Tina Jones Shadow Health Musculoskeletal Results
Tina Jones Shadow Health Musculoskeletal Results
Experience Overview
Patient: Tina Jones
Digital Clinical Experience Score
93.6%
This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 86.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.
Student Performance Index
| 46.8
out of 50 |
Proficiency Level:
Proficient
Students rated as “proficient” demonstrate an entry-level expertise in advanced practice competencies and clinical reasoning skills. In comparable programs, the top 25% of students perform at the level of a proficient practitioner.
Subjective Data Collection
18
out of
18
Objective Data Collection
27.8
out of
28
Education and Empathy
1
out of
4
Time
| 56 minutes total spent in assignment |
Interaction with patient
56 minutes
Transcript
Started: May 02, 2025 | Total Time: 56 min
All Lines (160)Interview Questions (22)Statements (1)Exam Actions (137)
| Hello, my name is Mileidy. I will be your nurse today | Greet 05/02/25 4:18 AM EDT |
|
| Hey. | ||
| What brings you here today? | Question 05/02/25 4:19 AM EDT |
|
| Well, I have a lot of pain in my lower back. It really hurts, and it doesn’t seem to be going away. It’s making it kind of hard to get things done, so I decided to come in and have it looked at. | ||
| I am sorry for that | Empathize 05/02/25 4:19 AM EDT |
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| Thanks for understanding. | ||
| Do you have joint pain? | Question 05/02/25 4:19 AM EDT |
|
| No, my joints feel fine. | ||
| Do you have walking problems | Question 05/02/25 4:19 AM EDT |
|
| Walking isn’t great, but I can do it. | ||
| Do you have joint problems? | Question 05/02/25 4:20 AM EDT |
|
| I don’t have any joint problems that I know of. | ||
| How is your mobility? (Clarified to How is your pain?.) | Question 05/02/25 4:20 AM EDT |
|
| The pain’s pretty bad. (Clarified to how my pain is.) | ||
| Are you able to stand? | Question 05/02/25 4:20 AM EDT |
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| It actually feels a little better when I’m standing than when I’m sitting. | ||
| When did the pain start? | Question 05/02/25 4:22 AM EDT |
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| It started three days ago, right when I first tweaked my back. | ||
| Where is the pain located? | Question 05/02/25 4:22 AM EDT |
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| It hurts in my lower back and even, like, the top of my butt. | ||
| What is the frequency and duration of the pain? (No matching questions found.) | Question 05/02/25 4:22 AM EDT |
|
| How frequent is the pain? | Question 05/02/25 4:23 AM EDT |
|
| It’s pretty constant. | ||
| What is the character of the pain? | Question 05/02/25 4:23 AM EDT |
|
| It’s like. . . an ache. | ||
| What relieves the pain? | Question 05/02/25 4:23 AM EDT |
|
| Taking Advil has been helping a little. | ||
| Do you use any medication? | Question 05/02/25 4:23 AM EDT |
|
| I’ve been taking Advil for my back, and I also have my inhalers. | ||
| Hos long have you been taking advil? | Question 05/02/25 4:24 AM EDT |
|
| I’ve been taking the Advil about three days, maybe a little less–since the night after I hurt myself. | ||
| Do you have any allergies? | Question 05/02/25 4:24 AM EDT |
|
| Yeah, I’m allergic to cats. | ||
| Do you have a history of back pain? | Question 05/02/25 4:24 AM EDT |
|
| No, nothing like this has ever happened to me. . . my back is usually totally fine. | ||
| How has the pain impacted your income and education? | Question 05/02/25 4:25 AM EDT |
|
| I haven’t missed any work. . . work isn’t so bad, since I’m mostly standing up for it. | ||
| Do you have fever? | Question 05/02/25 4:25 AM EDT |
|
| No, I don’t get a lot of fevers. | ||
| Do you have head related injury? | Question 05/02/25 4:26 AM EDT |
|
| No, never. | ||
| Do you have a family history of musculoskeletal problems? | Question 05/02/25 4:26 AM EDT |
|
| No, I don’t think so. | ||
| Have you had a head injury? | Question 05/02/25 4:27 AM EDT |
|
| No, never. | ||
| Do you have neurological problem? | Question 05/02/25 4:27 AM EDT |
|
| No. | ||
| Inspected front of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected right side of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected front of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected left side of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected back of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected right side of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected front of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected right side of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected back of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected left side of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected front of neck | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected shoulders from the front | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected right shoulder | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected upper back | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected right shoulder | Exam Action 05/02/25 4:28 AM EDT |
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| Inspected shoulders from the front | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected left shoulder | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected upper back | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected left shoulder | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected shoulders from the front | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected right arm | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected left arm | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected left elbow: No visible abnormal findings. | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected right elbow: No visible abnormal findings. | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected both wrists | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected right wrist | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected left wrist | Exam Action 05/02/25 4:29 AM EDT |
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| Inspected both wrists | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected both hands | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected right hand | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected left hand | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected both hands | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected front of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected front of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected right side of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected back of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected left side of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected back of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected right side of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected front of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected left side of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected front of hips | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected front of thighs | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected right thigh | Exam Action 05/02/25 4:30 AM EDT |
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| Inspected back of thighs | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected left thigh | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected back of thighs | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected right thigh | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected front of thighs | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected left thigh | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected front of thighs | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected left thigh | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected front of thighs | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected front of knees | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected right knee | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected back of knees | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected left knee | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected back of knees | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected right knee | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected front of knees | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected left knee | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected front of knees | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected front of legs | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected right leg | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected back of legs | Exam Action 05/02/25 4:31 AM EDT |
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| Inspected left leg | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected back of legs | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected right leg | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected front of legs | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected left leg | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected front of legs | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected right ankle | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected both ankles: Right Ankle: No visible abnormal findings. Left Ankle: No visible abnormal findings. | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected left ankle | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected both ankles: Right Ankle: No visible abnormal findings. Left Ankle: No visible abnormal findings. | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected right ankle | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected right foot | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected top of feet | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected left foot | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected top of feet | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected left foot | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected right foot | Exam Action 05/02/25 4:32 AM EDT |
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| Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature | Exam Action 05/02/25 4:33 AM EDT |
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| Inspected left foot | Exam Action 05/02/25 4:33 AM EDT |
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| Inspected top of feet | Exam Action 05/02/25 4:33 AM EDT |
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| Inspected right foot | Exam Action 05/02/25 4:33 AM EDT |
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| Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature | Exam Action 05/02/25 4:33 AM EDT |
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| Tested ROM of neck – flexion: Expected | Exam Action 05/02/25 4:33 AM EDT |
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| Tested ROM of neck – extension: Expected | Exam Action 05/02/25 4:34 AM EDT |
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| Tested ROM of neck – lateral bending: Expected | Exam Action 05/02/25 4:34 AM EDT |
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| Tested ROM of neck – rotation: Expected | Exam Action 05/02/25 4:34 AM EDT |
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| Tested ROM of shoulders – flexion: Expected | Exam Action 05/02/25 4:35 AM EDT |
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| Tested ROM of shoulders – extension: Expected | Exam Action 05/02/25 4:35 AM EDT |
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| Tested ROM of shoulders – adduction: Expected | Exam Action 05/02/25 4:35 AM EDT |
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| Tested ROM of elbows – flexion and extension: Expected | Exam Action 05/02/25 4:35 AM EDT |
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| Tested ROM of elbows – supination and pronation: Expected | Exam Action 05/02/25 4:36 AM EDT |
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| Tested ROM of wrists – flexion: Expected | Exam Action 05/02/25 4:37 AM EDT |
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| Tested ROM of wrists – extension: Expected | Exam Action 05/02/25 4:37 AM EDT |
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| Tested ROM of wrists – ulnar and radial deviation: Expected | Exam Action 05/02/25 4:37 AM EDT |
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| Tested spinal ROM – extension: Reduced | Exam Action 05/02/25 4:38 AM EDT |
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| Tested spinal ROM – flexion: Reduced | Exam Action 05/02/25 4:38 AM EDT |
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| Tested spinal ROM – lateral bending: Reduced | Exam Action 05/02/25 4:39 AM EDT |
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| Tested spinal ROM – rotation to the right: Reduced | Exam Action 05/02/25 4:39 AM EDT |
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| Tested spinal ROM – rotation to the left: Reduced | Exam Action 05/02/25 4:39 AM EDT |
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| Tested ROM of hips – flexion: Expected | Exam Action 05/02/25 4:40 AM EDT |
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| Tested ROM of hips – extension: Expected | Exam Action 05/02/25 4:40 AM EDT |
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| Tested ROM of hips – abduction: Expected | Exam Action 05/02/25 4:41 AM EDT |
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| Tested ROM of hips – adduction: Expected | Exam Action 05/02/25 4:41 AM EDT |
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| Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature | Exam Action 05/02/25 5:07 AM EDT |
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| Inspected left foot | Exam Action 05/02/25 5:07 AM EDT |
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| Inspected top of feet | Exam Action 05/02/25 5:07 AM EDT |
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| Inspected left foot | Exam Action 05/02/25 5:07 AM EDT |
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| Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature | Exam Action 05/02/25 5:07 AM EDT |
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| Inspected right foot | Exam Action 05/02/25 5:07 AM EDT |
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| Inspected top of feet | Exam Action 05/02/25 5:07 AM EDT |
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| Inspected right foot | Exam Action 05/02/25 5:08 AM EDT |
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| Inspected soles of feet: Right: No visible abnormal findings, new skin tissue from healed wound, expected curvature. Left: No visible abnormal findings, expected curvature | Exam Action 05/02/25 5:08 AM EDT |
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| Tested ROM of knees – flexion: Expected | Exam Action 05/02/25 5:09 AM EDT |
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| Tested ROM of knees – extension: Expected | Exam Action 05/02/25 5:09 AM EDT |
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| Tested ROM of ankles – inversion and eversion: Expected | Exam Action 05/02/25 5:10 AM EDT |
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| Tested ROM of ankles – dorsiflexion and plantar flexion: Expected | Exam Action 05/02/25 5:10 AM EDT |
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| Tested neck strength – head turned to the right: 5/5 | Exam Action 05/02/25 5:11 AM EDT |
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| Tested neck strength – head turned to the left: 5/5 | Exam Action 05/02/25 5:11 AM EDT |
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| Tested neck strength – head tilted to the right: 5/5 | Exam Action 05/02/25 5:11 AM EDT |
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| Tested neck strength – head tilted to the left: 5/5 | Exam Action 05/02/25 5:11 AM EDT |
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| Tested neck strength – head down: 5/5 | Exam Action 05/02/25 5:12 AM EDT |
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| Tested right and left shoulder strength: 5/5 | Exam Action 05/02/25 5:12 AM EDT |
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| Tested elbow strength during flexion: 5/5 | Exam Action 05/02/25 5:12 AM EDT |
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| Tested elbow strength during extension: 5/5 | Exam Action 05/02/25 5:12 AM EDT |
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| Tested wrist strength during extension – up: 5/5 | Exam Action 05/02/25 5:13 AM EDT |
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| Tested wrist strength during extension – down: 5/5 | Exam Action 05/02/25 5:13 AM EDT |
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| Tested right and left hand strength with grip test: 5/5 | Exam Action 05/02/25 5:13 AM EDT |
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| Tested right and left hip strength: 5/5 | Exam Action 05/02/25 5:14 AM EDT |
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| Tested right and left knee strength: 5/5 | Exam Action 05/02/25 5:14 AM EDT |
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| Tested right and left ankle strength: 5/5 | Exam Action 05/02/25 5:15 AM EDT |
Subjective Data Collection: 18 of 18 (100.0%)
Hover To Reveal…
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
- Found:
Indicates an item that you found.
- Available:
Indicates an item that is available to be found.
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Chief Complaint
Finding:
Established chief complaint
Finding:
Reports low back pain
(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:
What is your chief complaint today?
Finding:
Describes injury as a “tweak” to her back
(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:
How would you describe your injury?
History of Present Illness
Finding:
Asked about onset of pain
Finding:
Reports original injury occurred 3 days ago
(Found)
Pro Tip: By establishing a timeline of Tina’s injury, you’re soliciting information that can help you to understand the nature and extent of her injury.
Example Question:
When did the injury occur?
Finding:
Onset was sudden
(Found)
Pro Tip:
Example Question:
Was the onset of the pain sudden?
Finding:
Reports injury happened when lifting a heavy box
(Available)
Pro Tip: Determining what caused Tina’s injury might allow you to have a better understanding of the nature of her pain.
Example Question:
What were you doing when you were injured?
Finding:
Asked about location of pain
Finding:
Reports pain located in low back and buttocks
(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 back pain?
Finding:
Reports pain does not radiate or migrate
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest.
Example Question:
Does the pain radiate from your back?
Finding:
Denies neck pain
(Available)
Pro Tip: Asking Tina to locate the site of her pain can help you to assess the place and extent of her injury.
Example Question:
Do you have neck pain?
Finding:
Denies pain between the shoulder blades
(Available)
Pro Tip: Asking Tina to locate the site of her back pain can help you to assess the place and extent of her injury.
Example Question:
Is there pain between your shoulder blades?
Finding:
Reports pain is the same on both sides of her back
(Available)
Pro Tip: Asking Tina to locate the site of her pain can help you to assess the place and extent of her injury.
Example Question:
Is the pain on both sides of your back?
Finding:
Asked about frequency and duration of pain
Finding:
Reports pain has lasted three days
(Available)
Pro Tip: By establishing a timeline of Tina’s injury, you’re soliciting information that can help you to understand the nature and extent of her injury.
Example Question:
How long have you been in pain?
Finding:
Reports pain is constant
(Found)
Pro Tip: Sometimes pain changes over time. By establishing a timeline of Tina’s injury, you’re soliciting information that can help you to understand the nature and extent of her injury.
Example Question:
Is your pain constant?
Finding:
Asked about severity of pain
Finding:
Describes current pain as “pretty bad”
(Found)
Pro Tip: Subjective, open questions about pain severity can help you to understand how the patient perceives her or his pain. Asking Tina how severe her pain is will provide a relative comparison for understanding her amount of pain.
Example Question:
How severe is your pain?
Finding:
Rates pain of original injury as 6 or 7/10
(Available)
Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her pain when it started on a scale of 1-10 will provide a quantified and relative measurement of her condition.
Example Question:
How would you rate your pain when it started on a scale of one to ten?
Finding:
Reports current pain rating of 5/10
(Available)
Pro Tip: Pain severity might change over time for a variety of reasons. Asking Tina to rate the severity of her current pain on a scale of 1-10 will provide a quantified and relative measurement of her condition.
Example Question:
How would you rate your current pain on a scale of 1 to 10?
Finding:
Asked about character of pain
Finding:
Reports pain at the onset as sharp
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury felt like specifies the way her symptoms and pain manifest.
Example Question:
What did the injury feel like?
Finding:
Describes pain as aching
(Found)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest.
Example Question:
Would you describe the pain as aching?
Finding:
Denies burning pain
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest.
Example Question:
Would you describe the pain as burning?
Finding:
Reports back is sore to the touch
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest.
Example Question:
Is your lower back sore to the touch?
Finding:
Reports pain accompanied by stiffness
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina to describe what her injury feels like specifies the way her symptoms and pain manifest.
Example Question:
Do you have stiffness with the pain?
Finding:
Asked about aggravating factors
Finding:
Reports feeling least comfortable when sitting
(Available)
Pro Tip: For those with back injuries, certain movements or positions might make the pain worse. Asking Tina what position is worst for her back will allow you to see potential factors aggravating her injury.
Example Question:
What position is worst for your back?
Finding:
Reports some pain with movement such as bending or walking
(Found)
Pro Tip: Discerning what’s making Tina’s pain worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s injury.
Example Question:
Does the pain get worse when you move?
Finding:
Asked about relieving factors
Finding:
Reports slight pain relief with rest
(Available)
Pro Tip: Tina’s response to a question about pain management will reveal the severity of her injury, her health literacy, and the way she’s managing her symptoms.
Example Question:
Does resting help your pain?
Finding:
Reports feeling most comfortable when lying flat on back
(Available)
Pro Tip: Tina’s response to a question about pain management will reveal the severity of her injury, her health literacy, and the way she’s managing her symptoms.
Example Question:
Does lying on your back help your pain?
Finding:
Denies use of heating pad or ice
(Available)
Pro Tip: Finding out the non-medication modalities that a patient is treating her pain with will help you understand the severity of the pain.
Example Question:
Have you used a heating pad for your back?
Finding:
Asked about impact of pain on activities of daily living
Finding:
Confirms pain is interfering with activities of daily living
(Available)
Pro Tip: People with severe pain might find that they are unable to perform all of their daily activities. Asking Tina whether she is able to perform all of her usual daily activities would illustrate whether her pain is preventing her from activities that comprise her daily life.
Example Question:
Has the pain affected your usual activities?
Finding:
Reports slight sleep disturbance due to the pain
(Available)
Pro Tip: People with severe pain might find that the pain interferes with their sleep. Asking Tina whether the pain interferes with her sleep might indicate the severity and instance of her pain.
Example Question:
Is the pain interfering with your sleep?
Finding:
Reports no exercise since accident
(Available)
Pro Tip: People with severe pain might find that they are unable to perform all of their daily activities. Asking Tina whether she is able to exercise since her accident would illustrate whether her pain is preventing her from activities that comprise her daily life.
Example Question:
Do you exercise?
Finding:
Reports receiving help with daily tasks from mother and sister
(Available)
Pro Tip: Sometimes an injury is so severe that patients need help at home in order to accomplish their daily activities. Asking Tina whether she’s had help at home since her injury would indicate the degree to which her injury has been preventing her from her usual activities.
Example Question:
Have you had help at home since your injury?
Medical History
Finding:
Confirmed use of medications
Finding:
Confirms 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:
What medications do you take?
Finding:
Reports increased ibuprofen use for pain
(Found)
Pro Tip: If a patient needs increasing amounts of pain medication, it can indicate escalating symptoms.
Example Question:
Have you taken ibuprofen for the pain?
Finding:
Followed up on ibuprofen use
Finding:
Has taken ibuprofen for the past 3 days
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how the Ibuprofen makes her feel will illustrate the extent of her pain and how effectively OTC medication works for her injury.
Example Question:
When did you start taking ibuprofen?
Finding:
Last dose of ibuprofen was about 5 hours ago
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina when she last took the Ibuprofen will illustrate how effectively OTC medication works for her injury.
Example Question:
Do you remember when you last took the Ibuprofen?
Finding:
Reports taking two Ibuprofens at a time
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how frequently she is taking the Ibuprofen will illustrate the extent of her pain and how effectively OTC medication works for her injury.
Example Question:
How many ibuprofen do you take at a time?
Finding:
Takes ibuprofen every 5-6 hours as per instructions
(Available)
Pro Tip: It’s essential to understand how often a patient is taking a medication to determine if they are ingesting appropriate amounts of the active drug.
Example Question:
How often have you been taking ibuprofen?
Finding:
Unsure of dose, describes it as “not extra strength”
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how many milligrams of the Ibuprofen she has been taking will illustrate how effectively OTC medication works for her injury.
Example Question:
How many milligrams of Ibuprofen have you been taking?
Finding:
Ibuprofen provides relief for several hours
(Available)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if the Ibuprofen has been helping will illustrate the extent of her pain and how effectively OTC medication works for her injury.
Example Question:
Has the Ibuprofen been helping?
Finding:
Confirmed allergies
Finding:
Confirms allergies (no new allergies reported)
(Found)
Pro Tip: Asking Tina if she has any new allergies will allow you to understand how, beyond the chief complaint, Tina’s health has been.
Example Question:
Do you have new allergies?
Finding:
Asked about possible contributing factors in health history
Finding:
Reports no history of previous back pain or injury
(Found)
Pro Tip: Soliciting a relevant medical history can help you to understand the nature of a patient’s chief complaint. Asking Tina whether she’s had a similar injury in the past might indicate that she is prone to a specific type of injury or pain.
Example Question:
Have you ever had a similar injury?
Finding:
Denies history of severe trauma such as car accident or occupational injury
(Found)
Pro Tip: Past trauma to spine or limbs could make a patient more susceptible to future injury.
Example Question:
Have you ever injured your back?
Finding:
Denies past surgery
(Available)
Pro Tip: Soliciting your patient’s medical history can help you to understand the nature of a patient’s chief complaint. Asking Tina whether she’s ever had surgery might reveal relevant concerns she’d previously experienced.
Example Question:
Have you ever had surgery?
Finding:
Denies increase in alcohol use since injury
(Available)
Pro Tip: Some patients self-medicate with drugs or alcohol following an injury. Asking Tina whether the amount of alcohol she’s drinking has changed since her injury might uniquely reveal the degree or nature of her pain.
Example Question:
Has the amount of alcohol you’re drinking changed since the injury?
Finding:
Denies history of fractures
(Available)
Pro Tip: Soliciting your patient’s medical history can help you to understand the nature of a patient’s chief complaint. Asking Tina whether she’s ever broken a bone might reveal relevant concerns she’d previously experienced.
Example Question:
Have you ever broken a bone?
Finding:
Denies heavy lifting at work
(Available)
Pro Tip: Repetitive heavy lifting in the workplace is a common cause or contributing factor of back injury.
Example Question:
Are you required to lift heavy loads at work?
Social Determinants of Health
Finding:
Asked about impact of pain on income and education
Finding:
Reports no missed work due to pain
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Have you had to miss work because of the pain?
Finding:
Reports no missed school due to pain, but discomfort sitting in class
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Have you had to miss school because of your pain?
Review of Systems
Finding:
Asked about general symptoms
Finding:
Denies fever
(Found)
Pro Tip: Fever could signal that the patient’s symptoms are caused by an infection.
Example Question:
Do you have a fever?
Finding:
Denies chills
(Available)
Pro Tip: Chills could be an indication of fever, which could be an indication of infection.
Example Question:
Have you been getting chills?
Finding:
Denies night sweats
(Available)
Pro Tip: Night sweats, where a patient sweats an abnormal amount in sleep, can indicate a number of health conditions or fever.
Example Question:
Do you ever get night sweats?
Finding:
Denies nausea or vomiting
(Available)
Pro Tip: Nausea or vomiting can indicate an infection.
Example Question:
Have you felt nauseous?
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:
How is your energy level?
Finding:
Asked review of systems for musculoskeletal
Finding:
Denies muscle weakness
(Available)
Pro Tip: Muscle weakness can be a symptom different musculoskeletal or neurological diseases.
Example Question:
Do you have muscle weakness?
Finding:
Denies joint pain
(Found)
Pro Tip: Joint pain can indicate injury from repetitive movements, or from a degenerative joint disease.
Example Question:
Do you have any pain in your joints?
Finding:
Denies joint swelling or redness
(Available)
Pro Tip: Joint swelling can indicate overuse from repetitive movement, or autoimmune conditions.
Example Question:
Do you have any swelling in your joints?
Finding:
Denies joint stiffness
(Available)
Pro Tip: Joint stiffness can be a symptom of musculoskeletal or autoimmune diseases.
Example Question:
Do you have any joint stiffness?
Finding:
Asked review of systems for neurological
Finding:
Denies headache related to injury
(Available)
Pro Tip: Headaches can be a symptom from a back or spine injury, or indicate an underlying neurological problem.
Example Question:
Have you had headaches recently?
Finding:
Denies tingling or numbness in any body part
(Available)
Pro Tip: Numbness or tingling could indicate nerve damage, so it’s important to rule this symptom out.
Example Question:
Do you have any numbness or tingling?
Finding:
Denies changes to bowel or bladder function
(Available)
Pro Tip: Changes to bowel or bladder function can indicate serious damage to nerves caused by injury.
Example Question:
Have you had changes in your bowel function?
Finding:
Denies dizziness, light-headedness, and disequilibrium
(Available)
Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury details the way her individual symptoms and pain manifest.
Example Question:
Have you been dizzy?
Family History
Finding:
Asked about relevant family history
Finding:
Denies family history of general musculoskeletal problems
(Found)
Pro Tip: Some musculoskeletal diseases can be inherited, and so you will want to understand your patient’s risk level.
Example Question:
Do you have a family history of musculoskeletal problems?
Finding:
Denies family history of osteoporosis
(Available)
Pro Tip: Osteoporosis can be inherited, and so you will want to understand your patient’s risk level.
Example Question:
Do you have a family history of osteoporosis?
Finding:
Denies family history of any form of arthritis
(Available)
Pro Tip: Some forms of arthritis can be inherited, and so you will want to understand your patient’s risk level.
Example Question:
Do you have a family history of arthritis?
Finding:
Denies family history of bone cancer or disease
(Available)
Pro Tip: Some bone cancers or diseases can be inherited, and so you will want to understand your patient’s risk level.
Example Question:
Do you have a family history of bone cancer?
Finding:
Denies family history of degenerative muscle disease
Objective Data Collection: 27.8 of 28 (99.29%)
- Correct
- Partially correct
- Incorrect
- Missed
Symmetry (1/2 point)
- Symmetric
Appearance (1/2 point)
- Discoloration
Right: Appearance (1/3 point)
- No visible abnormal findings
Left: Appearance (1/3 point)
- No visible abnormal findings
Symmetry (1/3 point)
- Symmetric bilaterally
Right: Appearance (1/3 point)
- No visible abnormal findings
Left: Appearance (1/3 point)
- No visible abnormal findings
Symmetry (1/3 point)
- Symmetric bilaterally
Right: Appearance (1/3 point)
- No visible abnormal findings
Left: Appearance (1/3 point)
- No visible abnormal findings
Symmetry (1/3 point)
- Symmetric bilaterally
Right: Appearance (1/3 point)
- No visible abnormal findings
Left: Appearance (1/3 point)
- No visible abnormal findings
Symmetry (1/3 point)
- Symmetric bilaterally
Right: Appearance (1/3 point)
- No visible abnormal findings
Left: Appearance (1/3 point)
- No visible abnormal findings
Symmetry (1/3 point)
- Symmetric bilaterally
Appearance (1/1 point)
- No visible abnormal findings
Right: Appearance (1/3 point)
- No visible abnormal findings
Left: Appearance (1/3 point)
- No visible abnormal findings
Symmetry (1/3 point)
- Symmetric bilaterally
Right: Appearance (1/3 point)
- No visible abnormal findings
Left: Appearance (1/3 point)
- No visible abnormal findings
Symmetry (1/3 point)
- Symmetric bilaterally
Right: Appearance (1/3 point)
- No visible abnormal findings
Left: Appearance (1/3 point)
- No visible abnormal findings
Symmetry (1/3 point)
- Symmetric bilaterally
Right: Appearance (1/3 point)
- No visible abnormal findings
Left: Appearance (1/3 point)
- No visible abnormal findings
Symmetry (1/3 point)
- Symmetric bilaterally
Right: Appearance (1/5 point)
- No visible abnormal findings
Right: Arch Shape (1/5 point)
- Expected curvature
Left: Appearance (1/5 point)
- No visible abnormal findings
Left: Arch Shape (1/5 point)
- Expected curvature
- Pes planus
- Pes cavus
Symmetry (1/5 point)
- Symmetric bilaterally
Flexion (1/4 point)
- Expected range of motion (approx. 45 degrees)
Extension (1/4 point)
- Expected range of motion (approx. 45 degrees)
Lateral Bending (1/4 point)
- Expected range of motion (approx. 40 degrees) on both sides
Rotation (1/4 point)
- Expected range of motion (approx. 70 degrees) on both sides
Tested shoulder range of motion
Forward Flexion (1/3 point)
- Expected range of motion (approx. 180 degrees)
Extension (1/3 point)
- Expected range of motion (approx. 50 degrees)
Adduction (1/3 point)
- Expected range of motion (approx. 50 degrees)
Right: Flexion And Extension (1/4 point)
- Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
Left: Flexion And Extension (1/4 point)
- Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
Right: Supination And Pronation (1/4 point)
- Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees)
Left: Supination And Pronation (1/4 point)
- Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees)
Right: Flexion (1/8 point)
- Expected range of motion (approx. 90 degrees)
Left: Flexion (1/8 point)
- Expected range of motion (approx. 90 degrees)
Right: Extension (1/8 point)
- Expected range of motion (approx. 70 degrees)
Left: Extension (1/8 point)
- Expected range of motion (approx. 70 degrees)
Right: Ulnar Deviation (1/8 point)
- Expected range of motion (approx. 55 degrees)
Left: Ulnar Deviation (1/8 point)
- Expected range of motion (approx. 55 degrees)
Right: Radial Deviation (1/8 point)
- Expected range of motion (approx. 20 degrees)
Left: Radial Deviation (1/8 point)
- Expected range of motion (approx. 20 degrees)
Extension (1/4 point)
- Reduced extension
Flexion (1/4 point)
- Reduced flexion
Lateral Bending (1/4 point)
- Reduced lateral bending to the right
- Reduced lateral bending to the left
Rotation (1/4 point)
- Reduced rotation to the right
- Reduced rotation to the left
Flexion (1/4 point)
- Expected range of motion (approx. 90 degrees)
Extension (1/4 point)
- Expected range of motion (approx. 30 degrees)
Abduction (1/4 point)
- Expected range of motion (approx. 45 degrees)
Adduction (1/4 point)
- Expected range of motion (approx. 30 degrees)
Right: Flexion (1/4 point)
- Expected range of motion (approx. 130 degrees)
Left: Flexion (1/4 point)
- Expected range of motion (approx. 130 degrees)
Right: Extension (1/4 point)
- Expected range of motion (approx. 0 to 15 degrees)
Left: Extension (1/4 point)
- Expected range of motion (approx. 0 to 15 degrees)
Right: Eversion And Inversion (1/4 point)
- Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees)
Left: Eversion And Inversion (1/4 point)
- Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees)
- Reduced inversion
- Reduced eversion
Right: Dorsiflexion And Plantar Flexion (1/4 point)
- Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
Left: Dorsiflexion And Plantar Flexion (1/4 point)
- Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)
Strength (1/1 point)
- 5 – Active movement against full resistance without fatigue (normal)
Strength (1/1 point)
- 0 – No muscle contraction
- 1 – Barely detectable contraction
- 2 – Active movement with gravity eliminated
- 3 – Active movement against gravity
- 4 – Active movement against gravity and resistance
- 5 – Active movement against full resistance without fatigue (normal)
Right (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Right (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Right (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Strength (1/1 point)
- 5 – Active movement against full resistance without fatigue (normal)
Right (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Right (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Left (1/2 point)
- 5 – Active movement against full resistance without fatigue (normal)
Education & Empathy : 1 of 4 (25.0%)
During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.
- Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
- Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
- Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
| Description: Tina describes the symptoms that have been bothering her. | ||
| What brings you here today? | Question 04:19 AM EDT |
|
| Well, I have a lot of pain in my lower back. It really hurts, and it doesn’t seem to be going away. It’s making it kind of hard to get things done, so I decided to come in and have it looked at. | ||
| I am sorry for that | Empathize 04:19 AM EDT |
|
| Thanks for understanding. | ||
| Model Statement: “I’m sorry to hear you’re in pain. I would like to learn more about your pain and how it may have happened, and then we can talk about treating it so you feel better.” |
| Description: Tina discusses her lifting technique. | ||
| Model Statement: “You’re right; proper lifting technique is important to prevent injuries. We can go over how to lift things safely, so that you don’t further injure yourself when you go back to work.” |
| Description: Tina describes her medication regimen, which includes taking 8 to 10 tablets of ibuprofen per day to treat her back pain. | ||
| What relieves the pain? | Question 04:23 AM EDT |
|
| Taking Advil has been helping a little. | ||
| Do you use any medication? | Question 04:23 AM EDT |
|
| I’ve been taking Advil for my back, and I also have my inhalers. | ||
| Hos long have you been taking advil? | Question 04:24 AM EDT |
|
| I’ve been taking the Advil about three days, maybe a little less–since the night after I hurt myself. | ||
| Do you have any allergies? | Question 04:24 AM EDT |
|
| Yeah, I’m allergic to cats. | ||
| Do you have a history of back pain? | Question 04:24 AM EDT |
|
| No, nothing like this has ever happened to me. . . my back is usually totally fine. | ||
| Model Statement: “Thank you for letting me know that you’re taking ibuprofen in addition to the medications you usually take. I will ask you a few questions about how you’re using each medication.” |
| Description: Tina discusses her activity level and work tasks while on the job. | ||
| How has the pain impacted your income and education? | Question 04:25 AM EDT |
|
| I haven’t missed any work. . . work isn’t so bad, since I’m mostly standing up for it. | ||
| Do you have fever? | Question 04:25 AM EDT |
|
| No, I don’t get a lot of fevers. | ||
| Do you have head related injury? | Question 04:26 AM EDT |
|
| No, never. | ||
| Model Statement: “It sounds like you keep busy at work. Being on your feet all day can aggravate your back. We can talk about footwear and postural changes that will help you be more comfortable at work.” |
Documentation / Electronic Health Record
Document: Provider Notes
| Student Documentation | Model Documentation |
| Subjective
Tina Jones presents to the clinic complaining of lower back pain which she hurt while lifting a box. The pain has been contant for the last 3 days. The pain does not radiate. She rates the pain as 5/10. Uses Advil to releave the pain. She has difficulty sitting and walking but is able to do her daily tasks. She has no new allergies. Has no history of back pain. Dhe has no fever, numbness or dizziness. |
HPI: Ms. Jones presents to the clinic complaining of back pain that began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that lifted several boxes before this event without incident and does not know the weight of the box that caused her pain. The pain is in her low back and bilateral buttocks, is a constant aching with stiffness, and does not radiate. The pain is aggravated by sitting (rates a 7/10) and decreased by rest and lying flat on her back (pain of 3-4/10). The pain has not changed over the past three days and she has treated with 2 over the counter ibuprofen tablets every 5-6 hours. Her current pain is a 5/10, but she states that the ibuprofen can decrease her pain to 2-3/10. She denies numbness, tingling, muscle weakness, bowel or bladder incontinence. She presents today as the pain has continued and is interfering with her activities of daily living. Social History: Ms. Jones’ job is mostly supervisory, although she does report that she may have to sit or stand for extended periods of time. She denies lifting at work or school. She states that her pain has limited her activities of daily living. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. She does state that she has difficulties with range of motion. She does state that the pain in her lower back has impacted her comfort while sleeping and sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeletal injuries or fractures. • Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures. |
| Objective
Tina Jones is pleasant. She is obese and is in no acute distress. She is alert and well orineted. Spinal ROM extension, flexion and lateral bending are reduced. Spinal ROM rotation is reduced. Hip strength is 5 out of 5. No joint deformity. |
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. Musculoskeletal: Bilateral upper extremities without muscle atrophy or joint deformity. Bilateral upper extremities with full range of motion of shoulder, elbow, and wrist. No evidence of swollen joints or signs of infection. Bilateral lower extremities without muscle atrophy or joint deformity, full range of motion of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection. Flexion, extension, lateral bending, and rotation of the spine with reduced ROM – pain and difficulty. Bilateral upper extremity strength equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip flexors, knees, and ankles. |
| Assessment
Low back muscle strain related to lifting |
Low back muscle strain related to lifting |
| Plan
Educate patint on how to avoid lower back pain in the future. Initiate treatment with ibuprofen and acetaminophen 500-1000 mg by mouth Use heat or ice per comfort TID-QID Educate patient on lifting techniques. Seek medical attentio in case of acute changes Limit movment of lower back Review after two weeks for follow up |
Provide Ms. Jones with materials detailing stretching techniques for the lower back. • Initiate treatment with ibuprofen 600 mg by mouth every six to eight hours with food as needed for pain for the next two weeks. She may use acetaminophen 500-1000 mg by mouth every 8 hours for breakthrough pain. • Ms. Jones can also use adjunct therapy of topical heat or ice per comfort TID-QID. • Educate on proper body mechanics and lifting techniques. • Educate on when to seek emergent care including loss of bowel or bladder function, acute changes in sensation of lower extremities, or limitations in movement of lower extremities. • Return to clinic in two weeks for follow up and evaluation of symptoms. |
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