoke might indicate a proximate environmental trigger.
Example Question:
Have you been exposed to secondhand smoke recently?
Medical History
Finding:
Confirmed use of medications
Finding:
Confirmed medications from previous visit (no new medications)
(Found)
Pro Tip: Determining what, if any, medications a patient is taking is a crucial element of a thorough health history and will help you avoid unwanted drug interactions.
Example Question:
Have you started taking any new medications?
Finding:
Followed up about inhaler use
Finding:
Uses an inhaler to treat asthma symptoms
(Available)
Pro Tip: It’s essential to ask specifically what medications a patient is using to treat her current complaint or any ongoing medical conditions.
Example Question:
Do you use an inhaler for your asthma?
Finding:
Inhaler is Proventil
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.
Example Question:
What is the name of the inhaler you are currently using?
Finding:
Last use of inhaler was last week
(Available)
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 inhaler?
Finding:
Reports typical inhaler use is 2 – 3 times a week
(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 inhaler?
Finding:
Reports using 2 – 3 puffs of inhaler when used
(Available)
Pro Tip: Inhaler effectiveness can vary over time for a variety of reasons. Asking Tina about the number on inhaler puffs she needs to resolve symptoms can indicate whether her asthma has worsened or point to potential problems like poor inhaler technique.
Example Question:
How many puffs of your inhaler do you use?
Finding:
Prescribed dosage is 2 puffs
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how many puffs of her inhaler she’s prescribed will indicate her treatment plan and the degree to which she complies with it.
Example Question:
How many puffs of your inhaler are you supposed to do?
Finding:
Followed up about medications and relieving factors for nose and eye symptoms
Finding:
Reports no treatment for itchy eyes
(Available)
Pro Tip: Tina’s response to a question about managing her itchy eyes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.
Example Question:
Have you treated your eyes with anything?
Finding:
Reports no treatment for nasal symptoms
(Available)
Pro Tip: Tina’s response to a question about managing her runny nose will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.
Example Question:
Have you done anything for your runny nose?
Finding:
Reports no antihistamine
(Available)
Pro Tip: Tina’s response to a question about taking any antihistamines will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.
Example Question:
Have you taken any antihistamines?
Finding:
Reports no decongestant
(Available)
Pro Tip: Tina’s response to a question about taking any decongestants will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.
Example Question:
Have you taken any decongestants?
Finding:
Followed up about medications and relieving factors for throat symptoms
Finding:
Reports lozenges as treatment
(Available)
Pro Tip: Tina’s response to a question about managing her sore throat will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.
Example Question:
Have you taken anything for your sore throat?
Finding:
Reports lozenges reduce symptoms
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if the lozenges help will illustrate the extent of her pain and how effectively OTC treatments works for her throat.
Example Question:
Do the lozenges help?
Finding:
Reports ingesting lozenges every few hours
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how frequently she has a lozenge will illustrate the extent of her pain and how effectively OTC treatment works for her throat.
Example Question:
How often do you have a lozenge? Tina Jones shadow health
Finding:
Reports drinking water reduces symptoms
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Does drinking water help?
Finding:
Confirmed allergies
Finding:
Reports known allergy to cats
(Available)
Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such trigger.
Example Question:
Can you confirm that you’re allergic to cats?
Finding:
Reports known allergy to dust
(Available)
Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such trigger.
Example Question:
Are you allergic to dust?
Finding:
Reports no previous problems with seasonal allergies
(Available)
Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movement that may have a bearing on Tina’s breathing. Asking Tina whether she has seasonal triggers will indicate, in part, Tina’s health literacy. Tina Jones shadow health
Example Question:
Do you have seasonal allergies?
Review of Systems
Finding:
Asked about general symptoms
Finding:
Denies recent or frequent illnesses
(Available)
Pro Tip: Asking about recent illnesses can give help you determine the cause of a patient’s symptoms.
Example Question:
Have you been sick recently?
Finding:
Denies chills
(Available)
Pro Tip: Chills could be an indication of fever, which could be an indication of infection.
Example Question:
Have you had any chills?
Finding:
Denies fever
(Found)
Pro Tip: Fever could signal that the patient’s symptoms are caused by an infection.
Example Question:
Have you had a fever?
Finding:
Reports low energy level
(Available)
Pro Tip: Low energy or fatigue can be an important symptoms or contributing factor to discover, and can help you rule out certain conditions.
Example Question:
Have you felt fatigued?
Finding:
Denies nausea or vomiting
(Available)
Pro Tip: Nausea or vomiting can indicate an infection.
Example Question:
Have you felt nauseous?
Finding:
Asked about review of systems for head
Finding:
Reports occasional headaches
(Found)
Pro Tip: Sinus problems can result in increased pressure buildup and headaches. Asking Tina if she gets headaches is soliciting information about possible symptoms that she experiences. Tina Jones shadow health
Example Question:
Do you ever get headaches?
Finding:
Denies current headache
(Available)
Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Asking Tina if she currently has a headache solicits information about how she is feeling now.
Example Question:
Do you have a headache currently?
Finding:
Denies history of head injury
(Available)
Pro Tip: People who’ve experienced head injuries are at increased risk for sinusitis. Asking Tina whether she’s ever had a head injury solicits health history information that might explain the cause of her symptoms.
Example Question:
Have you ever had a head injury?
Finding:
Denies lightheadedness
(Found)
Pro Tip: Sinus infections can result in inner ear disturbances and thus lightheadedness. Asking Tina if she is lightheaded could point to inner ear disturbances.
Example Question:
Do you ever get lightheaded?
Finding:
Followed up on headaches
Finding:
Headaches occur once a week
(Found)
Pro Tip: Establishing a timeline for how often Tina gets headaches will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
How often do you get headaches?
Finding:
Headaches last “a few hours”
(Found)
Pro Tip: Establishing a timeline for how long Tina’s headaches last will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
How long do your headaches last?
Finding:
Describes headaches as tight and throbbing
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
How would you describe your headaches?
Finding:
Describes headache location as behind her forehead
(Found)
Pro Tip: Specifying the location of pain can narrow and define where Tina’s pain is occurring. Soliciting this information allows you to more accurately treat her symptoms. Tina Jones shadow health
Example Question:
Where do you feel your headaches?
Finding:
Rates headache pain as a 3 or 4
(Available)
Pro Tip: Pain severity might change for a variety of reasons. Asking Tina to rate the severity of her pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.
Example Question:
How would you rate your headache pain on a scale of 0 to 10?
Finding:
Reports treating headaches with Tylenol
(Found)
Pro Tip: Tina’s response to a question about managing her headaches will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.
Example Question:
How do you treat your headaches?
Finding:
Reading and studying seem to cause headaches
(Found)
Pro Tip: Soliciting information about possible headache triggers will allow Tina to consider what, if any, activities, weather patterns, movements, or sensory input is correlated with her headaches.
Example Question:
What seems to cause your headaches?
Finding:
Asked about review of systems for eyes
Finding:
Reports occasional blurry vision
(Found)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms.
Example Question:
Do you have blurry vision?
Finding:
Reports worsening vision
(Found)
Pro Tip: Establishing a timeline for whether Tina’s vision has gotten worse will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
Has your vision gotten worse? Tina Jones shadow health
Finding:
Denies eye pain
(Found)
Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms.
Example Question:
Have you had eye pain?
Finding:
Denies dry eyes
(Available)
Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom.
Example Question:
Have you had dry eyes?
Finding:
Reports last vision exam was in childhood
(Found)
Pro Tip: Asking Tina when her last vision test was will indicate the degree to which she’s seen her vision as something that has needed medical attention.
Example Question:
When was your last vision test?
Finding:
Does not use corrective lenses
(Found)
Pro Tip: Corrective lenses might indicate a recent change in vision. Asking Tina whether she has glasses or contacts solicits information about her vision history.
Example Question:
Do you have glasses or contacts?
Finding:
Followed up on vision problems
Finding:
Describes blurry vision as “fuzzy letters”
(Available)
Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.
Example Question:
Can you describe your blurry vision?
Finding:
Blurry vision occurs when reading for long periods
(Found)
Pro Tip: Establishing a timeline for how frequently Tina gets blurry vision will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
When do you get blurry vision?
Finding:
Blurry vision occurs after 2+ hours of reading
(Available)
Pro Tip: Establishing a timeline for how long Tina’s vision stays blurry will illustrate how long she has been suffering these particular symptoms and might indicate possible triggers.
Example Question:
How long have you been reading when your vision gets blurry?
Finding:
Reports that blurry vision and headaches often coincide
(Available)
Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Tina Jones shadow health
Example Question:
Do you get headaches when you have blurry vision?
Finding:
Asked about review of systems for ears
Finding:
Denies general ear problems
(Found)
Pro Tip: Soliciting a shallow medical history relevant to Tina’s chief complaint will allow you to assess her condition relative to past concerns.
Example Question:
Have you had ear problems?
Finding:
Denies change in hearing
(Found)
Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing.
Example Question:
Have you had any changes in your hearing?
Finding:
Denies ear pain
(Found)
Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous. Asking Tina if she has ear pain might indicate a possible ear infection.
Example Question:
Have you had ear pain?
Finding:
Denies ear discharge
(Available)
Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer’s ear. Asking whether she’s noticed ear discharge could indicate whether she has a ruptured eardrum.
Example Question:
Have you noticed ear discharge?
Finding:
Reports last hearing test was in childhood
(Available)
Pro Tip: Asking Tina when her last hearing test was will indicate the degree to which she’s seen her hearing as something that has needed medical attention.
Example Question:
When was your last hearing test?
Finding:
Asked about review of systems for nose
Finding:
Denies change in sense of smell
(Available)
Pro Tip: Changes in sense of smell could be a symptom of acute sinusitis. Asking Tina if she’s had any changes in her sense of smell indicates whether she might be suffering from acute sinusitis.
Example Question:
Have you had any changes in your sense of smell?
Finding:
Reports no nasal or sinus surgeries
(Available)
Pro Tip: A history of nasal surgery might indicate that Tina had chronic nasal problems. Asking Tina if she’s ever had nasal surgery solicits information about her medical history. Tina Jones shadow health
Example Question:
Have you ever had a nasal surgery?
Finding:
Denies nosebleeds
(Available)
Pro Tip: Nosebleeds are often caused by sinusitis. Asking Tina if she ever gets nosebleeds solicits information about her medical history.
Example Question:
Do you ever get nosebleeds?
Finding:
Asked about review of systems for mouth and jaw
Finding:
Denies general mouth problems
(Found)
Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing.
Example Question:
Have you ever had problems with your mouth?
Finding:
Denies change in sense of taste
(Available)
Pro Tip: Sinusitis can result in decreased smell or taste. Asking if Tina’s sense of taste has changed lately might indicate a sign of sinusitis.
Example Question:
Has your sense of taste changed?
Finding:
Denies dry mouth
(Found)
Pro Tip: Sinusitis can result in dry mouth. Asking if Tina’s recently had dry mouth might indicate a sign of sinusitis.
Example Question:
Have you had dry mouth recently?
Finding:
Denies history of oral surgery
(Available)
Pro Tip: A history of oral surgery might indicate that Tina had former oral problems. Asking Tina if she’s ever had oral surgery solicits information about her medical history.
Example Question:
Have you ever had oral surgery?
Finding:
Denies mouth pain
(Available)
Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she’s had mouth pain might indicate a problem area that has caused infection.
Example Question:
Do you have mouth pain?
Finding:
Denies mouth sores
(Available)
Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection.
Example Question:
Do you have any mouth sores?
Finding:
Denies gum problems
(Found)
Pro Tip: If left untreated, gum problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms.
Example Question:
Do you have any problems with your gums?
Finding:
Denies tongue problems
(Available)
Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms.
Example Question:
Do you have any problems with your tongue?
Finding:
Denies jaw problems
(Available)
Pro Tip: If left untreated, jaw problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms. Tina Jones shadow health
Example Question:
Do you have any problems with your jaw?
Finding:
Asked about review of systems for dentation
Finding:
Denies current dental problems
(Available)
Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she has any dental problems might indicate a problem area that has caused infection.
Example Question:
Do you have any current dental problems?
Finding:
Reports visit within the last 2 years
(Available)
Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area.
Example Question:
When did you last see the dentist?
ORDER SHADOW HEALTH ASSESSMENT HELP HERE
WE WILL SCORE ABOVE 95% AND HANDLE THE SOAP NOTE
DON’T STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW.
Finding:
Reports regular visits in childhood
(Available)
Pro Tip: Seeing a dentist regularly as a child can lay the foundation for good dental hygiene and prevent infection. Asking Tina how often she saw the dentist as a child will suggest her health and dental history.
Example Question:
How often did you see the dentist when you were a child?
Finding:
Reports a few cavities in childhood
(Available)
Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina what dental problems she’s had might indicate a problem area that has caused infection.
Example Question:
What dental problems have you had?
Finding:
Asked about review of systems for neck, throat and glands
Finding:
Denies history of recurrent strep throat
(Available)
Pro Tip: Soliciting a shallow medical history relevant to Tina’s chief complaint will allow you to assess her condition relative to past concerns.
Example Question:
Do you get strep throat often?
Finding:
Denies lymph node problems
(Available)
Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition.
Example Question:
Do you have any problems with your lymph nodes?
Finding:
Denies history of general throat problems
(Available)
Pro Tip: Throat problems are often linked to sinusitis. Asking Tina if she has a history of throat problems will illustrate her medical history in relation to similar concerns.
Example Question:
Do you have a history of throat problems?
Finding:
Denies voice changes
(Found)
Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems.
Example Question:
Have you noticed any changes to your voice?
Finding:
Denies history of tonsil problems
(Available)
Pro Tip: Sinusitis can often lead to tonsil problems. Asking Tina if she has a history of tonsil problems would reveal whether problems with her sinuses have led to tonsil problems. Tina Jones shadow health
Example Question:
Do you have any history of tonsil problems?
Finding:
Denies general neck pain
(Available)
Pro Tip: Neck pain, soreness, or soft tissue damage might result in sinus pain. Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms.
Example Question:
Do you have neck pain?
Family History
Finding:
Asked about relevant family history
Finding:
Reports sister with hay fever
(Available)
Pro Tip: A family history of allergies is an important factor to determine whether a patient is at risk for developing allergies.
Example Question:
Do you have any family members with allergies?
Finding:
Denies family history of vision problems
(Found)
Pro Tip: Vision problems are often genetic. Learning about a patient’s family history around vision can help you predict risk.
Example Question:
Do vision problems run in your family?
Finding:
Denies family history of sinus problems
(Available)
Pro Tip: Sinus problems are often genetic. Learning about a patient’s family history around sinus problems can help you predict risk.
Example Question:
Do sinus problems run in your family?
Finding:
Denies family history of ear or hearing problems
(Available)
Pro Tip: Ear problems are often genetic. Learning about a patient’s family history around ear problems can help you predict risk.
Example Question:
Do hearing problems run in your family?
Finding:
Denies family history of mouth, throat, or gland problems
(Available)
Pro Tip: Because problems like mouth or throat cancer can be genetic, it’s important to understand family history to determine risk factors.
Example Question:
Do you have any family history of throat problems?
Finding:
Denies family history of headache or migraine
Sclera
Injection
Color nasal
Pale
Bluish
Discharge (no point)
No discharge
Clear discharge
Bloody discharge
Purulent discharge
Turbinate Patency
Patent
Right: Tympanic Membrane Color right and left ear
Pearly gray
Oral Mucosa (No point)
Moist and pink
Tonsils
Edema
Tonsil Grade
1+: Tonsils <25% of space between pillars
Posterior Oropharynx Color (1/6 point)
Pink
Erythemic
Posterior Oropharynx Texture
Cobblestoning
Post Nasal Drip (no point)
Clear discharge
Appearance neck
Discoloration
Right: Retina
Cotton wool bodies
Right
20/xx
“It is possible to develop new allergies as an adult, and so I will take that into consideration as I try to determine the cause of your symptoms.”
“I’m sorry to hear you don’t feel well. I’ll ask you some questions to learn more about your symptoms, and we will make a plan to help you feel better.”
:
“Thank you for letting me know that you’re using throat drops in addition to the medications you usually take. I will ask you a few questions about how you’re using each medication.”
Student Response:
After verifying vaccination history you should be able to cross out certain disease such as diphtheria and move on to assess for other relevant causes of the sore throat. For his age I would consider hand-foot-mouth disease, and bacterial or viral pharyngitis. I would need to assess vital signs, including temperature as well as obtain a rapid strep swab and a throat culture swab to asses for bacterial or viral properties and verify if an antibiotic would be needed. He would need an assessment completed involving his eyes, ear, head, neck and throat. Looking for palpable nodes, redness, swelling, tenderness, drainage, loss of hearing, and pain.
Model Note:
Differential diagnosis includes viral pharyngitis, strep throat, influenza, cold, and sinusitis. To rule out strep, a rapid strep is indicated. Palpation of the cervical lymph nodes may demonstrate enlarged, tender, cervical lymph nodes. Visualization of the throat also gives clues to the diagnosis. White pus pockets and petechiae on the palate are classic signs of strep throat. Erythema alone may indicate viral infection or postnasal drip. If purulent discharge is noted in the posterior pharynx assess for nasal discharge and palpate the appropriate sinuses for the patient’s age. If palpation elicits pain and purulent nasal discharge is reported over the last 7-10 days, consider sinusitis. A negative rapid flu test would rule out influenza. Tina Jones shadow health
Tina’s 76-year-old great aunt comes into the clinic for a visit and you find that she frequently asks you to repeat what you say. During the Rinne test, you find that air conduction is greater than bone conduction in her left ear. What is your differential diagnosis? What additional assessments would you perform?
Model Note:
Differential diagnosis includes sensorineural hearing loss and anatomical defects. Sensorineural hearing loss is common in old age and can be caused by heredity, diabetes, cerebrovascular disease, excessive noise, ototoxic medications, hyperlipidemia, hypothyroidism, and renal failure. Assessments should include a history of hearing impairment and ear injuries. It is important to inquire about chronic ear infection or other trauma that leads to anatomical abnormalities. An analysis of Tina’s great aunt’s medications and past medications can be used to rule out ototoxicity. Fasting glucose levels and Hgb A1C can be tested to rule out diabetes. TSH and T4 levels can rule out hypothyroidism. GFR or creatinine levels can rule out renal failure. Triglycerides, cholesterol, HDL, and LDL levels can be used to rule out hyperlipidemia. A neurological assessment should be completed to rule out cerebral ischemia. If no concrete diagnosis is made, the hearing loss should be attributed to old age.
Suppose you had found that Tina’s pupils were reactive to both direct and consensual light, yet unequal in size. Which condition would you suspect?
Correct: Anisocoria is condition in which the pupils are unequal in size. Anisocoria can be found in about 20% of normal individuals.
Unequal visual acuity
Optic neuritis
Glaucoma
Anisocoria (Correct Response)
Imagine that, during your physical exam with Tina, you had palpated an enlarged left supraclavicular lymph node. What would this finding have indicated?
Correct: Malignancies originating in the pelvis or abdomen are likely to metastasize to the left supraclavicular lymph node, also known as Virchow’s node.
Nothing, because this is a normal variant
A serious pathology (Correct Response)
A previous infection of the throat
An active infection of the throat
If you had observed Arteriovenous (AV) nicking during the retinal exam on Tina, what would you have seen?
Correct: AV nicking is the compression of the vein at arteriovenous crossings due to arterial stiffening. This results in bulging of the vein on either side of the artery making the vein appear to stop on either side of the artery. AV nicking is usually a result of chronic hypertension.
Transparent arterial walls
Opaque arterial walls
Tortuous arteries and veins
Vein stops on either side of the artery (Correct Response)
Suppose that you had detected a click while palpating Tina’s temporomandibular joint (TMJ). What could have been the cause?
Model Note:
Crepitus, limited mobility, and pain in the jaw are probable indicators of temporomandibular joint dysfunction (TMJ syndrome). The clicking noises are most likely caused by displacement of the disc between the condyle and fossa (ball and socket) at the temporomandibular joint.
If Tina had reported new onset ear pain, what would have been the most useful finding to determine otitis media?
Model Note:
A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. This immobility is caused by increased pressure of the middle ear when air or fluid is trapped due to infection and impairment of the Eustachian tube. Tina Jones shadow health
Imagine that you inspected Tina’s throat and noted that her tonsils touched each other. How would you grade her tonsils on the tonsillar hypertrophy grading scale?
Model Note:
Using the standardized tonsillar hypertrophy grading scale, the tonsils are graded 4+ because they touch one another and, therefore, occupy more than 75% of the space between the posterior pillars of the throat. Tina Jones shadow health