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10/29/2017 Comprehensive Assessment | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/2841794 1/7

Comprehensive Assessment Results | Turned In Advanced Health Assessment - September '17 , NREO81 NRE-662 01A

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Your Results Lab Pass

Documentation

Vitals

Student Documentation Model Documentation

128/82 mm Hg (97.3 MAP) HP 78 99% SpO2 98.9 degrees F FVC 3.91 L FEV1 3.15 L FEV1/FVC - 0.81

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

Health History

Student Documentation Model Documentation

Identifying Data & Reliability

Able to state name and date of birth that matches EHR records. Oriented x3. (For the record, I did stop before starting asking questions. There should be a lapse in time. I was documenting)

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

Ms. Jones is a 28 year old obese, African American woman who is clearly able to keep up with her ADLs. Her hair is braided, her clothes are clean, she seems to be able to keep up with hygiene. She does not seem to be in any acute distress.

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.

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Documentation

Plan My Exam

Self-Reflection

Documentation / Electronic Health Record

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10/29/2017 Comprehensive Assessment | Completed | Shadow Health

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Student Documentation Model Documentation

Reason for Visit

Ms. Jones is here for a head-to-toe exam for insurance purposes for her new job.

“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

No present illness, does not admit to symptoms and states she is "doing well, thanks!"

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

Metformin 850 mg BID last taken today Proventil 2 puffs PRN 90 mcg/spray Flovent 2 puffs 88 mcg/spray BID

• Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning) • Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)

Allergies

Cats - breathing issues, sneezing, itchy eyes. Treat with leaving, showering, and rescue inhaler. Penicilin, not severe, per pt - hives/rash. Treat by not taking again.

• Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.

Medical History

T2DM at age 24. Treat with diet, exercise, and metformin Asthma at 2 1/2. Treat with inhalers and watching for triggers.

Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.

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10/29/2017 Comprehensive Assessment | Completed | Shadow Health

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Student Documentation Model Documentation

Health Maintenance

Doctors visits, diet, exercise, taking medication as directed.

Last Pap smear 4 months ago. Last eye exam three months ago. Last dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.

Family History

Mom - high cholesterol and bp Dad - high bp and cholesterol, diabetes Sister - asthma Brother - obese Maternal grandfather- died of MI Maternal grandma - died of stroke Pat. Grandma - high cholesterol and BP Pat. Grandpa - colon cancer, high BP, diabetes

• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • 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 colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems

Social History

Social drinker, no drugs, no tobacco.

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

No history.

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.

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10/29/2017 Comprehensive Assessment | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/2841794 4/7

Student Documentation Model Documentation

Review of Systems - General

HEENT: scalp normal, hair normal, ears normal (bilaterally pearly grey, cone of light aprox. 5 mm), nares reddish pink with no drainage, whisper test normal, eyelids normal, right eye woolen bodies, sharp disc, left eye sharp disc. 20/20 bilaterally with corrective lenses. PERRLA bilaterally. Mouth WDL, moist, no swelling, tonsils normal (2), gag reflex present. Lymph nodes not palpable in all areas, no goiter, no sinus pain. Resp: Fremitus equal bilatterally. Lung sounds and voice sounds present and normal in all areas, clear. Expansion symmetrical. Chest anterior and posterior normal upon inspection, resonant upon percussion. CV: Carotids 2+ with no thrill bilaterally, no bruits. PMI nondiscplaced, no heaves or lifts. S1 and S2 only, regular. No bruit in the AAA, arteries in abdomen and pelvis have no bruities, Pulses 2+ in all areas. Capilary refil <3 seconds in fingers and toes. No edema. GI: Bowel sounds normal in all quadrants. No masses or abnormalities upon inspection, palpation, ausculation, or percussion. Abdomen is soft with no masses. Liver is 1 cm below right costal margin, spleen not palpable, kidneys not palpable with no masses. Quadrants percussion tympanic, spleen not dull sounding. Musc: ROM in all areas normal, all muscle strengths 5/5. No CVA tenderness. DTR 2+ all over. Neuro: Finger/Nose test normal. Rapid alternating hand movements normal. Sensation normal everywhere except limited in feet, especially left foot. Able to sense position of body/fingers/toes. Graphesthesia: normal sense. Stereognosis: normal sense. Heel/sin normal. Hair, Skin, and Nails: No ridges or abnormalities in nails. Extra hair below belly button and on face. Acne present on face, acanthosis nigricans on neck. Skin normal, old scar on left shin. Hair on scalp normal.

No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase.

HEENT

Student Documentation Model Documentation

Subjective

"I'm doing really well" "

Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.

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10/29/2017 Comprehensive Assessment | Completed | Shadow Health

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Student Documentation Model Documentation

Objective

Scalp normal, hair normal, ears normal (bilateral pearly grey, cone of light aprox. 5 mm). Nares reddish pink with no drainage. Whisper test normal, eyelids normal, right eye 20/20 (corrective lenses) with woolen bodies and sharp disc, left eye 20/20 (corrective lenses) with sharp disc. PERRLA bilaterally. Mouth WDL, moist, tonsils 2, gag reflex present, lymph nodes not palpable, no goiter, no sinus pain. EOM normal. PCOS Diabetic Neuropathy Obesity

Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Respiratory

Student Documentation Model Documentation

Subjective

"I'm doing really well" "I don't have anything specific going on today" My asthma is "under control" Rarely needs rescue inhaler

Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.

Objective

Femitus equal bilteraly. Lung sounds clear and voice sounds present in all areas. Expansion symmetrical. Chest, anterior and posterior normal upon inspection, resonant upon percussion. PCOS Diabetic neuropathy Obesity

Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Cardiovascular

Student Documentation Model Documentation

Subjective

"I'm doing really well" "I don't have anything specific going on today"

Reports no palpitations, tachycardia, easy bruising, or edema.

Objective

Caroitds 2+ whit no thrill or bruit, bilaterally. PMI nondiscplaced, no heaves or lifts. S1 and S2 only, regular rhythm. No bruits in the aorta or any other arteries in the abdomen and pelvis. Pulses 2+ in all areas. Capillary refill <3 seconds in fingers and toes. No edema. PCOS Diabetic neuropathy Obesity

Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

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10/29/2017 Comprehensive Assessment | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/2841794 6/7

Abdominal

Student Documentation Model Documentation

Subjective

"I'm doing really well" "I don't have anything specific going on today"

Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.

Objective

Bowel sounds normal in all quadrants. No masses or abnormalities upon inspection, palpation, auscultation, or percussion. Abdomen is soft with no masses. Liver is 1 cm below right costal margin, spleen not palpable, kidneys not palpable and no masses present. Quadrants are tympanic and spleen not dull sounding. PCOS Diabetic Neuropathy Obesity

Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Musculoskeletal

Student Documentation Model Documentation

Subjective

"I'm doing realy well" "I don't have anything specific going on today"

Reports no muscle pain, joint pain, muscle weakness, or swelling.

Objective

ROM in all areas full, all muscle strengths are 5/5, no CVA tenderness, DTR 2+ all over. PCOS Diabetic Neuropathy Obesity

Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.

Neurological

Student Documentation Model Documentation

Subjective

"I'm doing really well" "I don't have anything specific going on today"

Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.

Objective

Finger/nose test normal, rapid alternationg hand movements normal. Sensation normal except for feet, especially left foor. Able to sense position of body/fingers/toes. Graphesthesia: normal sense. Sterognosis: normal sense. Heel/shin normal. Orientation normal. PCOS Diabetic neuropathy Obesity

Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

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10/29/2017 Comprehensive Assessment | Completed | Shadow Health

https://app.shadowhealth.com/assignment_attempts/2841794 7/7

Skin, Hair & Nails

Student Documentation Model Documentation

Subjective

"I'm doing really well" "I don't have anything specific going on today"

Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.

Objective

No ridges or abnormalities in nails. Extra hair below belly button and on face. Acne present on face, acanthosis nigricans on neck. Skin normal, old scar on left shin. Hair on scal normal, skin on scalp normal. PCOS Diabetic Neuropathy Obesity

Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities.

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