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Tina Jones Comprehensive Assessment Health Assessment Completed – January 2023

Tina Jones Comprehensive Assessment Health Assessment Completed – January 2023

Shadow Health provides students and faculty access to Digital Clinical Experience™ (DCE) products in which students interact (ask questions of, view anatomy, perform simulated examinations of) with virtual patients — computer-generated characters which play the role of a patient in a simulated provider-patient encounter. This is much like a “serious game” designed to improve students’ interviewing and examination abilities and allow faculty to evaluate students. The DCEs are delivered from a set of web applications and services to the user’s browser; in this manner out products are similar to a Software-as-a-Service model.

  • Shadow Health Simulations
  • Skin, Hair, and Nails
  • HEENT
  • Respiratory (Lungs)
  • Cardiovascular (Heart)
  • Abdominal
  • Musculoskeletal
  • Neurological
  • Comprehensive

Interviewing the patient

Performing physical assessments

In addition to the patient interviews, you will be performing physical assessments on the patients as you work through your Shadow Health assignments. All of these physical assessments will be performed via the Exam Menu, which will appear in the upper left of the simulation area. Clicking the Exam Actions in the menu will begin the physical assessment.

The Exam Menu will contain all of the relevant physical assessments that you should be performing in the assignment. If you are unable to locate the physical assessment, please check all of the available categories in the Exam Menu.

Education & Empathy score

The score you receive in the Education and Empathy section is based on the timing of your therapeutic statements during critical moments in the patient interview.

When asking interview questions to collect subjective data, there will be scored opportunities to provide either an educational or empathic statement in response to the patient.  To get credit for acknowledging the patient with therapeutic communication, you must respond within two lines of dialogue.

For example, if you ask the patient if they’re experiencing any pain and they say “Yes”, then that would be an ideal moment to respond with an empathetic statement.

Once you’ve completed the assignment and can see your results, you can click on the Education & Empathy tab to see the available points. Clicking on each of the Education & Empathy topics will show you more information and the part of your transcript

Post Exam activities

All of the non-Concept Lab assignments in Shadow Health have the potential to include additional activities after completing the Patient Exam portion of the assignment. Instructors have the ability to add any, or all, of the following activities.

  • Self Reflection– Self assess your patient teaching by comparing with model responses, and reflect on your performance as a whole.
  • Hallway– You will communicate with possibly different staff members after interviewing the patient. You should type a response to each person to practice your communication skills.
  • Lifespan– After completing the exam, you’ll explore issues related to how a patient’s phase in life affects the way you provide care for them.
  • Review Questions– Review concepts relevant to the simulation by answering the included questions.

Where are the Post Exam activities located?

  • Once you complete the Patient Exam, you will encounter each of the activities your instructor chose to include. Prior to loading the assignment, you can view which activities are present by navigating to the Activity Descriptions section on the Assignment Overview page.

Save/upload lab pass

The Lab Pass for your assignment attempt is available on the  Experience Overview page.

You can reach the Experience Overview page by clicking on “My Results” at the top of Shadow Health.

Find the assignment attempt you need a Lab Pass for. In this example, we are using the Abdominal assignment. Click on the green “Completed” link. This may also say “Completed (Reopened)” if you’ve reopened your attempt or “Reviewed” if your instructor has commented.

Now that you’re on the Experience Overview page for your attempt, you should see the Lab Pass button in the top right of the results.  If you do not see this button, your instructor may have chosen to not use the Lab Pass.

  • The next step after successfully downloading your Lab Pass is to upload it via your student portal.

Comprehensive Assessment Tina Jones

Vitals

Systolic – 128 mmHg

MAP/Cuff -973 mmHg

Diastolic – 82 mmHg

Heart Rate – 78BPM

Respiratory Rate – 15

SpO2 – 0.99%

Temperature 37.2C

Interview Questions

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Tina Jones – Skin, Hair, and Nails Results Health Assessment Complete- January 2023

Tina Jones – Skin, Hair, and Nails Results Health Assessment – January 2023

Transcript

All Lines (157)Interview Questions (27)Statements (0)Exam Actions (130)

Hello!
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation?
It’s 4 p.m. on Tina Jones’ second day as a patient here at Shadow General Hospital. In anticipation of Ms. Jones being discharged from the hospital, your role in this simulation is that of a healthcare provider who will assess her skin, hair, and nails for any additional wounds or signs of impaired healing.
What are my objectives in this assessment?
In your interview with Ms. Jones, you will gather subjective data by asking about her skin, hair, and nails. These features, which help make up the integumentary system, are often an indicator of overall health. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to skin, hair, and nails so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her hair, skin, and nails. In addition to collecting subjective data, you will also examine Ms. Jones’ skin, hair, and nails to gather objective data. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve?
You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
How will I be evaluated?
In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 50 and 70 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world?
In this assessment, you will become familiarized with the structure and content of skin, hair, and nail exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What effect might a patient’s diabetes have on their skin?
Skin may turn brown or red
Time to begin.
Hello my name is Nukol
Hey.
 Checked vitals
How is foot wound?
I think it’s getting much better. It had actually been getting worse, but I think being in the hospital has helped.
Do you have a history of slow healing wounds?
Usually I heal up fine. . . I’m really surprised this scrape has taken so long to get better. But being in the hospital has helped it.
Do you have a history of skin conditions?
No, unless acne counts. I suppose my dry skin counts, too.
What causes the skin dryness? (Clarified to What do you use for your dry skin?.)
I put lotion on my skin a lot, and that helps keep it from getting dry, it least for a while. (Clarified to what I do for my dry skin.)
Do you have acne?
Yeah, my skin breaks out a lot. . . it is right now.
How do you treat acne?
I just wash my face before bed every night.
Do you have moles?
I have some moles, yeah.
Where are the acne located?
My face breaks out a lot. . . and sometimes my back does, too.
Is there any mole changes?
I haven’t noticed anything different about them.
How is the mole appearance?
I don’t know. . . they’re just regular moles.
where is the mole location?
I think most of my moles are on my back.
Have you noted changes in skin color? (Clarified to Has your skin changed color?.)
Yeah, I was noticing recently that the skin on my neck is looking weird. . . it’s definitely getting darker. (Clarified to if my skin has changed color.)
when did the neck skin change start?
I only noticed the skin getting darker pretty recently, like in the last few months. But then I saw some photos of myself from a few years ago and it was getting darker then, so I guess it’s been that way for a while without my realizing it.
How is your neck skin sensation? (Clarified to Do you have sensation in your neck?.)
It’s. . . well, it’s definitely been getting darker, but it doesn’t hurt or feel weird or anything, it just looks different. (Clarified to if I have sensation in my neck.)
When did the body hair start?
I’ve had at least some hair there for a really long time, but it seems like it gets worse and worse every year.
have you noted tanning?
I don’t like tanning. I don’t get much sun, either. I’m not an outdoors person.
Have you noted changes in nail character?
My nails are normal. I haven’t noticed any problems with them.
do you have scalp problem?
Everything seems fine with my scalp.
Do you have related medical conditions?
Well, I have diabetes — I think that can affect your skin sometimes, but don’t quote me.
do you have family history of hair problems?
I don’t think so.
Do you have a family history of skin conditions?
I don’t think anyone in the family has skin problems.
 Palpated scalp: No tenderness reported, no masses
 Inspected hairline and top scalp
 Inspected right side of head
 Inspected hair on back of head
 Inspected left side of head
 Inspected hairline and top scalp
 Inspected left side of head
 Inspected hair on back of head
 Inspected right side of head
 Inspected hairline and top scalp
 Inspected general face
 Inspected nose and mouth
 Inspected right side of head
 Inspected general face
 Inspected left side of head
 Inspected general face
 Inspected right orbital area and sclera
 Inspected left orbital area and sclera
 Inspected upper conjunctiva
 Inspected lower conjunctiva
 Inspected front of neck
 Inspected right side of neck
 Inspected back of neck
 Inspected left side of neck
 Inspected front of neck
 Inspected left side of neck
 Inspected back of neck
 Inspected right side of neck
 Inspected front of neck
 Inspected anterior chest wall
 Inspected right side of chest wall
 Inspected anterior chest wall
 Inspected left side of chest wall
 Inspected anterior chest wall
 Inspected left side of abdomen
 Inspected front of abdomen
 Inspected right side of abdomen
 Inspected front of abdomen
 Inspected left side of abdomen
 Inspected front of abdomen
 Inspected left arm
 Inspected right arm
 Inspected right elbow
 Inspected left elbow
 Inspected left hand
 Inspected right hand
 Inspected fingernails of right hand
 Inspected fingernails of left hand
 Checked capillary refill in fingernails
 Inspected fingernails of right hand
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Inspected upper back
 Inspected mole closely
 Inspected left shoulder
 Inspected upper back
 Inspected right shoulder
 Inspected upper back
 Inspected left shoulder
 Inspected upper back
 Inspected back
 Inspected sacrum closely
 Inspected back
 Inspected front of hips
 Inspected right side of hips
 Inspected back of hips
 Inspected left side of hips
 Inspected front of hips
 Inspected left side of hips
 Inspected back of hips
 Inspected right side of hips
 Inspected front of hips
 Inspected front of legs
 Inspected right leg
 Inspected back of legs
 Inspected left leg
 Inspected front of legs
 Inspected left leg
 Inspected back of legs
 Inspected right leg
 Inspected front of legs
 Inspected front of knees
 Inspected right knee
 Inspected back of knees
 Inspected left knee
 Inspected front of knees
 Inspected left knee
 Inspected back of knees
 Inspected right knee
 Inspected front of knees
 Inspected left ankle
 Inspected front of ankles
 Inspected right ankle
 Inspected front of ankles
 Inspected left ankle
 Inspected front of ankles
 Inspected left foot
 Inspected top of feet
 Inspected right foot
 Inspected top of feet
 Inspected left foot
 Inspected soles of feet
 Inspected right foot
 Inspected soles of feet
 Inspected left foot
 Inspected top of feet
 Inspected left toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Inspected right toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Assessed wound location
 Assessed wound exudate: Serosanguineous and purulent exudate noted; no odor noted
 Assessed for necrotic tissue
 Assessed peripheral tissue: Red with slight edema
 Assessed for necrotic tissue
 Tested skin turgor on forearm

Subjective Data Collection: 23 of 23 (100.0%)

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.

Relevant Medical History

Finding:

Asked about foot wound

Finding:

Reports swelling has improved

(Available)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if her wound has any swelling specifies the symptoms she is experiencing.

Example Question:

Does your wound have any swelling?

Finding:

Reports wound warmth has improved

(Available)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if her wound is warm to the touch specifies the symptoms she is experiencing.

Example Question:

Does your wound feel warm to the touch?

Finding:

Reports wound discharge has improved

(Available)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if there is any discharge coming from her wound specifies the symptoms she is experiencing.

Example Question:

Is discharge coming from your wound?

Finding:

Reports wound is still a little red

(Available)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if her wound has any redness specifies the symptoms she is experiencing.

Example Question:

Does your wound have any redness?

Finding:

Asked history of slow healing wounds

Finding:

Denies history of slow healing wounds

(Found)

Pro Tip: Specific questions about Tina’s wounds can help you to assess the care that she will need. Asking Tina if she has a history of slow healing wounds specifies the symptoms she is experiencing.

Example Question:

Do you have a history of slow healing wounds?

Finding:

Asked current wound healing time

Finding:

Reports wound had been getting worse over the past week

(Found)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina how her foot wound has been healing specifies the symptoms she is experiencing.

Example Question:

How has your foot wound been healing?

Finding:

Reports wound has improved with hospital treatment

(Found)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if the hospital treatment has improved her foot wound will clarify the symptoms she is experiencing.

Example Question:

Has being in the hospital helped your wound?

Finding:

Asked about history of skin conditions

Finding:

Reports acne

(Found)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has acne solicits important health history information.

Example Question:

Have you ever had acne?

Finding:

Reports dry skin

(Found)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if her skin has been dry solicits important health history information.

Example Question:

Have you ever had dry skin?

Finding:

Denies skin cancer

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has ever been diagnosed with skin cancer solicits important health history information.

Example Question:

Have you ever been diagnosed with skin cancer?

Finding:

Denies skin rashes

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has had skin rashes solicits important health history information.

Example Question:

Have you had skin rashes?

Finding:

Denies sores other than foot wound

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has sores solicits important health history information.

Example Question:

Do you have sores?

Finding:

Reports skin has only itched due to cat exposure

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if her skin has been itching solicits important health history information.

Example Question:

Has your skin been itching?

Finding:

Denies bruising

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if her skin has been bruising solicits important health history information.

Example Question:

Have you noticed unusual bruising?

Finding:

Followed up on skin dryness

Finding:

Reports arms and legs get dry

(Available)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if her skin gets dry solicits important health information.

Example Question:

What part of your skin gets dry?

Finding:

Reports using lotion

(Found)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina how she treats skin dryness solicits important health information.

Example Question:

How do you treat skin dryness?

Finding:

Followed up on acne

Finding:

Reports having acne since middle school

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina about her history of acne solicits important information about her health history.

Example Question:

How long have you had acne?

Finding:

Reports current acne

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina if she currently has acne solicits important information about her health history.

Example Question:

Do you have acne now?

Finding:

Reports acne had been dormant but got worse recently

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina when she developed acne solicits important information about her health history.

Example Question:

When did you develop acne?

Finding:

Asked about acne treatment

Finding:

Reports last seeing a doctor for acne in high school

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina when she last saw a doctor about her acne solicits important information about her health history and any treatment plan she was following.

Example Question:

When was the last time you saw a doctor about acne?

Finding:

Reports doctor prescribed antibiotics for acne

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina how the doctor treated her acne solicits important information about her health history and any treatment plan she was following.

Example Question:

How did the doctor treat your acne?

Finding:

Reports antibiotic for acne was tetracycline

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina what antibiotic she was prescribed for her acne solicits important information about her health history and any treatment plan she was following.

Example Question:

What antibiotic were you prescribed for your acne?

Finding:

Reports antibiotics were ineffective

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina what antibiotic she was prescribed for her acne solicits important information about her health history and any treatment plan she was following.

Example Question:

Were the antibiotics effective on your acne?

Finding:

Reports only current treatment is washing her face

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina how she treats her acne solicits important information about her health history.

Example Question:

How do you treat your acne now?

Finding:

Reports washing her face every night

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina how she treats her acne solicits important information about her health history.

Example Question:

How do you treat your acne now?

Finding:

Asked acne location

Finding:

Reports acne is located on her face

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina where her acne is located solicits important information about her health history.

Example Question:

Where is your acne located?

Finding:

Reports acne is located on her back

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina where her acne is located solicits important information about her health history.

Example Question:

Where is your acne located?

Finding:

Asked if patient has moles

Finding:

Reports moles

(Found)

Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina about her moles solicits important information about her skin.

Example Question:

Do you have moles?

Finding:

Asked about mole changes

Finding:

Denies mole changes

(Found)

Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina about changes in her moles solicits important information about her skin.

Example Question:

Have your moles changed at all?

Finding:

Asked about mole appearance

Finding:

Reports moles are “just regular moles”

(Found)

Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina what her new moles are like solicits important information about her skin.

Example Question:

What are your moles like?

Finding:

Asked about mole location

Finding:

Reports moles are located on her back

(Found)

Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina where her moles are located solicits important information about her skin.

Example Question:

Where are your moles located?

Finding:

Asked about changes in skin color

Finding:

Reports folds in neck are getting darker

(Found)

Pro Tip: Changes in skin color can be the symptom of various diseases, disorders, or conditions. Asking Tina about changes in skin color solicits relevant information about a symptom she might be experiencing.

Example Question:

How has the skin on your neck changed?

Finding:

Asked about neck skin sensation

Finding:

Denies itchy neck skin

(Available)

Pro Tip: Establishing information about the character of Tina’s skin, like whether the skin on her neck is itchy, will allow you to compare her symptoms and assess her condition.

Example Question:

Is the skin on your neck itchy?

Finding:

Denies neck skin tingling

(Available)

Pro Tip: Establishing information about the character of Tina’s skin, like whether the skin on her neck is tingly, will allow you to compare her symptoms and assess her condition.

Example Question:

Does the skin on your neck tingle?

Finding:

Denies neck skin pain

(Found)

Pro Tip: Establishing information about the character of Tina’s skin, like whether the skin on her neck hurts, will allow you to compare her symptoms and assess her condition.

Example Question:

Does the skin on your neck hurt?

Finding:

Reports belief that neck skin has thickened

(Available)

Pro Tip: Establishing information about the character of Tina’s skin, like whether the skin on her neck is thickening, will allow you to compare her symptoms and assess her condition.

Example Question:

Has the skin on your neck thickened?

Finding:

Asked about neck skin change onset

Finding:

Reports a photograph from years earlier shows darkening skin

(Found)

Pro Tip: Establishing information about the character of Tina’s skin, like when she noticed the skin on her neck changing, will allow you to compare her symptoms and assess her condition.

Example Question:

When did you notice the skin on your neck change?

Finding:

Reports perceiving that skin was darkening in the last few months

(Found)

Pro Tip: Establishing information about the character of Tina’s skin, like when she noticed the skin on her neck changing, will allow you to compare her symptoms and assess her condition.

Example Question:

When did you notice the skin on your neck change?

Finding:

Asked about changes in body hair

Finding:

Reports increase in body hair

(Available)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if her body hair has changed solicits important health history information.

Example Question:

Have you had changes in your body hair?

Finding:

Reports increased hair on face

(Available)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if her body hair has changed solicits important health history information.

Example Question:

Where do you have body hair?

Finding:

Reports increased hair on abdomen

(Available)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if her body hair has changed solicits important health history information.

Example Question:

Where do you have body hair?

Finding:

Reports increased hair around nipples

(Available)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if her body hair has changed solicits important health history information.

Example Question:

Where do you have body hair?

Finding:

Asked about body hair onset

Finding:

Reports body hair has been increasing for a long time

(Found)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina when the amount of body hair started to increase solicits important health history information.

Example Question:

When did the amount of body hair start to increase?

Review of Systems

Finding:

Asked about hair and scalp problems

Finding:

Denies scalp problems

(Found)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has scalp problems solicits important health information.

Example Question:

Do you have scalp problems?

Finding:

Denies problems with head hair

(Available)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she had problems with the hair on her head solicits important health information.

Example Question:

Have there been problems with the hair on your head?

Finding:

Denies dandruff

(Available)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has dandruff solicits important health information.

Example Question:

Do you have dandruff?

Finding:

Asked about nails

Finding:

Denies change in character of nails

(Found)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has had changes in her nails solicits important health information.

Example Question:

Have you had nail changes?

Finding:

Denies nail fungus

(Available)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has nail fungus solicits important health information.

Example Question:

Do you have nail fungus?

Finding:

Asked about tanning and sun exposure

Finding:

Denies tanning

(Found)

Pro Tip: Sun exposure can directly affect a patient’s skin. Asking Tina about her sun exposure habits, like whether or not she tans, will help you to determine whether she is at risk for skin cancer.

Example Question:

Do you tan?

Finding:

Reports using sun block

(Available)

Pro Tip: Sun exposure can directly affect a patient’s skin. Asking Tina about her sun exposure habits, like if she uses sun block, will help you to determine whether she is at risk for skin cancer.

Example Question:

Do you use sun block?

Finding:

Reports sun block is SPF 35

(Available)

Pro Tip: Sun exposure can directly affect a patient’s skin. Asking Tina about her sun exposure habits, like the type of sun block she uses, will help you to determine whether she is at risk for skin cancer.

Example Question:

What is the SPF of your sun block?

Finding:

Asked about related medical conditions

Finding:

Reports diabetes

(Found)

Pro Tip: Some medical conditions can affect a patient’s integumentary system. Asking Tina about her medical conditions can help you assess whether or not integumentary symptoms are caused by something larger.

Example Question:

Do you have diabetes?

Relevant Family History

Finding:

Asked family history of hair problems

Finding:

Denies family history of hair problems

(Found)

Pro Tip: Family histories might indicate a genetic predisposition to certain conditions. Asking Tina if she has a family history of hair problems solicits relevant health history.

Example Question:

Does your family have a history of hair problems?

Finding:

Asked family history of skin conditions

Finding:

Denies family history of skin conditions

(Found)

Pro Tip: Family histories might indicate a genetic predisposition to certain conditions. Asking Tina if she has a family history of skin problems solicits relevant health history.

Example Question:

Does your family have a history of skin conditions?

Finding:

Denies family history of skin cancer

Objective Data Collection: 23 of 24 (95.83%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed

 Palpated scalp

1 of 1 point

 

Tenderness (1/2 point)

  •  None reported
  •  Tenderness reported

Observations (1/2 point)

  •  No additional abnormal findings
  •  Palpable masses

 Inspected hair

1 of 1 point

 

Distribution (1/3 point)

  •  No visible abnormal findings
  •  Balding or thinning areas in hair distribution

Texture (1/3 point)

  •  Coarse
  •  Fine

Scalp Observations (1/3 point)

  •  No visible abnormal findings
  •  Dandruff
  •  Discoloration

 Inspected face

1 of 1 point

 

Appearance (1/2 point)

  •  No visible abnormal findings
  •  Redness
  •  Rash
  •  Acne (papules, pustules, or comedones)
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, melasma, or other discoloration
  •  Excessive hair growth
  •  Excessive dry or flaking skin
  •  Scarring
  •  Laceration or wound
  •  Bruising

Location Of Observed Abnormal Findings (1/2 point)

  •  No additional abnormal findings
  •  Forehead
  •  Nose
  •  Cheeks
  •  Chin
  •  Upper lip

 Inspected orbital area and eyelids

1 of 1 point

 

Right: Eyebrow (1/6 point)

  •  Normal hair distribution
  •  Irregular hair distribution

Right: Eyelashes (1/6 point)

  •  Normal hair distribution
  •  Irregular hair distribution

Right: Eyelid (1/6 point)

  •  No visible abnormal findings
  •  Ptosis
  •  Eyelid edema
  •  Lesion
  •  Allergic shiners

Left: Eyebrow (1/6 point)

  •  Normal hair distribution
  •  Irregular hair distribution

Left: Eyelashes (1/6 point)

  •  Normal hair distribution
  •  Irregular hair distribution

Left: Eyelid (1/6 point)

  •  No visible abnormal findings
  •  Ptosis
  •  Eyelid edema
  •  Lesion
  •  Allergic shiners

 Inspected neck

1 of 1 point

 

Appearance (1/1 point)

  •  No visible abnormal findings
  •  Swelling
  •  Visible pulsation
  •  Visible mass
  •  Discoloration

 Inspected anterior chest

1 of 1 point

 

Symmetry (1/2 point)

  •  Symmetric
  •  Asymmetric

Appearance (1/2 point)

  •  No visible abnormal findings
  •  Redness
  •  Rash
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Striae
  •  Laceration, lesion, or wound
  •  Bruising
  •  Scarring

 Inspected abdomen

0 of 1 point

 

Appearance (No point)

  •  No visible abnormal findings
  •  Rash
  •  Moles or skin tags
  •  Freckles, birthmark, or other discoloration
  •  Excessive hair growth
  •  Excessive dry or flaking skin
  •  Purpura
  •  Striae
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Masses (warts, cysts, or tumors)

 Inspected arms

1 of 1 point

 

Right: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Redness
  •  Rash
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Striae
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

Left: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Redness
  •  Rash
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Striae
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

 Inspected elbows

1 of 1 point

 

Right: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Redness
  •  Rash
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

Left: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Redness
  •  Rash
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

Inspected hands

1 of 1 point

 

Right: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Redness
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Rash

Left: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Redness
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Rash

 Inspected fingernails

1 of 1 point

 

Right: Nail Changes (1/3 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Reperfusion
  •  Splinter hemorrhages
  •  Grooves
  •  Fungus
  •  Peeling
  •  Clubbing
  •  Spooning

Left: Nail Changes (1/3 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Reperfusion
  •  Splinter hemorrhages
  •  Grooves
  •  Fungus
  •  Peeling
  •  Clubbing
  •  Spooning

Capillary Refill Time (1/3 point)

  •  Less than 3 seconds
  •  Greater than 3 seconds

 Inspected back and shoulders

1 of 1 point

 

Appearance (1/2 point)

  •  No visible abnormal findings
  •  Redness
  •  Rash
  •  Moles or skin tags
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Striae
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

Location Of Abnormal Findings (1/2 point)

  •  Right shoulder
  •  Left shoulder

 Inspected sacrum

1 of 1 point

 

Appearance (1/1 point)

  •  No visible abnormal findings
  •  Lesions or pressure sores
  •  Redness
  •  Rash
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration or wound
  •  Bruising

 Inspected hips

1 of 1 point

 

Appearance (1/1 point)

  •  No visible abnormal findings
  •  Redness
  •  Rash
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Striae
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

 Inspected legs

1 of 1 point

 

Right: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Edema
  •  Redness
  •  Rash
  •  Moles
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Striae
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Varicosities

Left: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Edema
  •  Redness
  •  Rash
  •  Moles
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Striae
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Varicosities

 Inspected knees

1 of 1 point

 

Right: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Edema
  •  Redness
  •  Rash
  •  Moles
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

Left: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Edema
  •  Redness
  •  Rash
  •  Moles
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

 Inspected ankles

1 of 1 point

 

Right: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Edema
  •  Redness
  •  Rash
  •  Moles
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

Left: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Edema
  •  Redness
  •  Rash
  •  Moles
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising

 Inspected feet

1 of 1 point

 

Right: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Rash
  •  Moles
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Bunion
  •  Callus or corn
  •  Skin fungus

Left: Appearance (1/2 point)

  •  No visible abnormal findings
  •  Rash
  •  Moles
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Bunion
  •  Callus or corn
  •  Skin fungus

 Inspected toenails

1 of 1 point

 

Right: Nail Changes (1/3 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Reperfusion
  •  Splinter hemorrhages
  •  Grooves
  •  Fungus
  •  Peeling
  •  Clubbing

Left: Nail Changes (1/3 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Reperfusion
  •  Splinter hemorrhages
  •  Grooves
  •  Fungus
  •  Peeling
  •  Clubbing

Capillary Refill Time (1/3 point)

  •  Less than 3 seconds
  •  Greater than 3 seconds

 Assessed wound location

1 of 1 point

 

Injured Surface (1/2 point)

  •  Dorsal
  •  Plantar

Injury Site (1/2 point)

  •  Hindfoot
  •  Midfoot
  •  Forefoot

 Assessed wound exudate

1 of 1 point

 

Character (1/1 point)

  •  No exudate
  •  Bloody
  •  Serosanguineous
  •  Serous
  •  Purulent
  •  Foul purulent (yellow or green, with odor)

 Assessed for necrotic tissue

1 of 1 point

 

Observations (1/2 point)

  •  Absent
  •  Minimal
  •  Moderate
  •  Excessive

Type (1/2 point)

  •  No necrotic tissue
  •  Yellow slough
  •  Brown eschar
  •  Black eschar

 Assessed peripheral tissue

1 of 1 point

 

Color (1/2 point)

  •  No notable color difference
  •  Pink
  •  Purple
  •  Red

Observations (1/2 point)

  •  No additional observations
  •  Edema
  •  Cellulitis
  •  Callus
  •  Tracking

 Tested skin turgor

1 of 1 point

 

Observations (1/1 point)

  •  No tenting
  •  Tenting

 

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Tina Jones – Neurological Results Health Assessment – January 2023

Tina Jones – Neurological Results Health Assessment – January 2023

Transcript

All Lines (140)Interview Questions (57)Statements (0)Exam Actions (83)

Hello!
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation?
It’s noon on Tina Jones’ second day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a neurological exam on Ms. Jones. You will collect subjective and objective data about her risk for neuropathy, which is higher given her history of falls and diabetes.
What are my objectives in this assessment?
In your interview with Ms. Jones, you will ask about her neurological system and identify any risk factors so that you can determine any current and potential issues. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to the neurological system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her neurological system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ neurological system to gather objective data about the system’s health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve?
You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
How will I be evaluated?
In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 50 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world?
In this assessment, you will become familiarized with the structure and content of neurological exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What physical exam findings would indicate the presence of neuropathy?
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What physical exam findings would indicate the presence of neuropathy?
Skin dryness, Bruises, skin color change, calluses, Tinea pedisracks
Time to begin.
 Checked vitals
 Checked vitals
Do you have a history of numbness?
No, I don’t think so.
Do you have tingling?
I mean. . . my hand will fall asleep sometimes or something, and then it will tingle, like pins and needles, but that’s normal I think.
Do you have vision problem?
Yeah, actually, I have been noticing my eyes getting kind of blurry lately.
When did the vision problem start?
I don’t know when it started, exactly. Maybe a few months ago?
When do you notice vision problem?
I don’t know when it started, exactly. Maybe a few months ago?
Do you have blurry vision?
It definitely gets blurry or kind of fuzzy when I read. But that’s the only time I notice that.
Do you have headaches?
Yeah, my head aches sometimes. But it’s okay right now.
how are the headache patterns?
Uh, I guess I don’t know what you mean.
What triggers the headache?
The longer I read or study, the worse my headaches get. I try to take a break and rest when they start, but sometimes I’ll have a test or something coming up, and then I’ll just have to work through it.
How frequent are the headaches?
It’s whenever I have to read or study a long time for school, so I probably have them a few times a month on average, I’d say.
What are the characteristics of the headache?
It’s like a tight, throbbing ache behind my eyes.
How do you treat the headache?
When my headaches get bad, I take some acetaminophen and go to sleep. [AUDIO COMING SOON]
Do you have dizziness?
No, I’m not dizzy.
Do you have difficulty speaking?
No. I might stumble over my words sometimes but nothing like that.
Do you have difficulty swallowing?
I swallow fine.
Have you ever fainted?
I’ve never fainted, no.
do you have muscle weakness?
My muscles don’t feel weak ever.
do you have memory loss?
I think my memory’s been pretty much the same as it always was–not supergenius level, but pretty good.
any recent change in mood?
I can be in a bad mood sometimes, like around when I have my period or if I have a bad night’s sleep or something, but generally I’m pretty even-keeled, I think.
Do you use illicit drugs?
No.
Do you smoke tobacco?
No. I think it’s gross.
Do you take alcohol?
I do sometimes, yeah, when I go out with my friends.
How many drinks do you take? (Clarified to How many drinks do you have in a day?.)
I don’t drink every day–a couple times a month, I’ll go out on the weekend and have a few drinks. (Clarified to how many alcoholic drinks I have each day.)
Do you have family history of migraine?
No one in the family gets migraines that I know of.
Do you have a history of neurological problem?
My brain’s always been fine, thankfully. [AUDIO COMING SOON]
What is your name and date of birth?
My name’s Tina Jones, and my birthday’s February 17th.
 Evaluated orientation to person
What building are you in now?
This is Shadow General Hospital.
 Evaluated orientation to place
what is the date and year?
Um, today’s date is .
 Evaluated orientation to time
how are apples and oranges alike?
How are they alike? Um…. they’re both kinds of fruit.
 Evaluated abstract thinking: similarities among fruit
How are a lake and an ocean alike?
Uh…. they’re both bodies of water.
 Evaluated abstract thinking: similarities among bodies of water
How are a trumpet and a flute alike?
They…… they’re both musical instruments.
 Evaluated abstract thinking: similarities among instruments
Count backwards by 7s from 100
Okay. . . 100, 93. . . 86, 79, 72. . . 65. . . 58, 51. . . 44. . . 37, 30, 23, 16. . . 9, and 2.
 Evaluated attention with serial sevens
read and follow these instructions
Ok.
 Established one-stage comprehension
read and follow these instructions
Sure.
 Established two-stage comprehension
Who was the first president of the united states?
That’s George Washington.
 Evaluated knowledge of first president
who are the last four presidents of the united states?
Well . . . (Ms. Jones correctly names the last four presidents.)
 Evaluated knowledge of last four presidents
name five large cities in the united states?
Let’s see. . . New York City. . . and Chicago. . . Detroit. . . Los Angeles. . . and Houston. That’s five.
 Evaluated knowledge of five large cities
what would you do if you found a stamped and addressed envelope on the sidewalk?
What would I do…. Hmm.. Well, I’d try to figure out who dropped the envelope, but if not… Well, I’d probably just drop it in the first mailbox I saw, if there was one nearby.
 Evaluated judgment
repeat and remember burger, tulip, nose, and tea
Burger, tulip, nose, and tea.
 Evaluated immediate memory
how did you celebrate your last birthday?
Wow. . . it’s weird, birthdays were huge for us before Dad died because he would always make a really big deal out of them, like he loved planning these huge celebrations. But the past two birthdays, he hasn’t been there, so it’s been kind of sad, thinking about what he’s missing, and we haven’t done huge parties or anything. Last birthday. . . Michael and his fiance came over, and we all had dinner at the house, and I opened presents, and we had a really good cake from this bakery I love. It was nice.
 Evaluated remote memory
repeat the four words from before
Burger. . . tulip. . .nose. . . and tea.
 Evaluated immediate learning
 Observed patient’s general vocabulary
 Observed patient’s general ability to articulate
close your eyes and tell me what i trace on your palm
Ok.
That’s an “A.”
 Tested left-hand graphesthesia by letter identification
A figure “8.”
 Tested right-hand graphesthesia by number identification
close your eyes and tell me if the touch is sharp, dull or soft
Ok.
 Tested left arm proximal dull sensation
Dull.
 Tested left arm distal dull sensation
Dull.
 Tested right arm proximal dull sensation
Dull.
 Tested right arm distal dull sensation
Dull.
 Tested left arm proximal soft sensation
Soft.
 Tested left arm distal soft sensation
Soft.
 Tested right arm proximal soft sensation
Soft.
 Tested right arm distal soft sensation
Soft.
 Tested left arm proximal sharp sensation
Sharp.
 Tested left arm distal sharp sensation
Sharp.
 Tested right arm proximal sharp sensation
Sharp.
 Tested right arm distal sharp sensation
Sharp.
close your eyes and tell me if the touch is sharp, dull, or soft
Ok.
 Tested left leg proximal dull sensation
Dull.
 Tested left leg distal dull sensation
Dull.
 Tested right leg proximal dull sensation
Dull.
 Tested right leg distal dull sensation
Dull.
 Tested left leg proximal light sensation
Soft.
 Tested left leg distal light sensation
Soft.
 Tested right leg proximal light sensation
Soft.
 Tested right leg distal light sensation
Soft.
 Tested left leg proximal sharp sensation
Sharp.
 Tested left leg distal sharp sensation
Sharp.
 Tested right leg proximal sharp sensation
Sharp.
 Tested right leg distal sharp sensation
Sharp.
close your eyes and tell me when you feel the touch
Ok, I will.
 Tested sensation of left big toe with monofilament
 Tested sensation of left ball of foot under big toe with monofilament
 Tested sensation of left ball of foot under small toe with monofilament
 Tested sensation of left heel with monofilament
Yes.
 Tested sensation of right heel with monofilament
Yes.
 Tested sensation of right ball of foot with monofilament
 Tested sensation of right big toe with monofilament
 Tested sensation of left ball of foot under big toe with monofilament
 Tested sensation of left ball of foot under small toe with monofilament
 Tested sensation of left heel with monofilament
Yes.
 Tested sensation of right heel with monofilament
Yes.
close your eyes and tell me if your finger or toe moves up or down
Ok, I will.
Up.
 Tested position sense of finger on left hand
Down.
 Tested position sense of finger on right hand
Down.
 Tested position sense of toe on left foot
…I think that was up.
 Tested position sense of toe on right foot
close your eyes and tell me what i put in your hand
Ok, sure.
…Some kind of coin.
 Tested left-hand stereognosis with coin
Um… that feels like a key.
 Tested left-hand stereognosis with key
 Tested left-hand stereognosis with paper clip
This is… some wire thing… paperclip?
…Some kind of coin.
 Tested right-hand stereognosis with coin
Um… that feels like a key.
 Tested right-hand stereognosis with key
The paperclip again.
 Tested right-hand stereognosis with paper clip
 Tested reflexes of right triceps: 2+
 Tested reflexes of left triceps: 2+
 Tested reflexes of right biceps: 2+
 Tested reflexes of left biceps: 2+
 Tested reflexes of right brachioradialis: 2+
 Tested reflexes of left brachioradialis: 2+
 Tested reflexes of right patellar tendon: 2+
 Tested reflexes of left patellar tendon: 2+
 Tested reflexes of right achilles tendon: 2+
 Tested reflexes of left achilles tendon: 2+
close your eyes and touch your fingers to your nose
I can do that.
 Observed left index finger to nose
 Observed right index finger to nose
run your right foot down your shin
Sure.
 Observed right heel moving to shin
run your left foot down your right shin
Ok.
 Observed left heel moving to shin
place your hands on your knees and turn them over
Ok, like this?
 Observed rapid alternating hand movements: Movement is smooth, performed without difficulty
 Observed patient’s gait

 

Subjective Data Collection: 21 of 21 (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.

Relevant Medical History

 

Finding:

Asked about numbness

 

Finding:

Denies history of numbness

(Found)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina questions about her sensation, like if she has a history of numbness, will allow you to see the ways in which her individual symptoms manifest.

Example Question:

Do you have a history of numbness?

 

Finding:

Denies current numbness

(Found)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina questions about her sensation, like if she has current numbness, will allow you to see the ways in which her individual symptoms manifest.

Example Question:

Are you experiencing numbness?

 

Finding:

Asked about tingling

 

Finding:

Denies tingling

(Found)

Pro Tip: Tingling sensations can suggest a herniated disc. Asking Tina whether she’s experiencing tingling sensations might indicate additional musculoskeletal damage.

Example Question:

Are you experiencing tingling?

 

Finding:

Asked about vision

 

Finding:

Reports vision problems

(Found)

Pro Tip: Patients with diabetes may often experience issues with visual impairment, so it is important to ask Tina if she has had any changes to her eyesight that may indicate a diabetic complication.

Example Question:

Are you having vision problems?

 

Finding:

Followed up on vision problems

 

Finding:

Reports vision problems for past few months

(Found)

Pro Tip: Establishing a timeline of Tina’s visual problems will enable you to most effectively treat her symptoms.

Example Question:

How long have you had vision problems?

 

Finding:

Reports periods of blurry vision

(Found)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina broad, open questions about her vision will allow you to see the ways in which her individual symptoms manifest.

Example Question:

How would you describe your vision problems?

 

Finding:

Reports vision problems occur only when reading

(Found)

Pro Tip: Uncovering any aggravating factors for Tina’s vision problems will help you better under the severity of the condition and determine any necessary treatments.

Example Question:

When do your vision problems occur?

 

Finding:

Denies double vision

(Available)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina questions about her vision, like whether or not she has double vision, will allow you to see the ways in which her individual symptoms manifest.

Example Question:

Do you have double vision?

 

Finding:

Asked about headaches

 

Finding:

Reports occasional headaches

(Found)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina if she experiences headaches will allow you to see the ways in which her individual symptoms manifest.

Example Question:

Do you experience headaches?

 

Finding:

Reports last headache was a few days ago

(Available)

Pro Tip: Establishing a timeline of Tina’s headaches will enable you to most effectively treat her symptoms.

Example Question:

Have you had a headache recently?

 

Finding:

Denies current headache

(Found)

Pro Tip: Establishing if Tina currently has a headache will allow you to assess her medication needs and improve her comfort level.

Example Question:

Do you have a headache right now?

 

Finding:

Asked about headache patterns

 

Finding:

Reports headaches have been occurring for six months

(Available)

Pro Tip: Establishing a timeline of Tina’s headaches will enable you to most effectively treat her symptoms.

Example Question:

How long have your headaches been occurring?

 

Finding:

Reports headaches occur a few times per month

(Found)

Pro Tip: Establishing the frequency of Tina’s headaches can help you determine what type of headaches she has, which will allow you to assess the seriousness of her condition and effectively treat her symptoms.

Example Question:

How often do you have headaches?

 

Finding:

Reports headaches last a few hours

(Available)

Pro Tip: Establishing the duration of Tina’s headaches can help you determine what type of headaches she has, which will allow you to assess the seriousness of her condition and effectively treat her symptoms.

Example Question:

How long do your headaches last?

 

Finding:

Asked about headache triggers

 

Finding:

Reports headaches occur only when reading or studying

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina when the headaches begin specifies the way her individual symptoms and pain manifest.

Example Question:

When do your headaches occur?

 

Finding:

Asked about headache character

 

Finding:

Reports headaches are not severe

(Available)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina about the severity of her headaches will allow you to see the ways in which her individual symptoms manifest.

Example Question:

Are your headaches severe?

 

Finding:

Reports headaches feel the same on both sides of the head

(Available)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina about the location of her headaches will allow you to see the ways in which her individual symptoms manifest.

Example Question:

Do your headaches feel the same on both sides of your head?

 

Finding:

Reports headaches are tight

(Found)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina about the character of her headaches will allow you to see the ways in which her individual symptoms manifest.

Example Question:

What do your headaches feel like?

 

Finding:

Reports headaches are throbbing

(Found)

Pro Tip: Because symptoms often vary from patient to patient, asking Tina about the character of her headaches will allow you to see the ways in which her individual symptoms manifest.

Example Question:

What do your headaches feel like?

 

Finding:

Asked headache treatment

 

Finding:

Reports treating headaches with acetaminophen

(Found)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes will indicate her treatment plan and the degree to which she complies with it.

Example Question:

Do you take anything for your headaches?

 

Finding:

Reports taking regular strength acetaminophen medication

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina the strength of her medication will indicate her treatment plan and the degree to which she complies with it.

Example Question:

What strength acetaminophen do you take?

 

Finding:

Reports taking two pills at a time

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how much medication she takes will indicate her treatment plan and the degree to which she complies with it.

Example Question:

How much acetaminophen do you take?

Review of Systems

 

Finding:

Asked about dizziness

 

Finding:

Denies dizziness

(Found)

Pro Tip: Dizziness can have various triggers from stress to low blood sugar, to overeating. Asking Tina if she’s been dizzy addresses important health history concerns.

Example Question:

Have you been experiencing dizziness?

 

Finding:

Asked about speech

 

Finding:

Denies difficulty speaking

(Found)

Pro Tip: It is important to assess if Tina has difficulty speaking because it could be indicative of larger neurological issues that need to be addressed, such as a stroke or brain injury.

Example Question:

Do you have any trouble speaking?

 

Finding:

Asked about swallowing

 

Finding:

Denies difficulty swallowing

(Found)

Pro Tip: It is important to assess if Tina has difficulty swallowing because it could be indicative of larger neurological issues that need to be addressed, such as stroke or brain injury.

Example Question:

Are you having difficulty swallowing?

 

Finding:

Asked about fainting

 

Finding:

Denies fainting

(Found)

Pro Tip: Asking Tina if she has a history of fainting is important, as it could reveal an underlying neurological condition.

Example Question:

Have you ever fainted?

 

Finding:

Asked about muscle function

 

Finding:

Denies weakness

(Found)

Pro Tip: Feelings of weakness can suggest underlying neurological concerns. Asking Tina if she feels weakness addresses an important health history.

Example Question:

Are you experiencing weakness?

 

Finding:

Denies tremors

(Available)

Pro Tip: Experiencing tremors can be indicative of a severe neurological problem. Asking Tina if she’s had any tremors solicits important health information.

Example Question:

Have you been having tremors?

 

Finding:

Denies problems with balance

(Available)

Pro Tip: People with traumatic brain injuries commonly report an inability to maintain their equilibrium. Asking Tina whether she’s able to maintain her equilibrium can indicate that she suffered a traumatic brain injury.

Example Question:

Have you been having problems with your balance?

 

Finding:

Denies problems with coordination

(Available)

Pro Tip: People with traumatic brain injuries commonly report poor coordination. Asking Tina whether she’s had poor coordination can indicate that she suffered a traumatic brain injury.

Example Question:

Have you had poor coordination lately?

 

Finding:

Asked about memory loss

 

Finding:

Denies memory loss

(Found)

Pro Tip: Asking Tina whether she’s been experiencing memory problems is an important way to ensure that she has not been experiencing neurological issues that could cause these issues.

Example Question:

Are you having problems with memory loss?

 

Finding:

Asked about behavior changes

 

Finding:

Denies recent changes in behavior

(Available)

Pro Tip: Behavior changes can be indicative of a severe neurological problem. Asking Tina if she’s had any behavior changes solicits important health information.

Example Question:

Have you had recent changes in behavior?

 

Finding:

Denies recent changes in mood

(Found)

Pro Tip: Mood changes can be indicative of a severe neurological problem. Asking Tina if she’s had any mood changes solicits important health information.

Example Question:

Has your mood changed recently?

Risk Factors

 

Finding:

Asked about illicit drug use

 

Finding:

Reports history of recreational marijuana smoking

(Found)

Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted.

Example Question:

Do you smoke marijuana?

 

Finding:

Asked about tobacco use

 

Finding:

Denies smoking tobacco

(Found)

Pro Tip: Finding out if a patient smokes tobacco is important to understanding her overall health, and is a potential factor in delayed wound healing.

Example Question:

Do you smoke tobacco?

 

Finding:

Denies vaping

(Available)

Pro Tip: Finding out if a patient smokes or inhales substances is important to understanding her overall health, and is a potential factor in delayed wound healing.

Example Question:

Do you vape?

 

Finding:

Asked about alcoholic intake

 

Finding:

Reports last alcoholic drink was 3 weeks ago

(Available)

Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated.

Example Question:

When was your last alcoholic drink?

 

Finding:

Reports no more than 2 or 3 alcoholic drinks in one sitting

(Available)

Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient, including to the central nervous system.

Example Question:

How many alcoholic drinks do you typically have in one sitting?

 

Finding:

Reports no more than 1 or 2 nights a week drinking alcohol

(Found)

Pro Tip: Finding out how many nights a week your patient has alcohol gives insight into potential habits or abuse, and how they may be affecting the central nervous system.

Example Question:

How many alcoholic drinks do you typically have in a week?

 

Finding:

Asked about history of neurological problems

 

Finding:

Denies history of meningitis

(Available)

Pro Tip: Symptoms of meningitis include many neurological conditions like: double vision, confusion, nausea, headache, fever. Asking Tina if she ever had meningitis solicits important health history information.

Example Question:

Have you ever had meningitis?

 

Finding:

Denies history of strokes

(Available)

Pro Tip: Determining if Tina has a history of strokes will inform your focused exam and allow you to provide any necessary preventative care.

Example Question:

Have you ever had a stroke?

 

Finding:

Denies history of concussion

(Available)

Pro Tip: A history of concussion can leave lasting neurological damage. Asking Tina whether she has a history of concussion will allow you to assess whether concussions are a symptom of a neurological condition.

Example Question:

Do you have a history of concussion?

 

Finding:

Denies history of seizures

(Available)

Pro Tip: Asking Tina whether she has a family history of migraines can separate family history from other potential problems or injuries.

Example Question:

Have you ever had a seizure?

Relevant Family History

 

Finding:

Asked family history of migraines

 

Finding:

Denies family history of migraines

Objective Data Collection: 23 of 24 (95.83%)

Correct

Partially correct

Incorrect

Missed

 Confirmed orientation

1 of 1 point

 

To Person (1/3 point)

Oriented to person

Not oriented to person

To Place (1/3 point)

Oriented to place

Not oriented to place

To Time (1/3 point)

Oriented to time

Not oriented to time

 Evaluated abstract thinking

1 of 1 point

 

Abstractness (1/2 point)

Abstract

Concrete

Relevance (1/2 point)

Relevant

Not relevant

 Evaluated attention span

1 of 1 point

 

Serial 7s Test (1/1 point)

Accurate

Not accurate

 Evaluated comprehension

1 of 1 point

 

Observations (1/1 point)

Able to follow instructions

Unable to follow instructions

 Evaluated general knowledge

1 of 1 point

 

Accuracy (1/1 point)

Accurate

Not accurate

 Evaluated judgment

1 of 1 point

 

Observations (1/1 point)

Intact

Not intact

 Evaluated memory

1 of 1 point

 

Remote Memory (1/3 point)

Intact

Not intact

Immediate Memory (1/3 point)

Intact

Not intact

New Learning Ability (1/3 point)

Accurate

Not accurate

 Observed vocabulary

1 of 1 point

 

Complexity (1/1 point)

Expected complex for patient’s age, education level, and general ability

Lower than expected complexity

 Observed articulation

1 of 1 point

 

Observations (1/1 point)

No observed problems with pronunciation or expression

Imprecise pronunciation of consonants

Slurring

Hesitation

Stutter

 Tested graphesthesia

1 of 1 point

 

Right (1/2 point)

Able to identify

Unable to identify

Left (1/2 point)

Able to identify

Unable to identify

 Tested sensation in arms

1 of 1 point

 

Right: Dull Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Left: Dull Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Right: Soft Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Left: Soft Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Right: Sharp Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Left: Sharp Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

 Tested sensation in legs

1 of 1 point

 

Right: Dull Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Left: Dull Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Right: Soft Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Left: Soft Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Right: Sharp Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

Left: Sharp Touch (1/6 point)

Expected sensation in proximal and distal

Decreased proximal sensation

Decreased distal sensation

 Tested sensation in feet

1 of 1 point

 

Right (1/2 point)

Expected sensation

Decreased sensation

Left (1/2 point)

Expected sensation

Decreased sensation

Tested position sense

1 of 1 point

 

 Tested stereognosis

1 of 1 point

 

Right (1/2 point)

Able to identify

Unable to identify

Left (1/2 point)

Able to identify

Unable to identify

 Tested deep tendon reflexes in triceps

1 of 1 point

 

Right (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

Left (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

 Tested deep tendon reflexes in biceps

1 of 1 point

 

Right (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

Left (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

 Tested deep tendon reflexes in brachioradialis

1 of 1 point

 

Right (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

Left (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

 Tested deep tendon reflexes in patellar tendon

1 of 1 point

 

Right (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

Left (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

 Tested deep tendon reflexes in Achilles tendon

1 of 1 point

 

Right (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

Left (1/2 point)

0 – No response

1 – Diminished

2 – Expected (active)

3 – Hyperactive

4 – Hyperactive, with clonus

 Tested point-to-point movements: Finger to nose

1 of 1 point

 

Right (1/2 point)

Smooth and accurate

Jerky

Inaccurate

Left (1/2 point)

Smooth and accurate

Jerky

Inaccurate

 Tested point-to-point movements: Heel to shin

1 of 1 point

 

Right (1/2 point)

Smooth and accurate

Jerky

Inaccurate

Left (1/2 point)

Smooth and accurate

Jerky

Inaccurate

 Tested coordination with rapid alternating hand movements

1 of 1 point

 

Observations (1/1 point)

Able to perform without difficulty

Performs but with difficulty

Unable to perform

 Observed gait

0 of 1 point

 

Balance (No point)

Steady

Unsteady

Gait (No point)

Continuous, symmetric steps

Discontinuous steps

Asymmetric steps

Stagger

Swaying

Hesitancy due to injury

Use of arms

Documentation / Electronic Health Record

Flowsheets

Nursing Progress Notes

Vitals

Vitals 22:00 00:00 02:00 04:00 06:00 08:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 00:00 02:00 04:00 06:00 08:00 10:00 12:00
Temp (<38° C) 38.7 C / 101.7 F 39.1 C / 102.4 F 38.6 C / 101.5 F 37.9 C / 100.2 F 37.1 C / 98.8 F 36.7 C / 98.1 F 37 C / 98.6 F 36.7 C / 98.1 F 38 C / 100.4 F 38.3 C / 100.9 F 36.2 C / 97.1 F 36.7 C / 98.6 F 37 C / 98.6 F 36.7 C / 98.1 F 36.7 C / 98.1 F 36.7 C / 98.1 F 38 C / 100.4 F 36.7 C / 98.1 F 37 C / 98.6 F 36.7
BP (<120/80) 138/90 138/88 136/88 138/90 134/88 138/90 136/88 136/88 138/90 136/88 134/88 132/86 132/86 130/86 128/86 128/88 124/86 124/84 122/84
HR (60-100) 90 72 68 69 70 68 70 71 69 70 68 69 68 68 69 72 70 70 69
RR (12-20) 18 16 16 18 18 16 18 16 14 14 16 14 12 14 16 18 16 14 16
O2 Sat (>94%) 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 99% 98% 99% 98% 98%
Pain Scale 10 7 asleep asleep 9 6 8 6 8 6 7 7 8 asleep asleep asleep 9 6 6 5
Pain Reassessment after Intervention 7

@23:00

asleep 5

@07:00

 

 

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Tina Jones – Musculoskeletal Results Health Assessment – January 2023

Tina Jones – Musculoskeletal Results Health Assessment – January 2023

Transcript

All Lines (135)Interview Questions (28)Statements (2)Exam Actions (105)

Hello!
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation?
It’s 8 a.m. on Tina Jones’ second morning as a patient here at Shadow General Hospital. Ms. Jones has a physical therapy consultation later today. Your role in this simulation is that of healthcare provider who will perform a full musculoskeletal system exam on Ms. Jones so that her therapist can understand Ms. Jones’ musculoskeletal health and customize therapy accordingly.
What are my objectives in this assessment?
In your interview with Ms. Jones, you will ask about her musculoskeletal system and identify any risk factors or complications. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to the musculoskeletal system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her musculoskeletal system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ musculoskeletal system to gather objective data about the system’s health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve?
You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
How will I be evaluated?
In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 50 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world?
In this assessment, you will become familiarized with the structure and content of musculoskeletal exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What precautions should you take with a patient that is a fall risk?
Remove hazards and ensure the patient has sensible shoes, the room is well lit and provide the patient with assistive device.
Time to begin.
Hello, my name is Nukol. I will be your nurse today.
Hey.
 Vitals measured
Do you have joint pain?
My joints don’t hurt.
Are you able to walk?
I can walk by myself now, but it still hurts a lot.
I am sorry for the pain
Thanks.
What is the pain on a rating scale? (Clarified to What is your pain rating?.)
I’d give it a 5 or 6 out of 10 right now. (Clarified to how I would rate my pain.)
What is the pain rate while walking? (Clarified to Can you rate the pain when walking on a scale from 1 to 10?.)
It still hurts a lot to walk on. I’d say at least 7, maybe 8. (Clarified to how I would rate my pain when walking.)
Are you able to stand?
Last time I tried to stand normally it really hurt my foot, but at least I was able to stand on it. I’m hoping it’ll be better soon.
Do you have muscle soreness?
It’s not my muscles that are hurting.
Do you have ankle pain?
My ankles are fine.
Does your work cause any joint pain?
Nothing at work bothers me physically at all. . . I just haven’t been able to go because I can’t really stand or move around lately.
Does the pain affect your daily living?
I couldn’t really do much at all the last couple days without help. I’m glad my mom and sister were there to help, and the nurses here, too. Now, though, I feel like I can start to do things for myself again. My foot still hurts, but not nearly as bad.
Are your joints stiff?
No, I’m not stiff anywhere now.
Do you have a history of back pain?
I don’t usually have any back pain. Sometimes it aches a little, but nothing bad.
Have you ever injured your muscles? (Clarified to Has your muscle ever been pulled?.)
I can’t remember my muscles hurting ever. . . at least not enough for it to worry me. (Clarified to if I have ever pulled a muscle.)
Do you have a history of joint injury?
No, not really.
Do you have a history of fractures?
I’ve never broken a bone or anything like that.
Do you have a history of sprains?
I can’t remember spraining anything before. . . maybe in grade school? I did something to one of my fingers playing tether ball, I think. But nothing since then.
Do you have any neck pain?
My neck doesn’t hurt at all.
How is the range of motion of your body parts? (Clarified to How is your range of motion?.)
It hurts to move my foot, but I can do it. And everything else seems fine. [AUDIO COMING SOON] (Clarified to how my range of motion is.)
Do you have any muscle problem?
I don’t have any problems with my muscles.
Have you ever fallen?
I didn’t fall onto the ground. . . it was like, my foot just slipped as I stepped onto the ladder, but I caught my balance before I could topple over or anything.
I am sorry for that
Thanks.
Do you have a family history of osteoporosis?
No one in the family has osteoporosis that I know of.
Do you have a family history of joint problems?
I don’t know of any joint problems in the family.
Do you have a family history of bone cancer?
Oh wow — no, not that I know of.
 Tested spinal ROM – flexion: Expected
 Tested spinal ROM – extension: Expected
 Tested spinal ROM – lateral bending: Expected
 Tested spinal ROM – rotation to the left: Expected
 Tested spinal ROM – rotation to the right: Expected
 Tested ROM of neck – extension: Expected
 Tested ROM of neck – flexion: Expected
 Tested ROM of neck – lateral bending: Expected
 Inspected front of neck
 Inspected right side of neck
 Inspected back of neck
 Inspected left side of neck
 Inspected front of neck
 Inspected left side of neck
 Inspected back of neck
 Inspected right side of neck
 Inspected front of neck
 Inspected shoulders from the front
 Inspected right shoulder
 Inspected upper back
 Inspected left shoulder
 Inspected shoulders from the front
 Inspected left shoulder
 Inspected upper back
 Inspected right shoulder
 Inspected shoulders from the front
 Inspected left arm
 Inspected right arm
 Inspected right elbow
 Inspected left elbow
 Inspected right wrist
 Inspected both wrists
 Inspected left wrist
 Inspected right hand
 Inspected both hands
 Inspected left hand
 Inspected front of hips
 Inspected right side of hips
 Inspected back of hips
 Inspected left side of hips
 Inspected front of hips
 Inspected left side of hips
 Inspected back of hips
 Inspected right side of hips
 Inspected front of hips
 Inspected front of thighs
 Inspected right thigh
 Inspected back of thighs
 Inspected left thigh
 Inspected front of thighs
 Inspected left thigh
 Inspected back of thighs
 Inspected right thigh
 Inspected front of thighs
 Inspected front of knees
 Inspected right knee
 Inspected back of knees
 Inspected left knee
 Inspected front of knees
 Inspected left knee
 Inspected back of knees
 Inspected right knee
 Inspected front of knees
 Inspected front of legs
 Inspected right leg
 Inspected back of legs
 Inspected left leg
 Inspected front of legs
 Inspected left leg
 Inspected back of legs
 Inspected right leg
 Inspected front of legs
 Inspected left ankle
 Inspected both ankles
 Inspected right ankle
 Inspected both ankles
 Inspected left ankle
 Inspected left foot
 Inspected soles of feet: Right: Laceration and swelling, expected curvature. Left: No visible abnormal findings, expected curvature.
 Inspected left foot
 Inspected top of feet
 Inspected left foot
 Inspected top of feet
 Inspected right foot
 Inspected top of feet
 Inspected right foot
 Inspected soles of feet: Right: Laceration and swelling, expected curvature. Left: No visible abnormal findings, expected curvature.
 Inspected right foot
 Inspected soles of feet: Right: Laceration and swelling, expected curvature. Left: No visible abnormal findings, expected curvature.
 Inspected left foot
 Inspected top of feet
 Tested ROM of shoulders – adduction: Expected
 Tested ROM of shoulders – extension: Expected
 Tested ROM of shoulders – flexion: Expected
 Tested ROM of elbows – flexion and extension: Expected
 Tested ROM of elbows – supination and pronation: Expected
 Tested ROM of wrists – ulnar and radial deviation: Expected
 Tested ROM of wrists – extension: Expected
 Tested ROM of wrists – flexion: Expected
 Tested ROM of hips – abduction: Expected
 Tested ROM of hips – adduction: Expected
 Tested ROM of hips – extension: Expected
 Tested ROM of hips – flexion: Expected
 Tested ROM of knees – extension: Expected

Subjective Data Collection: 23 of 23 (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.

Relevant Medical History

 

Finding:

Asked about joint problems

 

Finding:

Denies joint pain

(Found)

Pro Tip: Uncovering if Tina has any joint pain is important, as they could be a result of her recent foot injury and could contribute to impaired mobility.

Example Question:

Do you have joint pain?

 

Finding:

Denies joint swelling

(Available)

Pro Tip: Uncovering if Tina has any swollen joints is important, as they could be a result of her recent foot injury and could contribute to impaired mobility.

Example Question:

Do you have swollen joints?

 

Finding:

Asked about mobility

 

Finding:

Denies history of walking problems

(Available)

Pro Tip: Discovering if Tina has a history of walking problems is imperative because it could show that her mobility issues predate the foot wound.

Example Question:

Have you ever had problems walking?

 

Finding:

Reports recent foot wound hindered mobility

(Found)

Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina whether the pain makes it hard for her to walk would illustrate whether her pain is preventing her from some of the activities that comprise her daily life.

Example Question:

Has your wound affected your mobility?

 

Finding:

Reports ability to walk on foot has recently improved

(Found)

Pro Tip: Determining if Tina’s mobility has recently improved will provide key information as to the healing process and what further steps are needed.

Example Question:

Has your mobility changed lately?

 

Finding:

Asked pain rating when walking

 

Finding:

Reports pain as a 7 or 8/10 when walking

(Found)

Pro Tip: People with severe pain might find that they are limited in their movements. Having Tina rank her pain on a scale will help you judge the severity of the wound and help you determine treatment needs.

Example Question:

How would you rate your pain when walking?

 

Finding:

Asked about ability to stand

 

Finding:

Denies trouble standing before foot problems

(Available)

Pro Tip: Asking Tina if she has a history of standing problems will reveal the severity of her injury and whether her standing problem predated her foot injury.

Example Question:

Do you have a history of standing problems?

 

Finding:

Reports recent foot wound hindered standing

(Found)

Pro Tip: Asking Tina if she can stand on her foot will reveal the severity of her injury and whether or not she is able to put weight on her foot.

Example Question:

Has your wound affected your ability to stand?

 

Finding:

Reports improved ability to stand on injured foot

(Found)

Pro Tip: Asking Tina if she can stand on her foot will reveal the severity of her injury and whether or not she is able to put weight on her foot.

Example Question:

Are you able to stand on your foot?

 

Finding:

Asked pain rating when standing

 

Finding:

Reports pain as a 7 or 8/10 when bearing weight on foot

(Available)

Pro Tip: Asking Tina about the pain if she’s standing will reveal the severity of her injury and whether or not standing exacerbates her pain.

Example Question:

How would you rate your pain on a scale of 1 to 10 when you are standing?

 

Finding:

Asked about muscle soreness

 

Finding:

Denies history of muscle soreness

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she has ever had muscle soreness specifies the way her symptoms and pain manifest.

Example Question:

Have you ever had muscle soreness?

 

Finding:

Denies current muscle soreness

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she is having muscle soreness specifies the way her symptoms and pain manifest.

Example Question:

Are you having muscle soreness?

 

Finding:

Asked about joints in proximity of injury

 

Finding:

Denies current ankle problems

(Found)

Pro Tip: Ankle problems can greatly affect a patient’s mobility. Asking Tina if she has problems with her ankles can reveal a major health concern.

Example Question:

Are your ankles giving you trouble?

 

Finding:

Asked about occupational impact on injury

 

Finding:

Denies work being dangerous

(Found)

Pro Tip: Determining if Tina’s workplace is safe will allow you to establish any occupational dangers that could exacerbate her current health issues or pose further risks.

Example Question:

Is your work dangerous?

 

Finding:

Denies work involving repetitive motion

(Available)

Pro Tip: Establishing if Tina’s job requires repetitive motion, such as picking up boxes, can help you determine if those motions have had an impact on her health or pose potential risks.

Example Question:

Does your work involve repetitive motion?

 

Finding:

Reports foot wound prevented her from working

(Found)

Pro Tip: People with severe pain might find that they are unable to perform all of their daily activities. Asking Tina whether she has been able to work in spite of the pain would illustrate whether her pain is preventing her from activities that constitute her daily life.

Example Question:

Did your wound prevent you from working?

 

Finding:

Asked about activities of daily living

 

Finding:

Denies difficulty transferring from sitting to standing

(Found)

Pro Tip: As a result of Tina’s foot wound, there is the risk that certain activities of daily living have been compromised. It is important to identify any difficulties with transferring so her quality of life does not suffer.

Example Question:

Are you able to go from sitting to standing?

 

Finding:

Denies difficulty bathing

(Available)

Pro Tip: As a result of Tina’s foot wound, there is the risk that certain activities of daily living have been compromised. It is important to identify any difficulties with bathing so her quality of life does not suffer.

Example Question:

Can you bathe yourself?

Review of Systems

 

Finding:

Asked about joint stiffness

 

Finding:

Denies joint stiffness

(Available)

Pro Tip: Because Tina’s foot wound has recently impaired mobility, which often leads to joint stiffness, it is important to ask Tina about her joints to ascertain the impact of her wound and what treatment she may require.

Example Question:

Do you feel stiff anywhere?

 

Finding:

Asked about back pain

 

Finding:

Denies history of back pain

(Found)

Pro Tip: Back pain can be a serious complaint that compromises a patient’s quality of life. It is important to determine Tina has suffered from back pain so you can most effectively treat the issue.

Example Question:

Have you had back pain before?

 

Finding:

Denies current back pain

(Available)

Pro Tip: Back pain can be a serious complaint that compromises a patient’s quality of life. It is important to determine if Tina is currently suffering from back pain so you can most effectively treat the issue.

Example Question:

Are you having back pain?

 

Finding:

Asked about muscle injury

 

Finding:

Denies history of muscle injury

(Found)

Pro Tip: It is important to establish if Tina has a history of muscle injuries because it may contribute to her recent mobility issues.

Example Question:

Have you ever had a muscle injury?

 

Finding:

Denies current muscle injury

(Found)

Pro Tip: It is important to establish if Tina has a muscle injury because it might contribute to her recent mobility issues.

Example Question:

Do you have a muscle injury?

 

Finding:

Asked about joint injury

 

Finding:

Denies past joint injury

(Found)

Pro Tip: It is important to establish if Tina has a history of joint injuries because it may contribute to her recent mobility issues.

Example Question:

Have you experienced a joint injury in the past?

 

Finding:

Denies current joint injury

(Found)

Pro Tip: It is important to establish if Tina has a joint injury because it might contribute to her recent mobility issues.

Example Question:

Do you have a joint injury?

 

Finding:

Asked history of fracture

 

Finding:

Denies history of fractures

(Found)

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:

Asked history of sprains

 

Finding:

Denies history of sprains

(Found)

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 has a history of getting sprains might reveal relevant concerns she’d previously experienced.

Example Question:

Do you have a history of getting sprains?

 

Finding:

Asked about bone problems

 

Finding:

Denies history of bone problems

(Found)

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 ever had bone problems might reveal relevant concerns she’d previously experienced.

Example Question:

Have you ever had bone problems?

 

Finding:

Denies current bone problems

(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 has bone problems might reveal relevant concerns she’d previously experienced.

Example Question:

Do you have bone problems?

 

Finding:

Asked about neck

 

Finding:

Denies history of neck problems

(Available)

Pro Tip: A history of neck problems may imply an illness or a problematic behavior in the patient. Asking Tina whether she has had neck problems in the past could prompt you to follow up on potential causes.

Example Question:

Have you had neck problems?

 

Finding:

Denies current neck problems

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she may be experiencing with her injury, like neck pain, details the way her individual symptoms and pain manifest.

Example Question:

Do you have neck problems?

 

Finding:

Asked about range of motion of body parts

 

Finding:

Reports normal range of motion

(Found)

Pro Tip: People with severe pain might find that they are limited in their movements. Asking Tina whether she is limited in her movements would illustrate whether her pain is preventing her from some of the activities that comprise her daily life.

Example Question:

Do you have full range of motion?

 

Finding:

Asked about muscle problems

 

Finding:

Denies muscle weakness

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle weakness, details the way her individual symptoms and pain manifest.

Example Question:

Are you experiencing any muscle weakness?

 

Finding:

Denies muscle cramping

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like muscle cramping, details the way her individual symptoms and pain manifest.

Example Question:

Are you experiencing any muscle cramping?

Risk Factors

 

Finding:

Asked fall history

 

Finding:

Reports fall

(Found)

Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density.

Example Question:

Have you fallen before?

 

Finding:

Reports fall was one week ago

(Available)

Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density.

Example Question:

When was the last time you fell?

 

Finding:

Reports belief that she is not particularly prone to falls

(Available)

Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina if she is prone to falling could provide you with information about her bone density.

Example Question:

Are you prone to falling?

 

Finding:

Denies other recent falls

(Available)

Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density.

Example Question:

Did you have any other recent falls?

 

Finding:

Reports no dizziness or weakness before recent fall

(Available)

Pro Tip: Changes in bone composition can leave a patient more at risk for falling. Asking Tina about her history of falling could provide you with information about her bone density.

Example Question:

Did you feel weak before you fell?

Relevant Family History

 

Finding:

Asked family history of osteoporosis

 

Finding:

Denies family history of osteoporosis

(Found)

Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has osteoporosis can indicate a potential predisposition.

Example Question:

Does anyone in your family have osteoporosis?

 

Finding:

Asked family history of joint problems

 

Finding:

Denies family history of joint problems

(Found)

Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has had joint problems can indicate a potential predisposition.

Example Question:

Has anyone in your family had joint problems?

 

Finding:

Denies family history of arthritis

(Available)

Pro Tip: Family histories can suggest a genetic predisposition. Asking Tina if anyone in her family has arthritis can indicate a potential predisposition.

Example Question:

Does arthritis run in your family?

 

Finding:

Asked family history of bone cancer

 

Finding:

Denies family history of bone cancer

Objective Data Collection: 25.8 of 28 (92.14%)

Correct

Partially correct

Incorrect

Missed

 Inspected neck

0.5 of 1 point

 

Symmetry (1/2 point)

Symmetric

Asymmetric

Appearance (No point)

No visible abnormal findings

Swelling

Visible pulsation

Visible mass

Irregular alignment

Discoloration

 Inspected shoulders

1 of 1 point

 

Symmetry (1/3 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Left: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

 Inspected arms

1 of 1 point

 

Symmetry (1/3 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Atrophy

Hypertrophy

Left: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Atrophy

Hypertrophy

 Inspected elbows

1 of 1 point

 

Symmetry (1/3 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Joint deformity

Left: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Joint deformity

 Inspected wrists

1 of 1 point

 

Symmetry (1/3 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Atrophy

Hypertrophy

Joint deformity

Left: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Atrophy

Hypertrophy

Joint deformity

 Inspected hands and fingers

1 of 1 point

 

Symmetry (1/3 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Joint deformity

Left: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Joint deformity

 Inspected hips

1 of 1 point

 

Appearance (1/1 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Pelvic tilt

 Inspected thighs

1 of 1 point

 

Symmetry (1/3 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Atrophy

Hypertrophy

Left: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Atrophy

Hypertrophy

 Inspected knees

1 of 1 point

 

Symmetry (1/3 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Genu recurvatum

Discoloration

Joint deformity

Left: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Genu recurvatum

Discoloration

Joint deformity

 Inspected lower legs

1 of 1 point

 

Symmetry (1/3 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Discoloration

Atrophy

Hypertrophy

Genu valgum

Genu varum

Left: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Discoloration

Atrophy

Hypertrophy

Genu valgum

Genu varum

 Inspected ankles

1 of 1 point

 

Symmetry (1/3 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Joint deformity

Left: Appearance (1/3 point)

No visible abnormal findings

Swelling

Visible mass

Irregular alignment

Discoloration

Joint deformity

 Inspected feet

0.8 of 1 point

 

Symmetry (1/5 point)

Symmetric bilaterally

Asymmetric

Right: Appearance (No point)

No visible abnormal findings

Swelling

Laceration, lesion, or wound

Visible mass

Irregular alignment

Discoloration

Joint deformity

Hallux valgus

Hammertoe(s)

Mallet toe(s)

Claw toe(s)

Right: Arch Shape (1/5 point)

Expected curvature

Pes planus

Pes cavus

Left: Appearance (1/5 point)

No visible abnormal findings

Swelling

Laceration, lesion, or wound

Visible mass

Irregular alignment

Discoloration

Joint deformity

Hallux valgus

Hammertoe(s)

Mallet toe(s)

Claw toe(s)

Left: Arch Shape (1/5 point)

Expected curvature

Pes planus

Pes cavus

 Tested neck range of motion

1 of 1 point

 

Extension (1/4 point)

Expected range of motion (approx. 45 degrees)

Reduced range of motion

Flexion (1/4 point)

Expected range of motion (approx. 45 degrees)

Reduced range of motion

Lateral Bending (1/4 point)

Expected range of motion (approx. 40 degrees) on both sides

Reduced range of motion on right

Reduced range of motion on left

Rotation (1/4 point)

Expected range of motion (approx. 70 degrees) on both sides

Reduced range of motion on right

Reduced range of motion on left

 Tested shoulder range of motion

1 of 1 point

 

Adduction (1/3 point)

Expected range of motion (approx. 50 degrees)

Reduced range of motion

Extension (1/3 point)

Expected range of motion (approx. 50 degrees)

Reduced range of motion

Forward Flexion (1/3 point)

Expected range of motion (approx. 180 degrees)

Reduced range of motion

 Tested elbow range of motion

1 of 1 point

 

Right: Flexion And Extension (1/4 point)

Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)

Reduced flexion

Reduced extension

Left: Flexion And Extension (1/4 point)

Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)

Reduced flexion

Reduced extension

Right: Supination And Pronation (1/4 point)

Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees)

Reduced pronation

Reduced supination

Left: Supination And Pronation (1/4 point)

Expected range of motion (approx. pronation of 90 degrees and supination of 90 degrees)

Reduced pronation

Reduced supination

 Tested wrist range of motion

1 of 1 point

 

Right: Ulnar And Radial Deviation (1/6 point)

Expected range of motion (approx. ulnar radiation 55 degrees and radial deviation 90 degrees)

Reduced ulnar deviation

Reduced radial deviation

Left: Ulnar And Radial Deviation (1/6 point)

Expected range of motion (approx. ulnar radiation 55 degrees and radial deviation 90 degrees)

Reduced ulnar deviation

Reduced radial deviation

Right: Extension (1/6 point)

Expected range of motion (approx. 70 degrees)

Reduced extension

Left: Extension (1/6 point)

Expected range of motion (approx. 70 degrees)

Reduced extension

Right: Flexion (1/6 point)

Expected range of motion (approx. 90 degrees)

Reduced flexion

Left: Flexion (1/6 point)

Expected range of motion (approx. 90 degrees)

Reduced flexion

 Tested spine range of motion

0.25 of 1 point

 

Extension (No point)

Expected range of motion (approx. 30 degrees)

Reduced extension

Flexion (1/4 point)

Expected range of motion (approx. 75 – 90 degrees)

Reduced flexion

Lateral Bending (No point)

Expected range of motion bilaterally (approx. 35 degrees)

Reduced lateral bending to the right

Reduced lateral bending to the left

Rotation (No point)

Expected range of motion bilaterally (approx. 30 degrees)

Reduced rotation to the right

Reduced rotation to the left

 Tested hip range of motion

1 of 1 point

 

Abduction (1/4 point)

Expected range of motion (approx. 45 degrees)

Reduced hip abduction

Adduction (1/4 point)

Expected range of motion (approx. 30 degrees)

Reduced hip adduction

Extension (1/4 point)

Expected range of motion (approx. 30 degrees)

Reduced hip extension

Flexion (1/4 point)

Expected range of motion (approx. 90 degrees)

Reduced hip flexion

 Tested knee range of motion

1 of 1 point

 

Right: Extension (1/4 point)

Expected range of motion (approx. 0 to 15 degrees)

Reduced extension

Left: Extension (1/4 point)

Expected range of motion (approx. 0 to 15 degrees)

Reduced extension

Right: Flexion (1/4 point)

Expected range of motion (approx. 130 degrees)

Reduced flexion

Left: Flexion (1/4 point)

Expected range of motion (approx. 130 degrees)

Reduced flexion

 Tested ankle range of motion

0.75 of 1 point

 

Right: Eversion And Inversion (1/4 point)

Expected range of motion (approx. inversion of 30 degrees and eversion of 20 degrees)

Reduced inversion

Reduced eversion

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 (No point)

Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)

Reduced dorsiflexion

Reduced plantar flexion

Left: Dorsiflexion And Plantar Flexion (1/4 point)

Expected range of motion (approx. flexion of 160 degrees and 180 of full extension)

Reduced dorsiflexion

Reduced plantar flexion

 Tested neck strength

1 of 1 point

 

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)

 Tested shoulder strength

1 of 1 point

 

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)

 Tested elbow strength

1 of 1 point

 

Right (1/2 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)

Left (1/2 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)

 Tested wrist strength

1 of 1 point

 

Right (1/2 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)

Left (1/2 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)

 Tested hand strength

1 of 1 point

 

Right (1/2 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)

Left (1/2 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)

 Tested hip strength

1 of 1 point

 

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)

 Tested knee strength

1 of 1 point

 

Right (1/2 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)

Left (1/2 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)

 Tested ankle strength

0.5 of 1 point

 

Right (No 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)

Left (1/2 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)

 

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Tina Jones – Abdominal Results Health Assessment – January 2023

Tina Jones – Abdominal Results Health Assessment – January 2023

Transcript

Started: Mar 03, 2023 | Total Time: 29 min

All Lines (71)Interview Questions (35)Statements (0)Exam Actions (36)

Hello! Question
03/03/23 4:48 AM MST
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation? Question
03/03/23 4:48 AM MST
It’s 8 p.m. on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full abdominal exam on Ms. Jones. She’s spent the whole day in bed, so you will want to determine whether she has full abdominal function and if bed rest has impacted her gastrointestinal health.
What are my objectives in this assessment? Question
03/03/23 4:49 AM MST
In your interview with Ms. Jones, you will ask about her inputs and outputs (I’s and O’s) and the overall health of her abdominal system so that you can identify any issues and document findings accurately. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to the abdominal system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her abdominal system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ abdominal system to gather objective data about the system’s health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve? Question
03/03/23 4:49 AM MST
You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
How will I be evaluated? Question
03/03/23 4:49 AM MST
In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 35 and 50 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world? Question
03/03/23 4:49 AM MST
In this assessment, you will become familiarized with the structure and content of abdominal exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What effects can bed rest have on the abdominal system?
Constipation and gastric reflux Statement
03/03/23 4:52 AM MST
Time to begin.
 Checked vitals Exam Action
03/03/23 4:53 AM MST
How is current stomach and bowels? (Clarified to How are your stomach and bowels doing?.) Question
03/03/23 4:57 AM MST
They’re fine. (Clarified to how my stomach and bowels are.)
How is your typical bowel habits? Question
03/03/23 4:58 AM MST
I don’t go every day. I go every two days, maybe.
Do you have constipation? Question
03/03/23 4:58 AM MST
No, I’m not having any problems with that.
do you have diarrhea? Question
03/03/23 4:58 AM MST
No.
How is your stool characteristics? Question
03/03/23 4:59 AM MST
It’s normal, I think. Not hard, and not too, uh, soft or anything.
Do you have bloating? Question
03/03/23 4:59 AM MST
No, I don’t feel bloated.
do you have nausea? Question
03/03/23 5:00 AM MST
No, I haven’t felt nauseous.
Do you vomit? Question
03/03/23 5:00 AM MST
No, I don’t feel sick at all.
how is your food tolerance? Question
03/03/23 5:00 AM MST
I think my diet’s normal.
How is your food intolerance? Question
03/03/23 5:00 AM MST
I think my diet’s normal.
Have you had appetite change? Question
03/03/23 5:01 AM MST
I’ve definitely been eating a lot more lately.
Do you have heartburn? Question
03/03/23 5:01 AM MST
No.
Do you have urinary problem? Question
03/03/23 5:01 AM MST
No, I can pee fine.
How is your frequency of urination? Question
03/03/23 5:02 AM MST
I’ve been noticing I’ve been having to pee a lot more recently, but I think that’s just because I’m drinking more water than normal.
what is the character of urine? Question
03/03/23 5:02 AM MST
Um, light yellow or almost clear? The regular color.
How is your fluid intake? Question
03/03/23 5:02 AM MST
I haven’t really been keeping track, but I drink a lot of water lately. I’ve been thirstier than usual. Oh, and sometimes I’ll drink Diet Coke too . . .
How often do you urinate? Question
03/03/23 5:02 AM MST
I don’t know. Every hour or two when I’m awake?
What do you each for breakfast? (Clarified to What’s your usual breakfast?.) Question
03/03/23 5:03 AM MST
I usually have either cereal or toast, or if I pick something up on my way to work, I’ll get a muffin or some pumpkin bread. (Clarified to what I usually eat for breakfast.)
Are you okay with all foods? Question
03/03/23 5:03 AM MST
I’m doing better than yesterday around this time, that’s for sure.
what kind of foods cause bloating? (Clarified to What kinds of foods do you eat?.) Question
03/03/23 5:04 AM MST
Let’s see. . . a muffin or pumpkin bread for breakfast, a sandwich for lunch, and some kind of meat with a veggie for dinner. (Clarified to what kinds of foods I eat.)
Do you use tobacco? Question
03/03/23 5:05 AM MST
No. I think it’s gross.
Do you consume alcohol? Question
03/03/23 5:05 AM MST
Very rarely.
Do you use illicit drugs? Question
03/03/23 5:05 AM MST
Yeah, in high school and a little after that I smoked pot sometimes. But I haven’t done anything like that in a long time.
Have you had recent weight loss? Question
03/03/23 5:05 AM MST
Well, I think I’ve lost some weight this month. [AUDIO COMING SOON]
Have much weight have you lost? Question
03/03/23 5:06 AM MST
I think I lost about ten pounds. [AUDIO COMING SOON]
Hos your gall bladder? (Clarified to Do you have problems with your gallbladder?.) Question
03/03/23 5:06 AM MST
No, as far as I know my gallbladder’s never had any problems. (Clarified to if I have gallbladder problems.)
Do you have a family history of bowel disease? Question
03/03/23 5:07 AM MST
No.
Do you have a family history of colon cancer? Question
03/03/23 5:07 AM MST
Um, Grandpa Jones died of colon cancer.
Do you have food allergies? Question
03/03/23 5:08 AM MST
Nope, no food allergies that I know of.
 Inspected left side of abdomen Exam Action
03/03/23 5:13 AM MST
 Inspected front of abdomen Exam Action
03/03/23 5:13 AM MST
 Inspected right side of abdomen Exam Action
03/03/23 5:13 AM MST
 Inspected front of abdomen Exam Action
03/03/23 5:14 AM MST
 Inspected left side of abdomen Exam Action
03/03/23 5:14 AM MST
 Auscultated right upper quadrant Exam Action
03/03/23 5:14 AM MST
 Auscultated left upper quadrant Exam Action
03/03/23 5:14 AM MST
 Auscultated left lower quadrant Exam Action
03/03/23 5:14 AM MST
 Auscultated right lower quadrant Exam Action
03/03/23 5:14 AM MST
 Auscultated aorta in abdomen Exam Action
03/03/23 5:14 AM MST
 Auscultated right renal artery Exam Action
03/03/23 5:15 AM MST
 Auscultated left renal artery Exam Action
03/03/23 5:15 AM MST
 Auscultated right Iliac artery Exam Action
03/03/23 5:15 AM MST
 Auscultated left Iliac artery Exam Action
03/03/23 5:15 AM MST
 Auscultated left femoral artery Exam Action
03/03/23 5:15 AM MST
 Auscultated right femoral artery Exam Action
03/03/23 5:15 AM MST
 Percussed right upper quadrant Exam Action
03/03/23 5:15 AM MST
 Percussed left upper quadrant Exam Action
03/03/23 5:15 AM MST
 Percussed right lower quadrant Exam Action
03/03/23 5:15 AM MST
 Percussed left lower quadrant Exam Action
03/03/23 5:15 AM MST
 Percussed left flank for CVA tenderness Exam Action
03/03/23 5:15 AM MST
 Percussed right flank for CVA tenderness Exam Action
03/03/23 5:15 AM MST
 Percussed for liver span: 7 cm in the mid-clavicular line Exam Action
03/03/23 5:15 AM MST
 Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action
03/03/23 5:16 AM MST
 Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action
03/03/23 5:16 AM MST
 Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action
03/03/23 5:16 AM MST
 Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension Exam Action
03/03/23 5:16 AM MST
 Palpated right upper quadrant with deep pressure: No masses Exam Action
03/03/23 5:16 AM MST
 Palpated left upper quadrant with deep pressure: No masses Exam Action
03/03/23 5:16 AM MST
 Palpated right lower quadrant: with deep pressure: No masses Exam Action
03/03/23 5:16 AM MST
 Palpated left lower quadrant with deep pressure: No masses Exam Action
03/03/23 5:16 AM MST
 Palpated liver: Palpable 1 cm below right costal margin Exam Action
03/03/23 5:16 AM MST
 Palpated for spleen: Not palpable Exam Action
03/03/23 5:17 AM MST
 Palpated for right kidney: Not palpable Exam Action
03/03/23 5:17 AM MST
 Palpated for left kidney: Not palpable Exam Action
03/03/23 5:17 AM MST

 

Subjective Data Collection: 24 of 24 (100.0%)

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.

Relevant Medical History

Finding:

Asked about current stomach and bowels

Finding:

Denies current abdominal issues

(Found)

Pro Tip: Asking Tina whether she is currently experiencing any stomach or bowel difficulties helps you determine her ability to receive an interview and her need for immediate care.

Example Question:

Do you have any current abdominal issues?

Finding:

Asked about typical bowel habits

Finding:

Reports a bowel movement every two days

(Found)

Pro Tip: Asking Tina how often she has bowel movements is significant in understanding her gastrointestinal symptoms, as the bowels can cause or be caused by numerous conditions.

Example Question:

How often do you have a bowel movement?

Finding:

Reports last bowel movement was yesterday morning

(Available)

Pro Tip: Asking Tina when her last bowel movement was is significant in understanding her gastrointestinal symptoms, as a long period of time between bowel movements can indicate an underlying condition and potential discomfort.

Example Question:

When was your last bowel movement?

Finding:

Asked about constipation

Finding:

Denies constipation

(Found)

Pro Tip: Asking Tina about any constipation she experiences is significant in understanding her gastrointestinal symptoms, as constipation can be uncomfortable and point to an underlying condition.

Example Question:

Have you been constipated?

Finding:

Denies hard stools

(Found)

Pro Tip: Asking Tina about any hard stools she experiences is significant in understanding her gastrointestinal symptoms, as hard stools can be uncomfortable and point to an underlying condition.

Example Question:

Have you had hard stools?

Finding:

Denies straining during bowel movement

(Available)

Pro Tip: Asking Tina about any straining she experiences during bowel movements is significant in understanding her gastrointestinal symptoms, as straining can be uncomfortable and point to an underlying condition.

Example Question:

Do you strain during a bowel movement?

Finding:

Asked about diarrhea

Finding:

Denies diarrhea

(Found)

Pro Tip: Asking Tina whether she is currently experiencing any diarrhea helps you determine her ability to receive an interview and her need for immediate care.

Example Question:

Do you have diarrhea?

Finding:

Followed up on stool characteristics

Finding:

Reports stool is formed

(Found)

Pro Tip: Asking Tina if her stools are formed is significant in understanding her gastrointestinal symptoms and any potential conditions.

Example Question:

Are your stools formed?

Finding:

Reports color is medium-brown

(Available)

Pro Tip: Asking Tina what colors her stools are is significant in understanding her gastrointestinal symptoms and any potential conditions.

Example Question:

What color are your stools?

Finding:

Denies blood in stool

(Available)

Pro Tip: Asking Tina if her stools contain blood is significant in understanding her gastrointestinal symptoms and any potential conditions.

Example Question:

Do you notice blood in your stool?

Finding:

Denies mucus in stool

(Available)

Pro Tip: Asking Tina if her stools contain mucus is significant in understanding her gastrointestinal symptoms and any potential conditions.

Example Question:

Do you notice mucus in your stool?

Finding:

Asked about gassiness

Finding:

Denies excessive gassiness

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like gas, details the way her individual symptoms and pain manifest.

Example Question:

Have you been feeling gassy?

Finding:

Denies bloating

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like bloating, details the way her individual symptoms and pain manifest.

Example Question:

Have you been experiencing bloating?

Finding:

Asked about nausea

Finding:

Denies nausea

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like nausea, details the way her individual symptoms and pain manifest.

Example Question:

Have you been having nausea?

Finding:

Asked about vomiting

Finding:

Denies vomiting

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like vomiting, details the way her individual symptoms and pain manifest.

Example Question:

Have you been vomiting recently?

Finding:

Asked about food intolerance

Finding:

Denies food intolerance

(Found)

Pro Tip: Certain foods can cause people to become ill depending on their personal physiology. Asking Tina whether there are foods she can’t tolerate allows you to determine her need for follow-up tests or diet recommendations.

Example Question:

Are there any foods that make you sick?

Finding:

Asked about appetite changes

Finding:

Reports recent increase in appetite

(Found)

Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina if her appetite has increased will illustrate the ways in which her symptoms are manifesting.

Example Question:

Has your appetite increased?

Finding:

Reports appetite increase started about a month ago

(Available)

Pro Tip: Pain can have a substantial effect on diet and appetite. Asking Tina when her appetite increased will illustrate the ways in which her symptoms are manifesting.

Example Question:

When did your appetite increase?

Finding:

Asked about GERD and heartburn

Finding:

Denies heartburn

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like heartburn, details the way her individual symptoms and pain manifest.

Example Question:

Do you have heartburn?

Finding:

Denies chest pain

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like chest pain, details the way her individual symptoms and pain manifest.

Example Question:

Do you ever get chest pain?

Finding:

Denies history of GERD

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing, like GERD, details the way her individual symptoms and pain manifest.

Example Question:

Have you ever had GERD?

Finding:

Asked about urinary problems

Finding:

Reports increased urination

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been urinating more than usual can help you to determine the cause of Tina’s symptoms.

Example Question:

Have you been urinating more frequently?

Finding:

Reports waking up to urinate during the night

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has to wake up to urinate can help you to determine the cause of Tina’s symptoms.

Example Question:

Are you waking up in the middle of the night to urinate?

Finding:

Denies incontinence

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she is having bladder control problems can help you to determine the cause of Tina’s symptoms.

Example Question:

Are you having bladder control problems?

Finding:

Denies painful or difficult urination

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if urination has been difficult for her can help you to determine the cause of Tina’s symptoms.

Example Question:

Has urinating been difficult for you?

Finding:

Asked frequency and duration of increased urination

Finding:

Reports urinating every hour or two during the day

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina how many times she urinates during the day can help you to determine the cause of Tina’s symptoms.

Example Question:

How many times do you urinate during the day?

Finding:

Reports waking up to pee more than once per night

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina how frequently she has to wake up to urinate can help you to determine the cause of Tina’s symptoms.

Example Question:

How often do you wake up to urinate in the night?

Finding:

Reports frequent urination started a few months ago

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Establishing a timeline of Tina’s increase in urinary frequency can help you to determine the cause of Tina’s symptoms.

Example Question:

When did you start urinating more frequently?

Finding:

Asked about character of urine

Finding:

Reports urine is light yellow or clear

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina what color her urine is can help you to determine the cause of Tina’s symptoms.

Example Question:

What color is your urine usually?

Finding:

Denies blood in urine

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine ever contains blood can help you to determine the cause of Tina’s symptoms.

Example Question:

Have you had blood in your urine?

Finding:

Denies abnormal odor to urine

(Available)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine has a strong odor can help you to determine the cause of Tina’s symptoms.

Example Question:

Does your urine have an abnormal odor?

Finding:

Asked about fluid intake

Finding:

Reports increased water intake

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she is drinking more water lately can help you to determine the cause of Tina’s symptoms.

Example Question:

Are you drinking more water lately?

Finding:

Reports increased thirst

(Found)

Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been thirstier lately can help you to determine the cause of Tina’s symptoms.

Example Question:

Have you been thirstier lately?

Finding:

Asked about typical meals

Finding:

Reports typical breakfast is cereal, bread, or a muffin

(Found)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for breakfast will illustrate her recent dietary patterns.

Example Question:

What is your typical breakfast?

Finding:

Reports typical lunch is a sandwich and chips

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns.

Example Question:

What is your typical lunch?

Finding:

Reports typical dinner is chicken, a vegetable or potatoes, and bread

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for dinner will illustrate her recent dietary patterns.

Example Question:

What is your typical dinner?

Finding:

Reports typical snack is pretzels, French fries, crackers or chips

(Available)

Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for a snack will illustrate her recent dietary patterns.

Example Question:

What is a typical snack for you?

Risk Factors

Finding:

Asked about tobacco use

Finding:

Denies tobacco use

(Found)

Pro Tip: Smoking tobacco can affect a patient’s gastrointestinal health in numerous ways. Asking Tina about her use of any tobacco will help you contextualize the functioning of her abdominal system.

Example Question:

Do you smoke tobacco?

Finding:

Denies vaping

(Available)

Pro Tip: Smoking tobacco can affect a patient’s gastrointestinal health in numerous ways. Asking Tina about her use of any tobacco will help you contextualize the functioning of her abdominal system.

Example Question:

Do you vape?

Finding:

Asked about alcohol intake

Finding:

Reports last alcoholic drink was a few weeks ago

(Available)

Pro Tip: Confirming when a patient had her last alcohol intake is important, because she will receive medications while admitted, and alcohol is often contraindicated.

Example Question:

When was your last alcoholic drink?

Finding:

Reports no more than 2 or 3 alcoholic drinks in one sitting

(Available)

Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient, including to the abdominal system.

Example Question:

How many alcoholic drinks do you typically have in one sitting?

Finding:

Reports no more than 1 or 2 nights a week drinking alcohol

(Available)

Pro Tip: Finding out how many alcoholic drinks a patient has per week is essential to uncover any binge-drinking habits that can be unhealthy for your patient, including to the abdominal system.

Example Question:

How many alcoholic drinks do you typically have in a week?

Finding:

Asked about illicit drugs

Finding:

Reports history of smoking recreational marijuana

(Found)

Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted.

Example Question:

Have you ever smoked marijuana?

Review of Systems

Finding:

Asked about additional stomach and bowels

Finding:

Reports recent weight loss

(Found)

Pro Tip: Foundational questions about general health and wellbeing can help you to determine how your patient perceives her health. Asking Tina if her weight changed recently can indicate whether Tina has concerns about changes in weight.

Example Question:

Have you had any recent changes in your weight?

Finding:

Denies excessive burping

(Available)

Pro Tip: Increased burping can be a result of heartburn, acid reflux, or indigestion. Asking Tina if she’s been burping more would indicate that Tina has been swallowing more air recently.

Example Question:

Have you been burping?

Finding:

Denies difficulty swallowing

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like difficulty swallowing, details the way her individual symptoms and pain manifest.

Example Question:

Have you had difficulty swallowing?

Finding:

Denies rectal bleeding

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like rectal bleeding, details the way her individual symptoms and pain manifest.

Example Question:

Have you had rectal bleeding?

Finding:

Denies ulcers

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she ever had any ulcers will allow her to describe any historical concerns or problems she’s had.

Example Question:

Have you ever had an ulcer?

Finding:

Followed up on weight change

Finding:

Reports losing about 10 lbs

(Found)

Pro Tip: Weight change can occur for a variety of reasons, some healthier than others, and can impact the functioning of the gastrointestinal system. Asking Tina about her recent weight loss allows you to determine its magnitude and whether her health could be affected.

Example Question:

How much weight did you lose?

Finding:

Asked about organs of the gastrointestinal system

Finding:

Denies history of gall bladder problems

(Found)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of gall bladder problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of gall bladder problems?

Finding:

Denies history of pancreas problems

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of pancreas problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of pancreas problems?

Finding:

Denies history of liver problems

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of liver problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of liver problems?

Finding:

Denies history of kidney problems

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of kidney problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of kidney problems?

Finding:

Denies history of bladder problems

(Available)

Pro Tip: Soliciting a relevant medical history from your patient will aid in effectively treating your patient’s symptoms. Asking Tina if she has a history of bladder problems will allow her to describe any historical concerns or problems she’s had.

Example Question:

Do you have a history of bladder problems?

Family History

Finding:

Asked family history of gastrointestinal issues

Finding:

Denies family history of bowel disease

(Found)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking about any bowel disease in Tina’s family might reveal a predisposition to gastrointestinal disorders.

Example Question:

Does IBS run in your family?

Finding:

Denies family history of liver disease

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina has a family history of liver cancer might reveal a predisposition to gastrointestinal issues.

Example Question:

Does liver cancer run in your family?

Finding:

Asked family history of colon cancer

Finding:

Reports paternal grandfather died of colon cancer

Objective Data Collection: 12 of 12 (100%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed

 Inspected abdomen

1 of 1 point

 

Symmetry (1/3 point)

  •  Symmetric
  •  Asymmetric

Contour (1/3 point)

  •  Flat
  •  Rounded
  •  Protuberant
  •  Hollowed

Appearance (1/3 point)

  •  No visible abnormal findings
  •  Rash
  •  Striae
  •  Bulging around umbilicus
  •  Distension
  •  Visible masses (warts, cysts, or tumors)
  •  Freckles, birthmarks, or moles
  •  Excessive hair growth
  •  Scarring
  •  Laceration, lesion or wound
  •  Bruising
  •  Redness
  •  Jaundice
  •  Prominent veins

 Auscultated bowel sounds

1 of 1 point

 

Sounds (1/2 point)

  •  Absent
  •  Hypoactive
  •  Normoactive
  •  Hyperactive

Location Of Non Normoactive Bowel Sounds (1/2 point)

  •  All quadrants normoactive
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant

 Auscultated abdominal aorta

1 of 1 point

 

Sound (1/1 point)

  •  No bruit
  •  Bruit

 Auscultated abdominal arteries

1 of 1 point

 

Right: Renal (1/6 point)

  •  No bruit
  •  Bruit

Right: Iliac (1/6 point)

  •  No bruit
  •  Bruit

Right: Femoral (1/6 point)

  •  No bruit
  •  Bruit

Left: Renal (1/6 point)

  •  No bruit
  •  Bruit

Left: Iliac (1/6 point)

  •  No bruit
  •  Bruit

Left: Femoral (1/6 point)

  •  No bruit
  •  Bruit

 Percussed abdomen

1 of 1 point

 

Observations (1/1 point)

  •  All areas tympanic
  •  Some areas dull, some tympanic
  •  Some areas resonant

 Percussed CVA tenderness

1 of 1 point

 

Patient Reaction (1/1 point)

  •  Did not react
  •  Pain reaction

 Percussed for liver span

1 of 1 point

 

Size (1/1 point)

  •  Smaller than 6 cm
  •  Between 6 and 12 cm
  •  Greater than 12 cm

 Palpated abdomen – light

1 of 1 point

 

Tenderness (1/3 point)

  •  None reported
  •  Tenderness reported

Location Of Tenderness (1/3 point)

  •  No quadrants tender
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant

Observations (1/3 point)

  •  No additional observations
  •  Masses
  •  Guarding
  •  Distension

 Palpated abdomen – deep

1 of 1 point

 

Presence Of Unexpected Mass (1/2 point)

  •  No palpable mass
  •  Palpable mass

Location Of Mass (1/2 point)

  •  No palpable mass
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant
  •  Around umbilicus

 Palpated liver

1 of 1 point

 

Detection (1/1 point)

  •  Not palpable
  •  Palpable

 Palpated spleen

1 of 1 point

 

Detection (1/1 point)

  •  Not palpable
  •  Palpable

 Palpated kidneys

1 of 1 point

 

Right (1/2 point)

  •  Not palpable
  •  Palpable

Left (1/2 point)

  •  Not palpable
  •  Palpable

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Esther Park – Focused Exam: Abdominal Pain Results Health Assessment – January 2023

Esther ParkFocused Exam: Abdominal Pain Results Health Assessment – January 2023

Transcript

Started: Mar 03, 2023 | Total Time: 105 min

All Lines (140)Interview Questions (53)Statements (1)Exam Actions (86)

Hello!
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation?
Your patient is Esther Park, a 78-year-old Korean-American woman presenting with abdominal pain in Shadow General Hospital’s Emergency Department. Your role in this simulation is that of a healthcare provider who will conduct a focused history and physical examination of Ms. Park in order to assess her condition and transfer her care.
What are my objectives in this assessment?
In your interview with Ms. Park, you will ask about the history of her presenting illness and the functioning of relevant systems in order to obtain subjective data related to her abdominal pain. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. In addition to collecting subjective data, you will perform a physical exam on Ms. Park to gather objective data about her health and physiology. Throughout the conversation, you should educate and empathize with Ms. Park when appropriate to increase her health literacy and sense of well-being. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve?
You will complete nursing tasks to protect the patient’s safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care.
How will I be evaluated?
The activities evaluated by the simulation are Subjective and Objective Data Collection and Education and Empathy. Nursing tasks and Documentation, while they provide valuable practice for their real-world counterparts, are not automatically evaluated by the simulation. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. This assignment takes on average between 45 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world?
In this assessment, you will become familiarized with the structure and content of an abdominal focused exam so that with real-life patients, you can: º ask effective and comprehensive questions º educate and empathize with the patient º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: In a geriatric patient, what are some common considerations regarding abdominal pain?
Physiologic changes associated with aging
Time to begin.
Hi, my name is Nukol, how can I help? (No matching questions found.)
Hi, my name is Nukol. I will be your nurse today.
Hi. I’m. . .I have this pain in my stomach.
I am sorry for that
Thank you, dear.
Do you know where you are?
Yes. I am at Shadowville General Hospital. [AUDIO COMING SOON]
When did the the pain start?
The pain started as a general discomfort, about five days ago, when I started having the. . . difficulties going to the bathroom.
How can you rate the pain on a scale?
It has its ups and downs. At the moment, I’d say it’s a 2.
where is the location of the pain?
The pain and discomfort is down low in my belly.
Do you take pain medications? (Clarified to Are you taking a prescription pain med?.)
No. The only time I’ve ever taken those was ages ago, after my surgeries. (Clarified to if I am taking prescription pain meds.)
Do you take pain medications? (Clarified to Are you taking anything for pain?.)
I’m not taking anything for it. (Clarified to if I am taking pain medication.)
Do you use non-pharmacological relieving factors? (No matching questions found.)
non-pharmacological relieving factors? (No matching questions found.)
do you take laxatives?
No. I can’t imagine they are very good for you.
What aggravates the pain?
Moving around certainly doesn’t help. Neither does eating.
How does it impact on daily life? (Clarified to How does your health affect your activities of daily living?.)
Well, I have been slowed down lately. This week I missed both of my fitness classes. I never miss a class. . . and I like to help with the cleaning at home, but I’m just too weak. It’s very discouraging. (Clarified to how my health affects my activities of daily living.)
what relieves the pain?
Resting seems to settle things down a little, but there doesnt seem to be any real relief.
do you diarrhea?
No. The last time I had anything of that nature was . . . maybe six months ago.
is there mucus on stool? (Clarified to Have you had mucus in your stool?.)
No, I haven’t noticed anything like that. (Clarified to if there has been mucus in my stool.)
Do you urinate normally?
I’ve been going slightly less often because. . . well, I’ve been little less thirsty than usual.
have you contacted illnesses? (No matching questions found.)
have you contacted any illness? (Clarified to Have you been around anyone sick?.)
I haven’t heard any of my friends complain of anything… anything similar to the symptoms I have. (Clarified to if I have been around anyone who is sick.)
have you travelled recently?
No, I haven’t gone on any trips in several years.
have you been exposed to food poisoning?
No, I didn’t eat anything unusual.
have you been close to someone sick?
I haven’t heard any of my friends complain of anything… anything similar to the symptoms I have.
Do you have a history of constipation?
I don’t usually have problems going to the bathroom, but this has been going on for . . . about five days now. It’s taken quite a toll.
how is your bowel movement?
My bowel movements are usually. . . what I assume one would call normal. Not too soft, a normal brown color. Fairly regular.
Do you have allergies?
I have an allergy to latex.
do you have pre-existing health conditions? (Clarified to Do you have other health conditions?.)
My only known health issue is hypertension, but it’s very well managed. At my age, I feel that’s very healthy. (Clarified to if I have other medical problems.)
which medications do you take? (Clarified to What medications do you take?.)
Just the medication for my blood pressure. (Clarified to what medications I am taking.)
Have you had surgery?
I’ve had two operations, both many years ago.
How is your access to healthcare? (Clarified to Do you have difficulty accessing healthcare because of transportation?.)
No. I dont drive anymore, but my daughter drives me around if I need it. [AUDIO COMING SOON] (Clarified to if I have difficulty accessing healthcare because of transportation.)
How is your access to healthcare? (Clarified to Do you have access to healthcare?.)
I have health insurance. Shadow Mutual. (Clarified to if I have access to healthcare.)
How is your diet?
I would say my diet is fine . . . I don’t do anything special.
Do you have a cardiovascular system?
I don’t have heart problems. Just a little high blood pressure.
Do you have a urinary system?
No, it seems normal enough to me. Maybe a little darker than usual.
Do you have GYN problems?
I haven’t had any.
Do you drink alcohol?
Yes, but very little.
Do you use illicit drugs?
I have never used drugs of any kind.
Do you consume alcohol?
Yes, but very little.
 Measured vitals
 Inspected general face: Slight flushing of cheeks
 Inspected forehead and scalp
 Inspected nose and mouth
 Inspected left side of face
 Inspected back of head
 Inspected left side of face
 Inspected general face: Slight flushing of cheeks
 Inspected right side of face
 Inspected back of head
 Inspected right side of face
 Inspected general face: Slight flushing of cheeks
 Performed otoscopic examination of right naris
 Performed otoscopic examination of left naris
 Inspected mouth and throat
 Inspected right side of abdomen
 Inspected front of abdomen
 Inspected right side of abdomen
 Inspected front of abdomen
 Inspected left side of abdomen
 Inspected front of abdomen
 Inspected right leg for edema: No edema
 Inspected front of legs for edema: No edema
 Inspected left leg for edema: No edema
 Inspected front of legs for edema: No edema
 Inspected right leg for edema: No edema
 Auscultated aortic area with the bell
 Auscultated aortic area with the diaphragm
 Auscultated pulmonic area with the diaphragm
 Auscultated pulmonic area with the bell
 Auscultated Erb’s point with the bell
 Auscultated Erb’s point with the diaphragm
 Auscultated tricuspid area with the diaphragm
 Auscultated tricuspid area with the bell
 Auscultated mitral area with the bell
 Auscultated mitral area with the diaphragm
 Auscultated mitral area with the bell
 Auscultated breath sounds in anterior right upper lobe
 Auscultated breath sounds in anterior left upper lobe
 Auscultated breath sounds in anterior right middle lobe
 Auscultated breath sounds in anterior left mid-chest (upper lobe)
 Auscultated breath sounds in anterior right lower lobe
 Auscultated breath sounds in anterior left lower lobe
 Auscultated breath sounds in posterior left upper lobe
 Auscultated breath sounds in posterior right upper lobe
 Auscultated breath sounds in posterior left mid-back (lower lobe)
 Auscultated breath sounds in posterior right mid-back (lower lobe)
 Auscultated breath sounds in posterior left lower lobe
 Auscultated breath sounds in posterior right lower lobe
 Auscultated breath sounds in posterior left lower lobe on side
 Auscultated breath sounds in posterior left lower lobe near spine
 Auscultated breath sounds in posterior right lower lobe near spine
 Auscultated breath sounds in posterior right lower lobe on side
 Auscultated aorta in abdomen
 Auscultated right upper quadrant
 Auscultated left upper quadrant
 Auscultated right lower quadrant
 Auscultated left lower quadrant
 Auscultated right renal artery
 Auscultated left renal artery
 Auscultated right iliac artery
 Auscultated left iliac artery
 Auscultated left femoral artery
 Auscultated right femoral artery
 Percussed right upper quadrant
 Percussed left upper quadrant
 Percussed right lower quadrant
 Percussed left lower quadrant
 Percussed right flank for CVA tenderness
 Percussed left flank for CVA tenderness
 Percussed for spleen
 Percussed for liver span: 7 cm in the mid-clavicular line
 Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
 Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
 Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
 Palpated left lower quadrant with light pressure: Tenderness reported; palpable guarding and distension, no masses
 Palpated right upper quadrant with deep pressure: No masses
 Palpated left upper quadrant with deep pressure: No masses
 Palpated left lower quadrant with deep pressure: Firm, oblong mass (2x4cm)
 Palpated right lower quadrant: with deep pressure: No masses
 Palpated for liver: Palpable 1 cm below right costal margin
 Palpated for spleen: Not palpable
 Palpated bladder: Not palpable; no distention or tenderness
 Palpated for right kidney: Not palpable
 Palpated for left kidney: Not palpable
 Tested skin turgor
Hello, I am back
Hello, dear.
Do you take fiber supplements?
No, I don’t take any extra fiber. I hadn’t quite considered it . . .
How much alcohol do you take?
Perhaps a glass of white wine a week.
how is your gastrointestinal system?
I suppose I have felt bloated. . .and less hungry.
Do you have nausea?
No. I haven’t vomited or had any nausea. It’s more of a problem with pain. . . and difficulty going to the bathroom.
Do you have a problem with your genitourinary system?
No. I have managed to avoid diabetes.
Do you have a headache?
No.
Do you take any antibiotics?
The only medication I take is for my blood pressure. It doesn’t seem to affect these belly troubles, one way or the other.
Do you eat a lot of fiber?
I don’t know how much fiber is in what . . . I don’t think about it, even. I have a vegetable every day or two, which I’d guess has fiber.
Do you exercise?
Yes, I usually love exercise–water aerobics, Pilates. . . I take classes at the community center. But with this pain and feeling so uncomfortable this week, I’ve skipped my classes. I don’t like that . . . I feel out of sorts.
Do you have problem swallowing?

 

No. I am able to swallow without any problems.

Subjective Data Collection: 36 of 41 (87.8%)

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 abdominal pain

(Found)

Pro Tip: Abdominal pain can be caused by problems in the underlying organs, peritoneum, muscles, or blood vessels, changes in electrolytes or other blood contents, or even anxiety. Asking for details about the pain helps to determine the origin.

Example Question:

Do you have any abdominal pain?

Finding:

Reports difficulty with bowel movements

(Found)

Pro Tip: Understanding all of a patient’s reason for visiting is an important foundation to establish. If there are multiple symptoms, especially related symptoms like constipation and bowel pain, follow up on each one during your interview.

Example Question:

Are you able to have a bowel movement?

Orientation

Finding:

Asked about orientation

Finding:

Oriented to own person

(Available)

Pro Tip: You should ask geriatric patients to state their name so you can determine their cognitive functioning.

Example Question:

Can you tell me who you are?

Finding:

Oriented to place

(Found)

Pro Tip: You should ask geriatric patients to identify where they are so you can determine their cognitive functioning.

Example Question:

Do you know where you are right now?

Finding:

Oriented to situation

(Available)

Pro Tip: You should ask geriatric patients to identify their reason for being here so you can determine their cognitive functioning.

Example Question:

Do you know why you are here today?

Finding:

Oriented to time

(Available)

Pro Tip: You should ask geriatric patients to identify the date and year so you can determine their cognitive functioning.

Example Question:

What is the date and year?

History of Presenting Illness

Finding:

Asked about onset of the pain

Finding:

Reports discomfort for the past five days

(Found)

Pro Tip: Whenever you are assessing a symptom or a health condition, in this case stomach pain, inquiring about onset allows you to assess the severity and the progression of the problem.

Example Question:

How long have you had stomach pain?

Finding:

Reports pain worsened intensely 2-3 days ago

(Available)

Pro Tip: Whenever you are assessing a symptom or a health condition, in this case stomach pain, inquiring about changes in the pain allows you to assess the severity and the progression of the problem.

Example Question:

Has the stomach pain changed?

Finding:

Asked about location of the pain

Finding:

Reports pain in lower abdomen

(Found)

Pro Tip: Identification of the location of your patient’s discomfort can provide important clues about its cause and how it should be best treated.

Example Question:

Where is your discomfort located?

Finding:

Reports pain is not localized

(Available)

Pro Tip: Identifying the location of your patient’s pain provides important clues about its cause and how to treat it best.

Example Question:

Is the pain in a specific spot?

Finding:

Denies flank pain

(Available)

Pro Tip: Flank pain often occurs with disorders of the urinary tract. When a patient complains of flank pain, assess for co-occurring symptoms such as fever, chills, hematuria, and dysuria.

Example Question:

Do you have pain on your sides?

Finding:

Asked about pain rating on a scale

Finding:

Reports current pain rating of 2/10

(Found)

Pro Tip: For many people, it is difficult to clearly describe pain. Asking your patient to rate her pain on a scale from zero to 10 develops a consistent measure of pain severity.

Example Question:

How would you rate your pain on a scale of one to ten?

Finding:

Reports pain at its lowest is 2/10

(Available)

Pro Tip: For many people, it is difficult to clearly describe pain. Asking your patient to rate her pain at its lowest on a scale from zero to 10 develops a consistent measure of pain severity.

Example Question:

How would you rate your pain at its lowest?

Finding:

Reports pain at its worst is 8/10

(Available)

Pro Tip: For many people, it is difficult to clearly describe pain. Asking your patient to rate her pain at its highest on a scale from zero to 10 develops a consistent measure of pain severity.

Example Question:

How would you rate your pain at its worst?

Finding:

Asked about characteristics of the pain

Finding:

Describes pain as dull

(Available)

Pro Tip: Asking your patient to describe her pain helps identify its cause and the severity. Patients may not know how to answer, so you may need to suggest words like sharp, dull, burning, throbbing, or shooting.

Example Question:

Can you describe the pain?

Finding:

Describes pain as cramping

(Available)

Pro Tip: Asking your patient to describe her pain helps identify its cause and the severity. Patients may not know how to answer, so you may need to suggest words like sharp, dull, burning, throbbing, or shooting.

Example Question:

Can you describe the pain?

Finding:

Describes pain as constant

(Found)

Pro Tip: It’s important to ask your patient if her pain is constant or intermittent in order to determine her level of discomfort and identify the cause of the pain. Constant pain is often best managed with around-the-clock pain medications.

Example Question:

Is your pain constant?

Finding:

Describes pain as fluctuating in severity

(Found)

Pro Tip: Whenever you are assessing a symptom or a health condition, in this case stomach pain, inquiring about changes in the pain allows you to assess the severity and the nature of the problem.

Example Question:

Does your pain fluctuate?

Finding:

Asked about non-pharmacological relieving factors

Finding:

Reports that resting helps relieve pain

(Found)

Pro Tip: Asking about how your patient has been managing her pain assesses her current condition and her approach to self-care. The results of her previous treatment may be helpful in your diagnosis and the development of her new treatment plan, as well as a good opportunity to educate your patient on effective self-care practices.

Example Question:

What relieves your pain besides medication?

Finding:

Reports drinking warm water to relieve pain was ineffective

(Available)

Pro Tip: Asking about how your patient has been managing her pain assesses her current condition and her approach to self-care. The results of her previous treatment may be helpful in your diagnosis and the development of her new treatment plan, as well as a good opportunity to educate your patient on effective self-care practices.

Example Question:

What relieves your pain besides medication?

Finding:

Asked about pharmacological relieving factors

Finding:

Denies taking pain medication

(Found)

Pro Tip: It’s important to assess the nature of pain by asking about relief. If you know your patient is taking pain medication, asking about the medication’s effectiveness can help you adjust treatment as needed.

Example Question:

Have you taken medication for the stomach pain?

Finding:

Denies taking laxatives

(Found)

Pro Tip: It’s important to assess the nature of pain by asking about relief. If you know your patient is taking laxatives for constipation, asking about the medication’s effectiveness can help you adjust treatment as needed.

Example Question:

Have you taken laxatives?

Finding:

Asked about aggravating factors

Finding:

Reports pain is aggravated by eating

(Found)

Pro Tip: Asking your patient what aggravates her pain can point to factors that exacerbate symptoms and the ways in which your patient is approaching self-care. In patients with stomach pain, whether or not eating exacerbates pain may help you identify the nature of the condition.

Example Question:

Does eating aggravate the pain?

Finding:

Reports pain is aggravated by physical activity

(Found)

Pro Tip: Asking your patient what aggravates her pain can point to factors that exacerbate symptoms and the ways in which your patient is approaching self-care. In patients with stomach pain, whether or not physical activity exacerbates pain may help you identify the nature of the condition.

Example Question:

Does physical activity aggravate the pain?

Finding:

Asked about impact of pain on daily life

Finding:

Reports recent difficulty participating in usual activities

(Found)

Pro Tip: Asking about changes in activity level will help determine the level of disability caused by your patient’s condition.

Example Question:

How has your illness affected your daily life?

Finding:

Reports low energy

(Found)

Pro Tip: Asking about changes in energy level will help determine the level of disability caused by your patient’s condition.

Example Question:

Have you had low energy?

Finding:

Followed up on constipation

Finding:

Reports current constipation

(Found)

Pro Tip: Asking a patient with recent constipation if they are currently experiencing symptoms can help you to determine the patient’s discomfort level, ability to conduct an interview, and need for immediate care.

Example Question:

Are you constipated right now?

Finding:

Reports constipation all of last 5 days

(Found)

Pro Tip: Whenever you are assessing a symptom such as constipation, inquiring about onset allows you to assess the severity and the progression of the problem.

Example Question:

For how long have you been constipated?

Finding:

Asked about diarrhea

Finding:

Reports recent diarrhea

(Found)

Pro Tip: Whenever you are assessing a symptom or a health condition, inquiring about onset assesses the severity and the progression of the problem.

Example Question:

Have you had diarrhea recently?

Finding:

Followed up on diarrhea

Finding:

Reports diarrhea about six months ago

(Found)

Pro Tip: It’s important to ask about the onset of stool changes because it may be a sign of a new onset of a gastrointestinal disease or disorder. Diarrhea is a common symptom of inflammatory bowel diseases, food allergies and intolerance, gastrointestinal infections, and many other conditions.

Example Question:

How long ago did you get diarrhea?

Finding:

Reports diarrhea had a sudden onset

(Available)

Pro Tip: It’s important to ask about the suddenness of diarrhea because it may be a sign of a new onset of a gastrointestinal disease or disorder. Diarrhea is a common symptom of inflammatory bowel diseases, food allergies and intolerance, gastrointestinal infections, and many other conditions.

Example Question:

Did the diarrhea happen suddenly?

Finding:

Reports diarrhea lasted one day

(Available)

Pro Tip: It’s important to ask about the duration of diarrhea because it may be a sign of a new onset of a gastrointestinal disease or disorder. Diarrhea is a common symptom of inflammatory bowel diseases, food allergies and intolerance, gastrointestinal infections, and many other conditions.

Example Question:

How long did your diarrhea last?

Finding:

Asked about substances in stool

Finding:

Denies mucus in stool

(Found)

Pro Tip: While small amounts of mucus may be present in normal stool, increased mucus in the stool is associated with a variety of intestinal disorders.

Example Question:

Has there been mucus in your stool?

Finding:

Denies blood in stool

(Available)

Pro Tip: Bloody stool is an alarming symptom that indicates bleeding in the digestive tract. Bright red bloody stool suggests bleeding in the colon or rectum. Bloody stool that appears black or tarry suggests bleeding in upper digestive tract, such as the small intestine or stomach.

Example Question:

Has there been blood in your stool?

Finding:

Asked about urination

Finding:

Reports slight decrease in frequency of urination

(Found)

Pro Tip: Frequency of urination can be an important clue to many underlying conditions. It’s important to ask whether your patient has noticed changes in her typical habits.

Example Question:

Have you had any changes in the frequency of your urination?

Finding:

Reports darker urine recently

(Found)

Pro Tip: Darker urination can be an important clue to many underlying conditions like cirrhosis or hepatitis. It’s important to ask whether your patient has noticed changes in her typical urinary patterns.

Example Question:

Has your urine been darker recently?

Finding:

Denies blood in urine

(Found)

Pro Tip: Blood in the urine can be an important clue to many underlying conditions like cancer or kidney problems. It’s important to ask whether your patient has noticed changes in her typical urinary patterns.

Example Question:

Have you had blood in your urine?

Finding:

Asked about fluid intake

Finding:

Reports decreased thirst

(Found)

Pro Tip: An increase in thirst can mean a variety of underlying conditions. Asking your patient if she has been thirstier than usual can indicate a possible underlying symptom.

Example Question:

Have you been thirstier lately?

Finding:

Reports decreased fluid intake for the last few days

(Found)

Pro Tip: Asking about fluid intake is a key component of a thorough health assessment, especially for patients experiencing symptoms often affected by hydration, like stomach pain and constipation.

Example Question:

Have you had changes in your fluid intake?

Finding:

Typical fluid intake is 1-2 glasses of water a day

(Available)

Pro Tip: Asking about how many glasses of water a patient drinks daily is a key component of a thorough health assessment, especially for patients experiencing symptoms often affected by hydration, like stomach pain and constipation.

Example Question:

How many glasses of water do you drink daily?

Finding:

Denies drinking caffeinated drinks such as coffee or soda

(Available)

Pro Tip: Asking about fluid intake is a key component of a thorough health assessment. Inadequate fluid intake or dehydration can be a common problem among aging adults.

Example Question:

Do you drink caffeinated beverages?

Past Medical History

Finding:

Asked about history of constipation

Finding:

Denies history of constipation

(Found)

Pro Tip: In geriatric patients, constipation is often caused by inadequate fluid intake, medication side effects, low-fiber diets, and difficulty ambulating to the toilet, which can result in retention of stool. Ask patients experiencing constipation whether it is a recurring issue so you can explore for potential causes.

Example Question:

Are you typically constipated?

Finding:

Asked about typical bowel movements

Finding:

Reports typically having a bowel movement almost every day

(Available)

Pro Tip: Asking about usual bowel movements facilitates baseline data collection. Asking specifically about bowel movement frequency aids in the identification of abnormalities.

Example Question:

How many bowel movements do you typically have per week?

Finding:

Reports typical stools are brown

(Found)

Pro Tip: Although it may be uncomfortable, it is important to ask about the color of usual bowel movements because the stool relays valuable information about gastrointestinal health.

Example Question:

Are your stools typically brown?

Finding:

Reports typical stools are formed

(Found)

Pro Tip: Although it may be uncomfortable, it is important to ask about formedness of usual bowel movements because the stool relays valuable information about gastrointestinal health.

Example Question:

Are your stools typically formed?

Finding:

Reports typical stools are soft

(Found)

Pro Tip: Although it may be uncomfortable, it is important to ask the softness or hardness of usual bowel movements because the stool relays valuable information about gastrointestinal health.

Example Question:

Are your stools typically soft?

Finding:

Asked about allergies

Finding:

Reports latex allergy

(Found)

Pro Tip: Latex allergies can cause severe and even life-threatening consequences. Always asking specifically about allergies can help ensure that your patient does not receive medication or treatment that will do her harm.

Example Question:

Do you have a latex allergy?

Finding:

Denies medication allergies

(Available)

Pro Tip: Medication allergies can cause severe and even life-threatening consequences. Always asking specifically about these allergies can help ensure that your patient does not receive medication that will do her harm.

Example Question:

Are you allergic to any medications?

Finding:

Denies food allergies

(Available)

Pro Tip: Knowing your patient’s food allergies prevents your patient from receiving harmful food, and it helps to identify specific allergies, such as shellfish or eggs, which can contraindicate the administration of common medications or treatments that include derivatives of these substances.

Example Question:

Do you have any food allergies?

Finding:

Asked about health maintenance

Finding:

Reports annual check-ups

(Available)

Pro Tip: Access to healthcare and resources heavily influences one’s health condition. This information can be helpful when educating your patient and developing a discharge plan.

Example Question:

Do you have a primary care doctor?

Finding:

Reports last Pap smear was over 10 years ago

(Available)

Pro Tip: A regular Pap smear is indicated for female patients between 21 and 65. Checking your patient’s screening status can give important information about overall health care compliance as well as gynecological health.

Example Question:

When was your last pap smear?

Finding:

Reports belief that her level of health and activity is very good for her age

(Found)

Pro Tip: Your patient’s perception of health provides insight into her self-awareness, her health goals, and her approach to self-care. This information should be considered when developing her plan of care.

Example Question:

Do you feel you are healthy?

Finding:

Reports colonoscopy 10 years ago

(Available)

Pro Tip: Colonoscopies are an important part of geriatric health maintenance. Establishing Esther’s last colonoscopy will help you assess any possible complications with her colon.

Example Question:

Have you had a colonoscopy?

Finding:

Asked about sexually transmitted infections

Finding:

Denies ever getting STI testing

(Available)

Pro Tip: When assessing your patient’s sexual health, it is critical to ask whether she has been tested for sexually transmitted infections, especially patients with gastrointestinal conditions, as these are sometimes caused by STIs.

Example Question:

Have you ever been tested for STIs?

Finding:

Denies STI symptoms

(Available)

Pro Tip: When assessing your patient’s sexual health, it is critical to ask whether she has experienced symptoms of sexually transmitted infection. As many sexually transmitted infections are asymptomatic in women, your patient may not recognize if she has been infected.

Example Question:

Have you had STI symptoms?

Finding:

Asked about current sexual activity

Finding:

Reports currently sexually active

(Available)

Pro Tip: Sexual activity can increase your patient’s risk factor for sexually transmitted infections, so it’s important to ask specifically about current sexual activity.

Example Question:

Are you sexually active?

Finding:

Asked about pre-existing health conditions

Finding:

Reports high blood pressure

(Found)

Pro Tip: Asking generally about a patient’s pre-existing health conditions allows you to ascertain how well they are controlled and whether they may be affecting the patient’s present illness.

Example Question:

Do you have high blood pressure?

Finding:

Asked about history of surgery

Finding:

Reports C-section

(Available)

Pro Tip: Information about your patient’s pregnancy complications can provide you with insight into past medical conditions.

Example Question:

Did you have any complications during pregnancy?

Finding:

Reports C-section at age 40

(Available)

Pro Tip: Information about your patient’s pregnancy can provide you with insight into past medical conditions.

Example Question:

At what age did you have a C-section?

Finding:

Reports cholecystectomy

(Available)

Pro Tip: Information about your patient’s gallbladder and whether it has been removed can provide you with potential insight into her current gastrointestinal pain.

Example Question:

Have you had your gallbladder removed?

Finding:

Reports cholecystectomy at age 42

(Available)

Pro Tip: Information about your patient’s gallbladder and when it was removed can provide you with potential insight into her current gastrointestinal pain.

Example Question:

At what age did you have your gallbladder removed?

Finding:

Denies post-operative complications

(Available)

Pro Tip: Asking about any postoperative complications in your patient’s history may provide information relevant to identifying her present condition.

Example Question:

Did you have any complications after your surgery?

Home Medications

Finding:

Asked about typical medications

Finding:

Reports high blood pressure medication

(Found)

Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about relevant, in this case for the patient’s high blood pressure, medication will help you to treat your patient.

Example Question:

Do you take high blood pressure medication?

Finding:

Followed up on high blood pressure medication

Finding:

Reports medication for high blood pressure is quinapril (Accupril)

(Available)

Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about the name of the medication, in this case for blood pressure, will help you to treat your patient.

Example Question:

What medication do you take for your high blood pressure?

Finding:

Reports high blood pressure medication is 10 mg

(Available)

Pro Tip: The medication that a patient takes will indicate any relevant health conditions, their treatment plan, and how well they comply with it. Asking about the dose of the medication, in this case for blood pressure, will help you to treat your patient.

Example Question:

What dose is your high blood pressure medication?

Finding:

Reports taking high blood pressure medication daily at 8 a.m.

(Available)

Pro Tip: Asking about the last dose of the patient’s high blood pressure medication will help you to treat your patient, especially in considering whether there are contraindications for any new medications the patient may receive in care.

Example Question:

When do you take your high blood pressure medication?

Finding:

Denies typically taking any OTC medications

(Found)

Pro Tip: Patients should always be asked specifically about over-the-counter medications, as many patients will overlook talking about them. Over-the-counter medications can cause medical complications of their own or can indicate medical problems that your patient has been attempting to self-treat.

Example Question:

Do you take any over-the-counter medications?

Social History

Finding:

Asked about activities of daily living

Finding:

Denies difficulty toileting alone

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to get on and off the toilet allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty getting on and off the toilet?

Finding:

Denies difficulty dressing

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to dress on their own allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty dressing yourself?

Finding:

Denies difficulty feeding self

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to feed themselves allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty feeding yourself?

Finding:

Denies difficulty walking

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to walk allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty walking?

Finding:

Denies difficulty bathing

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to bathe on their own allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty bathing yourself?

Finding:

Denies difficulty transferring in and out of chairs

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people may have greater difficulty with activities of daily living. Asking older patients about their ability to get in and out of chairs allows you to determine if greater caretaking is necessary.

Example Question:

Do you have difficulty getting in and out of chairs?

Finding:

Asked about diet

Finding:

Reports last meal was toast at breakfast

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about her last meal will indicate her typical eating habits and allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.

Example Question:

What was your last meal?

Finding:

Reports typically eating 3 meals

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically eats will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.

Example Question:

How many meals do you typically eat per day?

Finding:

Denies eating snacks regularly

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has for a snack will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.

Example Question:

What do you typically eat for a snack?

Finding:

Reports typical breakfast is toast

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has for breakfast will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.

Example Question:

What do you usually eat for breakfast?

Finding:

Reports typical lunch is soup

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has for lunch will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.

Example Question:

What do you usually eat for lunch?

Finding:

Reports sometimes skipping lunch due to low appetite

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has for lunch will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.

Example Question:

What do you usually eat for lunch?

Finding:

Reports typical dinner is chicken or fish with rice

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Esther about what she typically has for dinner will allow you to assess whether her eating habits put her at risk of cardiovascular disease or other health complications.

Example Question:

What do you usually eat for dinner?

Finding:

Asked about fiber intake

Finding:

Denies taking fiber supplements

(Found)

Pro Tip: A high fiber diet helps to reduce constipation. Asking Esther if she takes fiber supplements will help you to assess whether she gets enough fiber in her diet.

Example Question:

Do you take fiber supplements?

Finding:

Denies efforts to incorporate fiber in her diet

(Found)

Pro Tip: A high fiber diet helps to reduce constipation. Asking Esther about how she perceives her fiber consumption will help you to assess whether her intake and any gaps in health literacy.

Example Question:

Do you think you get enough fiber?

Finding:

Reports eating a vegetable every 1 or 2 days

(Found)

Pro Tip: A high fiber diet helps to reduce constipation. Asking Esther what sources of fiber she eats will help you to assess whether she gets enough fiber in her diet.

Example Question:

What sources of fiber do you eat?

Finding:

Reports eating fruit every 3 or 4 days

(Available)

Pro Tip: A high fiber diet helps to reduce constipation. Asking Esther what sources of fiber she eats will help you to assess whether she gets enough fiber in her diet.

Example Question:

Do you eat fruit?

Finding:

Asked about typical activity level

Finding:

Reports typically high level of mobility and independence

(Found)

Pro Tip: Assessing your patient’s typical level of activity and mobility will help you determine the level of disability associated with their current medical condition.

Example Question:

Do you stay active?

Finding:

Reports typically having a moderate activity level

(Found)

Pro Tip: Assessing your patient’s typical level of activity and mobility will help you determine the level of disability associated with their current medical condition.

Example Question:

What is your typical activity level?

Finding:

Asked about substance use

Finding:

Denies illicit drug use

(Found)

Pro Tip: Many drugs affect the central nervous system or can cause cardiovascular complications. Asking Esther if she uses illicit drugs will indicate whether drug use puts her at risk for health complications.

Example Question:

Do you use illicit drugs?

Finding:

Denies cigarette smoking

(Available)

Pro Tip: Tobacco affects the heart by reducing the amount of oxygen the blood is able to carry. Asking Esther if she uses tobacco will allow you to assess whether the condition is caused, in part, by tobacco use.

Example Question:

Do you smoke cigarettes?

Finding:

Reports low alcohol consumption

(Found)

Pro Tip: Chronic alcohol use can result in a range of health problems. Asking Esther whether she drinks alcohol will allow you to assess whether she has any indicators of alcoholism or other health conditions.

Example Question:

Do you consume alcohol?

Finding:

Followed-up on alcohol consumption

Finding:

Reports drinking 1 night a week

(Found)

Pro Tip: Finding out the number of nights a patient drinks each week is a good baseline for asking additional questions about alcohol consumption.

Example Question:

How many nights a week do you drink alcohol?

Finding:

Reports 1 drink per sitting

(Found)

Pro Tip: Asking the patient how many drinks she has per month is a way to gauge her understanding of her own level of drinking.

Example Question:

How many alcoholic drinks do you have in a month?

Finding:

Reports typical drink is white wine

(Found)

Pro Tip: The type of drink the patient consumes gives you a basic indicator of what proof of alcohol the patient is ingesting.

Example Question:

When you have alcohol, what do you typically drink?

Finding:

Asked about psychosocial history

Finding:

Reports living with her daughter

(Found)

Pro Tip: Asking your patient whom she lives with will help to identify any caregivers in the home who are available to assist her. Living situation can also relay information about your patient’s relationships, socioeconomic status, functional ability, and sense of self.

Example Question:

Do you live with anyone?

Finding:

Reports strong familial support system

(Found)

Pro Tip: Social support is important for coping with daily stressors and for maintaining quality of life. Your patient’s relationships with others can be assessed by your asking about social support.

Example Question:

Who can you go to for support?

Finding:

Denies recent travel

(Found)

Pro Tip: Recent travel or new experiences can result in gastrointestinal or other stressors. Asking Esther if she’s traveled recently might reveal a new experience that’s affected her health.

Example Question:

Have you traveled anywhere recently?

Finding:

Asked about experience of abuse

Finding:

Denies being physically abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being physically abused so you can follow up appropriately.

Example Question:

Have you experienced any physical abuse?

Finding:

Denies being sexually abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being sexually abused so you can follow up appropriately.

Example Question:

Have you experienced any sexual abuse?

Finding:

Denies being emotionally abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being emotionally abused so you can follow up appropriately.

Example Question:

Have you experienced any emotional abuse?

Finding:

Denies being financially abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being financially abused so you can follow up appropriately.

Example Question:

Have you experienced any financial abuse?

Finding:

Denies being verbally abused

(Available)

Pro Tip: Due to their potentially impaired physical and cognitive functioning, geriatric people are particularly susceptible to an array of abuses. It is important to ask older patients if they are being verbally abused so you can follow up appropriately.

Example Question:

Have you experienced any verbal abuse?

Review of Systems

Finding:

Asked about constitutional health

Finding:

Denies recent weight changes

(Available)

Pro Tip: Changes in weight can be a symptom of many medical conditions or may simply be a result of a change in lifestyle. It’s important to ask about changes in weight during your assessment.

Example Question:

Have you had any recent weight changes?

Finding:

Denies recent fever

(Available)

Pro Tip: When a patient presents with abdominal pain, the presence or absence of fever may help identify the patient’s condition.

Example Question:

Have you had a fever recently?

Finding:

Denies chills

(Available)

Pro Tip: If a patient has chills, it could indicate the onset of a fever.

Example Question:

Have you had chills?

Finding:

Denies night sweats

(Available)

Pro Tip: Night sweats can be a symptom of conditions such as perimenopause, or diseases or serious physical ailments.

Example Question:

Do you have night sweats?

Finding:

Denies swelling

(Available)

Pro Tip: Swelling can indicate allergic reaction or edema, both of which could be caused by medication.

Example Question:

Have you had any swelling?

Finding:

Reports short-term feeling of exhaustion

(Found)

Pro Tip: Asking about fatigue as a symptom is an important gauge for the seriousness of a patient’s condition, and as an indicator of the impact on the patient’s daily life.

Example Question:

Do you have fatigue?

Finding:

Denies sleep issues

(Available)

Pro Tip: Sleep issues can be an indicator of health problems, and it is important to ask the patient about it in order to narrow your treatment plan.

Example Question:

Have you had difficulty sleeping?

Finding:

Asked about history of gastrointestinal disorders

Finding:

Denies history of GERD or ulcer

(Available)

Pro Tip: If a patient has a history of GERD, ulcer, heartburn, or perceived indigestion, it could contribute to her present condition.

Example Question:

Do you have a history of heartburn?

Finding:

Denies history of appendicitis

(Available)

Pro Tip: In patients with lower quadrant abdominal pain, confirming a previous appendectomy can help rule out appendicitis as a cause for her current symptoms. It is important to note that elderly patients with appendicitis may present atypically and often lack certain classic symptoms such as rebound tenderness, right lower quadrant pain, fever, and anorexia.

Example Question:

Have you ever had appendicitis?

Finding:

Denies history of stomach cancer

(Available)

Pro Tip: If a patient has a history of stomach cancer, abdominal pain could be a sign of recurrence.

Example Question:

Do you have a history of stomach cancer?

Finding:

Denies history of liver disease

(Available)

Pro Tip: A history of liver disease could cause additional gastrointestinal complaints for a patient.

Example Question:

Do you have a history of liver disease?

Finding:

Asked about cardiovascular health

Finding:

Denies palpitations

(Available)

Pro Tip: Palpitations might be an indicator of an underlying cardiovascular or mental health condition, such as anxiety.

Example Question:

Do you have palpitations?

Finding:

Denies chest discomfort

(Available)

Pro Tip: Chest discomfort could be a symptom of gastrointestinal conditions such as GERD.

Example Question:

Do you have chest pain?

Finding:

Denies racing heartbeat

(Available)

Pro Tip: Racing heart might be an indicator of an underlying cardiovascular or mental health condition, such as anxiety.

Example Question:

Does your heart race?

Finding:

Asked about throat irritation

Finding:

Denies sore throat

(Available)

Pro Tip: A sore throat could be a symptom of gastrointestinal conditions such as GERD.

Example Question:

Do you have a sore throat?

Finding:

Asked about respiratory health

Finding:

Denies coughing

(Available)

Pro Tip: Coughing could be a symptom of gastrointestinal conditions such as GERD.

Example Question:

Have you been coughing?

Finding:

Denies difficulty swallowing

(Found)

Pro Tip: Difficulty swallowing could be a symptom of gastrointestinal conditions such as GERD.

Example Question:

Do you have difficulty swallowing?

Finding:

Denies difficulty breathing

(Available)

Pro Tip: Difficulty breathing could be an indicator that the patient’s condition is serious. It’s important to confirm that a patient is able to breathe without problems.

Example Question:

Have you had difficulty breathing?

Finding:

Asked additional review of systems for gastrointestinal

Finding:

Reports bloating

(Found)

Pro Tip: Bloating can occur alone or as a symptom of an underlying disorder. It is important to assess other symptoms in order to determine the cause of bloating.

Example Question:

Do you feel bloated?

Finding:

Reports slight increase in gas

(Available)

Pro Tip: While the normal frequency of burping and flatus varies widely, a sudden or marked increase in gas can be a symptom of a gastrointestinal disorder. When a patient complains of increased gas, it is important to identify any co-occurring symptoms.

Example Question:

Do you have more gas than usual?

Finding:

Reports loss of appetite in the past few days

(Found)

Pro Tip: Assessing appetite guides understanding of patient health. Lack of appetite may indicate an abnormality.

Example Question:

How is your appetite?

Finding:

Denies nausea

(Found)

Pro Tip: Nausea is an important subjective symptom to understand in any gastrointestinal complaint.

Example Question:

Do you have nausea?

Finding:

Denies vomiting

(Found)

Pro Tip: Presence of vomiting would indicate a complaint such as food poisoning or infection.

Example Question:

Have you been vomiting?

Finding:

Denies food poisoning

(Found)

Pro Tip: If a patient has a past experience with food poisoning, she may be able to compare and contrast her present symptoms with previous illnesses.

Example Question:

Do you have food poisoning?

Finding:

Asked review of systems for genitourinary

Finding:

Denies history of bladder problems

(Found)

Pro Tip: If a patient has a history of bladder disease, it could contribute or relate to her present condition.

Example Question:

Do you have a history of bladder disease?

Finding:

Denies painful urination

(Available)

Pro Tip: It is important to ask about pain during urination to assess for infection or inflammation of the urinary tract.

Example Question:

Do you have any pain when you urinate?

Finding:

Denies burning with urination

(Available)

Pro Tip: It is important to ask about burning during urination to assess for infection or inflammation of the urinary tract.

Example Question:

Do you have burning with urination?

Finding:

Denies urinary incontinence

(Available)

Pro Tip: Stress incontinence is common in geriatric women, particularly those who have had multiple vaginal deliveries. It’s important to ask about incontinence, especially during physical strain, laughing, coughing, or sneezing.

Example Question:

Do you have problems holding your urine?

Finding:

Denies history of UTIs

(Available)

Pro Tip: A history of frequent or severe UTIs could lead to scar tissue in the urinary tract, bladder, or kidneys.

Example Question:

Have you had past urinary tract infections?

Finding:

Denies holding in urine unnecessarily

(Available)

Pro Tip: Holding in urine unnecessarily can increase a patient’s risk of urinary tract infections.

Example Question:

Do you hold your urine in unnecessarily?

Finding:

Denies gynecological problems

(Found)

Pro Tip: Broad open questions are efficient and useful in eliciting a large amount of information from your patient. Asking about any gynecological problems should guide your assessment.

Example Question:

Do you have any gynecological problems?

Finding:

Denies vaginal bleeding

(Available)

Pro Tip: Postmenopausal vaginal bleeding is an abnormal finding that can often be attributed to the thinning of uterine and vaginal linings. However, it may also occur due to trauma, certain cancers, and infections, including STDs.

Example Question:

Do you have vaginal bleeding?

Finding:

Denies vaginal discharge

(Available)

Pro Tip: A patient whose vaginal discharge is foul-smelling, yellow or green, or curd-like, or irritating should be assessed for disorders of the reproductive system, including STDs.

Example Question:

Do you have vaginal discharge?

Finding:

Reports onset of menopause was age 54

(Available)

Pro Tip: Establishing a timeline for when Esther began menopause is important in assessing her gynecological history and understanding any concerns she might have.

Example Question:

When did you start menopause?

Finding:

Denies history of kidney problems

Objective Data Collection: 19.67 of 21 (93.67%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed

 Inspected head and face

0.67 of 1 point

 

Skull Symmetry (1/3 point)

  •  Symmetric
  •  Asymmetric

Facial Feature Symmetry (1/3 point)

  •  Symmetric
  •  Asymmetric

Appearance (No point)

  •  No visible abnormal findings
  •  Flushed appearance
  •  Rash or lesion
  •  Skin growths (freckles, moles, or birth mark)
  •  Excessive hair growth
  •  Evidence of skin trauma (scar, laceration, or bruising)

 Inspected nasal mucosa

1 of 1 point

 

Appearance (1/1 point)

  •  Moist and pink
  •  Dry appearance
  •  Redness

 Inspected mouth

1 of 1 point

 

Oral Mucosa (1/1 point)

  •  Moist and pink
  •  Dry appearance
  •  Redness

 Inspected abdomen

1 of 1 point

 

Symmetry (1/3 point)

  •  Symmetric
  •  Asymmetric

Contour (1/3 point)

  •  Flat
  •  Rounded
  •  Protuberant
  •  Hollowed

Appearance (1/3 point)

  •  No visible abnormal findings
  •  Rash
  •  Striae
  •  Bulging around umbilicus
  •  Distension
  •  Visible masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or discoloration
  •  Excessive hair growth
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Redness
  •  Jaundice
  •  Prominent veins

 Inspected for edema in lower extremities

1 of 1 point

 

Right: Edema (1/4 point)

  •  No edema
  •  Pitting
  •  Non-pitting

Right: Severity Of Edema (1/4 point)

  •  No edema
  •  1+ Slight pitting
  •  2+ Deeper pit, disappears in 10 to 15 seconds
  •  3+ Noticeably deep pit that lasts more than a minute
  •  4+ Very deep pit that lasts 2 to 5 minutes

Left: Edema (1/4 point)

  •  No edema
  •  Pitting
  •  Non-pitting

Left: Severity Of Edema (1/4 point)

  •  No edema
  •  1+ Slight pitting
  •  2+ Deeper pit, disappears in 10 to 15 seconds
  •  3+ Noticeably deep pit that lasts more than a minute
  •  4+ Very deep pit that lasts 2 to 5 minutes

 Auscultated heart sounds

1 of 1 point

 

Heart Sounds (1/2 point)

  •  S1 and S2 audible
  •  S1, S2, and S3 audible
  •  S1, S2, and S4 audible
  •  S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

  •  No extra sounds
  •  Gallops
  •  Murmur
  •  Friction rub
  •  Valve clicks

 Auscultated breath sounds

1 of 1 point

 

Breath Sounds (1/3 point)

  •  Present in all areas
  •  Diminished in some areas
  •  Absent in some areas

Adventitious Sounds (1/3 point)

  •  No adventitious sounds
  •  Wheezing
  •  Fine crackles
  •  Stridor
  •  Rhonchi
  •  Rales

Location (1/3 point)

  •  All areas clear
  •  Adventitious sounds in anterior right upper lobe
  •  Adventitious sounds in anterior right middle lobe
  •  Adventitious sounds in anterior right lower lobe
  •  Adventitious sounds in anterior left upper lobe
  •  Adventitious sounds in anterior left lower lobe
  •  Adventitious sounds in posterior right upper lobe
  •  Adventitious sounds in posterior right lower lobe
  •  Adventitious sounds in posterior left upper lobe
  •  Adventitious sounds in posterior left lower lobe

 Auscultated abdominal aorta

1 of 1 point

 

Sound (1/1 point)

  •  No bruit
  •  Bruit

 Auscultated bowel sounds

1 of 1 point

 

Bowel Sounds (1/2 point)

  •  Absent
  •  Hypoactive
  •  Normoactive
  •  Hyperactive

Location Of Non Normoactive Bowel Sounds (1/2 point)

  •  All quadrants normoactive
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant

 Auscultated abdominal arteries

1 of 1 point

 

Right: Renal (1/6 point)

  •  No bruit
  •  Bruit

Right: Iliac (1/6 point)

  •  No bruit
  •  Bruit

Right: Femoral (1/6 point)

  •  No bruit
  •  Bruit

Left: Renal (1/6 point)

  •  No bruit
  •  Bruit

Left: Iliac (1/6 point)

  •  No bruit
  •  Bruit

Left: Femoral (1/6 point)

  •  No bruit
  •  Bruit

 Percussed abdomen

0 of 1 point

 

Observations (No point)

  •  All areas generally tympanic
  •  Some areas dull, some tympanic
  •  Some areas resonant

 Percussed CVA tenderness

1 of 1 point

 

Patient Reaction (1/1 point)

  •  Did not react
  •  Pain reaction

 Percussed spleen

1 of 1 point

 

Spleen (1/1 point)

  •  Tympany
  •  Dullness

 Percussed liver

1 of 1 point

 

Liver Span (1/1 point)

  •  Smaller than 6 cm
  •  Between 6 and 12 cm
  •  Greater than 12 cm

 Palpated abdomen – light

1 of 1 point

 

Tenderness (1/3 point)

  •  None reported
  •  Tenderness reported

Location Of Tenderness (1/3 point)

  •  No quadrants tender
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant

Observations (1/3 point)

  •  No additional observations
  •  Masses
  •  Guarding
  •  Distension

 Palpated abdomen – deep

1 of 1 point

 

Presence Of Unexpected Mass (1/2 point)

  •  No palpable mass
  •  Palpable mass

Location Of Mass (1/2 point)

  •  No palpable mass
  •  Right upper quadrant
  •  Right lower quadrant
  •  Left upper quadrant
  •  Left lower quadrant
  •  Around umbilicus

 Palpated liver

1 of 1 point

 

Detection (1/1 point)

  •  Not palpable
  •  Palpable

 Palpated spleen

1 of 1 point

 

Detection (1/1 point)

  •  Not palpable
  •  Palpable

 Palpated bladder

1 of 1 point

 

Detection (1/1 point)

  •  Not palpable
  •  Palpable

 Palpated kidneys

1 of 1 point

 

Right (1/2 point)

  •  Palpable
  •  Not palpable

Left (1/2 point)

  •  Palpable
  •  Not palpable

 Tested skin turgor

1 of 1 point

 

Observations (1/1 point)

  •  No tenting
  •  Tenting

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

 1 Pain and Constipation

Followed Up

 

 Description: Ms. Park describes the symptoms that have been bothering her.
Hi, my name is Nukol. I will be your nurse today.
Hi. I’m. . .I have this pain in my stomach.
I am sorry for that
Thank you, dear.
 Model Statement: “I’m sorry you’re having these symptoms; it sounds like you’re under great discomfort. It’s good that you came in today so we can discuss how to alleviate your discomfort and improve your gastrointestinal health.”

 2 Fatigue and Activity Level

Not Followed Up

 

 Description: Ms. Park describes being more fatigued and having less energy for her daily activities.
Do you exercise?
Yes, I usually love exercise–water aerobics, Pilates. . . I take classes at the community center. But with this pain and feeling so uncomfortable this week, I’ve skipped my classes. I don’t like that . . . I feel out of sorts.
Do you have problem swallowing?
No. I am able to swallow without any problems.
 Model Statement: “I’m sorry you’ve been more tired and haven’t been able to live your daily life with your normal vigor. It’s always unpleasant when an illness makes you feel unlike yourself. Rest assured that we will work to improve your energy levels and get you able to participate in your regular activities.”

 3 Diet and Fiber

Not Followed Up

 

 Description: Ms. Park describes her dietary habits and reveals a lack of consistent fiber intake.
Do you eat a lot of fiber?
I don’t know how much fiber is in what . . . I don’t think about it, even. I have a vegetable every day or two, which I’d guess has fiber.
Do you exercise?
 Model Statement: “Thanks for telling me about your diet. The USDA recommends that adults eat around 28 grams of fiber per day, which is several servings of fruits, vegetables, and whole grains. Enough fiber can help regulate your digestive system and prevent gastrointestinal upsets, so let’s talk about ways you might increase your fiber intake.”

 4 Fluid Intake

Not Followed Up

 

 Description: Ms. Park describes drinking 1-2 glasses of water a day.
Do you urinate normally?
I’ve been going slightly less often because. . . well, I’ve been little less thirsty than usual.
have you contacted any illness? (Clarified to: Have you been around anyone sick?)
I haven’t heard any of my friends complain of anything… anything similar to the symptoms I have. (Clarified to: if I have been around anyone who is sick)
have you travelled recently?
No, I haven’t gone on any trips in several years.
 Model Statement: “It’s a really healthy practice to be drinking water every day, and it’s great that you are! You have room to drink even a few more glasses per day, or as much as is comfortable. This would help prevent dehydration and increase your overall health, especially in your gastrointestinal system.”

 

 

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Tina Jones – Cardiovascular Results Health Assessment – January 2023

Tina Jones – Cardiovascular Results Health Assessment – January 2023

Transcript

Started: Feb 25, 2023 | Total Time: 37 min

All Lines (109)Interview Questions (32)Statements (0)Exam Actions (77)

Hello!
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation?
It’s 4 p.m. on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a cardiovascular exam on Ms. Jones. This will give you a baseline of her cardiac condition prior to the new blood pressure medication her attending physician will be starting her on.
What are my objectives in this assessment?
In your interview with Ms. Jones, you will ask about her cardiovascular system and identify any risk factors so that you can determine any current and potential issues. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to the cardiovascular system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her cardiovascular system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ cardiovascular system to gather objective data about the system’s health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve?
You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
How will I be evaluated?
In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 40 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world?
In this assessment, you will become familiarized with the structure and content of cardiovascular exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: How might you educate a patient about high blood pressure?
Normal blood pressure is less than 120/80. High blood pressure can be managed by lifestyle changes and medication.
Time to begin.
Hi, my name is Nukol
Hey.
 Checked vitals
do you have a heart problem?
Nope, I’ve never had a heart problem.
how are your heartbeats? (Clarified to What is your heartbeat like?.)
My heartbeat’s fine. . . it feels normal. (Clarified to what my heartbeat is like.)
Do you have high blood pressure?
I’ve never had problems with high blood pressure, and I really hope I never do. I don’t need another health problem to worry about.
Do you have heart murmur?
No, I’ve never had a problem like that with my heart, luckily.
Do you have any swellings?
Nowhere but the bottom of my foot around the scrape, and that feels like it’s going down at least a little.
Do you have blue skin?
No, I don’t get blue anything. That sounds like science fiction. [AUDIO COMING SOON]
Have you had cardiac tests?
Luckily I’ve never had to have any heart tests or anything.
Have you had cardiac surgery?
No heart surgeries. . .that would be scary. [AUDIO COMING SOON]
Do you have chest pain?
No, my chest never hurts. Sometimes it feels kind of tight, like I can’t take in air, when I have asthma problems.
What triggers breathing problems? (Clarified to Can you tell me about what started your breathing problems?.)
My allergies got really bad. . . they always do when I’m at my cousin’s because she has cats. My asthma started to go crazy, but I used my inhaler, and I felt better. (Clarified to to tell you about what started my breathing problems.)
Do you have leg cramping?
Growing up my legs would cramp while I was sleeping sometimes, but that hasn’t happened in years.
How is your mobility?
There were about three days before I came in that I couldn’t walk at all, and then I’ve basically been in this bed since.
Do you have venous thrombosis?
I doubt I’ve had that, since I have no idea what it means.
Do you have cholesterol problems?
I have no idea–I’ve never had it checked.
how is your diet habit? (Clarified to How is your diet?.)
I think my diet is normal. (Clarified to how my diet is.)
how is your perceived weight?
I honestly don’t think about my weight much. It’s not something I stress out about. I’ve always been on the heavy side–I’m just not built to be skinny.
have you noted weight change?
Yeah, I’ve lost some weight recently.
do you take alcohol?
I do sometimes, yeah, when I go out with my friends.
do you take illicit drugs?
No.
do you use tobacco?
No. I think it’s gross.
are you exposed to second hand smoke?
I’m never really around smokers.
do you have a family history of high blood pressure?
We’ve got high blood pressure in our family for sure.
do you have a family history of cholesterol?
High cholesterol definitely runs in the family, yeah.
do you have a family history of stroke?
Yeah, that’s how my Nana died.
do you have a family history of heart attack?
Yeah, my Poppa died of a heart attack.
do you have a family history of obesity?
Well, dad was pretty big, and so’s my brother, but I don’t think they’re obese.
 Inspected anterior chest wall
 Inspected right side chest wall
 Inspected posterior chest wall
 Inspected left side chest wall
 Inspected anterior chest wall
 Inspected left side chest wall
 Inspected posterior chest wall
 Inspected right side chest wall
 Inspected anterior chest wall
 Inspected for jugular venous distension: JVP 1 cm above sternal angle
 Inspected fingernails of right hand
 Inspected fingernails of left hand
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Inspected legs
 Inspected left leg
 Inspected legs
 Inspected right leg
 Inspected legs
 Inspected right leg for edema: Pitting edema, 1+
 Inspected left leg for edema: No edema
 Inspected toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Inspected legs
 Palpated temporal arteries: No thrill on either side, 2+ on both sides
 Palpated right carotid pulse: No thrill, 2+
 Palpated left carotid pulse: No thrill, 2+
 Palpated left carotid pulse: No thrill, 2+
 Palpated right carotid pulse: No thrill, 2+
 Palpated chest at PMI: Present at midclavicular line and 5th intercostal space, brisk and tapping, diameter 2 cm
 Palpated right brachial pulse: No thrill, 2+
 Palpated left brachial pulse: No thrill, 2+
 Palpated right radial pulse: No thrill, 2+
 Palpated left radial pulse: No thrill, 2+
 Palpated right femoral pulse: No thrill, 2+
 Palpated left femoral pulse: No thrill, 2+
 Palpated right popliteal pulse: No thrill, 2+
 Palpated left popliteal pulse: No thrill, 2+
 Palpated right tibial pulse: No thrill, 1+
 Palpated left tibial pulse: No thrill, 2+
 Palpated right dorsalis pedis pulse: No thrill, 1+
 Palpated left dorsalis pedis pulse: No thrill, 2+
 Auscultated right carotid pulse
 Auscultated left carotid pulse
 Auscultated aortic area with the bell
 Auscultated aortic area with the diaphragm
 Auscultated pulmonic area with the diaphragm
 Auscultated pulmonic area with the bell
 Auscultated Erb’s point with the bell
 Auscultated Erb’s point with the diaphragm
 Auscultated tricuspid area with the diaphragm
 Auscultated tricuspid area with the bell
 Auscultated mitral area with the bell
 Auscultated mitral area with the diaphragm
 Auscultated aorta in abdomen
 Auscultated right renal pulse
 Auscultated left renal pulse
 Auscultated right iliac pulse
 Auscultated left iliac pulse
 Auscultated left femoral pulse
 Auscultated right femoral pulse

Subjective Data Collection: 28 of 28 (100.0%)

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.

Relevant Medical History

Finding:

Asked about heart problems

Finding:

Denies heart problems

(Found)

Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina if she’s had any problems with her heart will allow her to mention any concerns she’s recently had regarding her heart.

Example Question:

Do you experience heart problems?

Finding:

Asked about heartbeat

Finding:

Reports normal heartbeat

(Found)

Pro Tip: Broad questions like this one enable the patient to establish their chief complaint. Asking Tina about her heartbeat will allow her to mention any concerns she’s recently had regarding her heart.

Example Question:

Is your heartbeat regular?

Finding:

Reports normal heart rate

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if her heart rate is normal specifies the way her individual symptoms manifest.

Example Question:

Is your heart rate normal?

Finding:

Denies palpitations

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she has palpitations specifies the way her individual symptoms manifest.

Example Question:

Do you have palpitations?

Finding:

Denies arrhythmia

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she has arrhythmia specifies the way her individual symptoms manifest.

Example Question:

Do you have arrhythmia?

Finding:

Asked about high blood pressure

Finding:

Denies high blood pressure

(Found)

Pro Tip: Cardiovascular disease can manifest in various conditions. Inquiring into Tina’s relevant history can reveal past diagnoses and previous conditions or concerns.

Example Question:

Do you have a history of high blood pressure?

Finding:

Reports last blood pressure check 140 over 80 or 90

(Available)

Pro Tip: Blood pressure might change over time due to such factors as caffeine consumption, stress, diet, and exercise. Asking Tina what her blood pressure was last time it was measured will provide a baseline for comparing her last reading to her blood pressure now.

Example Question:

What was your blood pressure last time you checked?

Finding:

Reports belief that current blood pressure is on the high side of normal range

(Found)

Pro Tip: Hypertension is the most important risk factor for stroke. Soliciting a health history from Tina will allow you to assess her risk of cardiovascular disease.

Example Question:

How is your blood pressure?

Finding:

Asked about heart murmur

Finding:

Denies heart murmur

(Found)

Pro Tip: Some heart murmurs can indicate a damaged or overworked heart valve. Asking Tina whether she’s experienced a heart murmur allows you to assess whether she’s noticed a symptom that indicates a heart condition.

Example Question:

Do you have problems with a heart murmur?

Finding:

Asked about swelling

Finding:

Denies swelling other than foot wound

(Found)

Pro Tip: When the heart weakens and pumps blood less effective, the resulting fluid that accumulates can lead to edema. Asking Tina whether she’s experienced edema allows you to assess if her heart is pumping less effectively.

Example Question:

Have you been experiencing swelling?

Finding:

Asked about blue skin

Finding:

Denies blue skin

(Found)

Pro Tip: Changes in skin color may be indicative of difficulty breathing or differences in oxygen levels in the blood. Asking Tina about blue skin can help you check for larger health issues.

Example Question:

Has your skin ever turned blue?

Finding:

Asked about cardiac tests

Finding:

Denies having a stress test

(Found)

Pro Tip: Inquiring into whether Tina has had a stress test can lead to a discussion about any test results and their implications for her cardiovascular health.

Example Question:

Have you had a stress test?

Finding:

Denies having an echocardiogram

(Found)

Pro Tip: Inquiring into whether Tina has had an echocardiogram can lead to a discussion about any test results and their implications for her cardiovascular health.

Example Question:

Have you had an echocardiogram?

Finding:

Denies having a coronary artery CT scan

(Found)

Pro Tip: Inquiring into whether Tina has had a coronary artery CT scan can lead to a discussion about any test results and their implications for her cardiovascular health.

Example Question:

Have you had a coronary artery CT scan?

Finding:

Asked about cardiac surgeries

Finding:

Denies having a heart catheterization

(Found)

Pro Tip: Knowing if Tina has had a heart catheterization can inform your understanding of her broader cardiovascular health before and after the procedures.

Example Question:

Have you had a heart catheterization?

Finding:

Denies having angioplasty or stent

(Found)

Pro Tip: Knowing if Tina has had an angioplasty or stent can inform your understanding of her broader cardiovascular health before and after the procedures.

Example Question:

Have you had angioplasty?

Finding:

Denies having a pacemaker

(Found)

Pro Tip: Knowing if Tina has had a pacemaker can inform your understanding of her broader cardiovascular health before and after the procedures.

Example Question:

Do you have a pacemaker?

Review of Systems

Finding:

Asked about chest pain

Finding:

Denies chest pain

(Found)

Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina whether she’s had angina can point to such conditions as angina or heart attack, among others.

Example Question:

Do you have problems with chest pain?

Finding:

Denies angina

(Available)

Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina whether she’s had angina can point to such conditions as angina or heart attack, among others.

Example Question:

Have you had problems with angina?

Finding:

Asked about chest tightness

Finding:

Reports chest tightness during asthma exacerbations

(Found)

Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina when she’s had chest tightness can point to such conditions as angina or heart attack, among others.

Example Question:

When do you have chest tightness?

Finding:

Denies current chest tightness

(Available)

Pro Tip: Chest pain manifests in various ways, from a muted ache to a stabbing pain. Asking Tina if she currently has chest tightness can point to such conditions as angina or heart attack, among others.

Example Question:

Do you currently have chest tightness?

Finding:

Asked about breathing problems

Finding:

Reports wheezing

(Available)

Pro Tip: Breathing problems can often cause or be caused by cardiac problems. Asking Tina about whether she wheezes can help you assess whether it may be affecting her cardiovascular system.

Example Question:

Do you ever wheeze?

Finding:

Reports shortness of breath

(Found)

Pro Tip: Breathing problems can often cause or be caused by cardiac problems. Asking Tina about if she has shortness of breath can help you assess whether it may be affecting her cardiovascular system.

Example Question:

Do you ever have shortness of breath?

Finding:

Denies waking at night, unable to breathe

(Available)

Pro Tip: Breathing problems can often cause or be caused by cardiac problems. Asking Tina about waking up at night with difficulty breathing can help you assess whether it may be affecting her cardiovascular system.

Example Question:

Do you wake suddenly with shortness of breath?

Finding:

Denies sleep apnea

(Available)

Pro Tip: Breathing problems can often cause or be caused by cardiac problems. Asking Tina about whether she has sleep apnea can help you assess whether it may be affecting her cardiovascular system.

Example Question:

Do you ever have sleep apnea?

Finding:

Denies difficulty breathing when lying down

(Available)

Pro Tip: Breathing problems can often cause or be caused by cardiac problems. Asking Tina about any difficulty breathing while lying down can help you assess whether it may be affecting her cardiovascular system.

Example Question:

Do you have difficulty breathing when lying down?

Finding:

Denies current breathing problems

(Available)

Pro Tip: Breathing problems can often cause or be caused by cardiac problems. Asking Tina about her current respiratory functioning can help you assess whether it may be affecting her cardiovascular system.

Example Question:

Are you currently having breathing problems?

Finding:

Followed up on breathing problem triggers

Finding:

Reports breathing problems occur during asthma exacerbations

(Available)

Pro Tip: Breathing problems can often cause or be caused by cardiac problems. Asking Tina about her respiratory functioning can help you assess whether it may be affecting her cardiovascular system.

Example Question:

What triggers your breathing problems?

Finding:

Asked about leg cramping

Finding:

Denies leg cramping

(Found)

Pro Tip: Leg cramping can be a sign of peripheral arterial disease. Asking Tina if she has leg cramping solicits relevant history that might be linked to cardiovascular troubles.

Example Question:

Do you have leg cramping?

Risk Factors

Finding:

Asked about mobility

Finding:

Reports being immobile for past three days

(Found)

Pro Tip: Staying immobile for long periods of time can have disastrous effects on the cardiovascular system. Asking Tina how long she’s been immobile solicits information relevant to the health of her heart.

Example Question:

How long have you been immobile?

Finding:

Asked about Venous Thrombosis

Finding:

Denies tender or painful areas other than foot wound

(Available)

Pro Tip: Tender areas can indicate underlying problems with the heart. Asking Tina whether she has unusual tender or painful areas solicits information about her heart history.

Example Question:

Do you have tender areas other than your foot wound?

Finding:

Denies redness other than foot wound

(Available)

Pro Tip: Unusual redness can indicate underlying problems with the heart. Asking Tina whether she has unusual redness solicits information about her heart history.

Example Question:

Do you have unusual redness other than your foot wound?

Finding:

Denies unusual warmth

(Available)

Pro Tip: Unusual warmth can indicate underlying problems with the heart. Asking Tina whether she has unusual warmth solicits information about her heart history.

Example Question:

Do you have unusual warmth anywhere?

Finding:

Denies history of venous thrombosis

(Found)

Pro Tip: Many cardiovascular risk factors have been associated with venous thrombosis. Asking Tina if she has ever had venous thrombosis solicits a relevant history.

Example Question:

Have you ever had venous thrombosis?

Finding:

Asked about cholesterol

Finding:

Denies cholesterol problems

(Found)

Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Tina whether she’s had a history of high cholesterol reveals her recent medical history.

Example Question:

Do you have cholesterol problems?

Finding:

Asked about dietary habits

Finding:

Reports drinking Diet Coke

(Available)

Pro Tip: Dietary intake of excessive sugars or sodium can lead to or exacerbate cardiac problems. Asking Tina about her diet can help you assess the context of her existing cardiovascular health and risk for cardiac disorders.

Example Question:

Do you drink soda?

Finding:

Reports trying to avoid sugar

(Available)

Pro Tip: Dietary intake of excessive sugars or sodium can lead to or exacerbate cardiac problems. Asking Tina about her diet can help you assess the context of her existing cardiovascular health and risk for cardiac disorders.

Example Question:

Do you consume much sugar?

Finding:

Reports not worrying about diet

(Available)

Pro Tip: Dietary intake of excessive sugars or sodium can lead to or exacerbate cardiac problems. Asking Tina about her diet can help you assess the context of her existing cardiovascular health and risk for cardiac disorders.

Example Question:

Is your diet important to you?

Finding:

Asked about perceived weight

Finding:

Reports being overweight for whole life

(Found)

Pro Tip: Weight and body mass are important factors in cardiovascular health. Asking Tina a history of her weight will help you to assess whether her weight is a risk factor for cardiovascular disease.

Example Question:

Have you had problems with your weight?

Finding:

Reports being satisfied with weight

(Found)

Pro Tip: Weight and body mass are important factors in cardiovascular health. Asking Tina how she feels about her current weight will help you determine her receptivity to healthy behaviors and reducing her risk of cardiovascular disease.

Example Question:

How do you feel about your weight?

Finding:

Asked about recent weight change

Finding:

Reports recent weight loss

(Found)

Pro Tip: Weight and body mass are important factors in cardiovascular health. Asking Tina her current weight will help you to assess whether her weight is a risk factor for cardiovascular disease.

Example Question:

Has your weight changed recently?

Finding:

Reports losing about 10 lbs

(Available)

Pro Tip: Weight and body mass are important factors in cardiovascular health. Asking Tina her current weight will help you to assess whether her weight is a risk factor for cardiovascular disease.

Example Question:

How much weight did you lose?

Finding:

Asked about alcohol intake

Finding:

Reports last alcoholic drink was 3 weeks ago

(Available)

Pro Tip: Finding out the last time your patient consumed alcohol gives insight into potential abuse and how it might affect the cardiovascular system.

Example Question:

When was the last time you drank alcohol?

Finding:

Reports no more than 2 or 3 alcoholic drinks in one sitting

(Available)

Pro Tip: Finding out how many alcoholic drinks a patient has in a single day or sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient, including the cardiovascular system.

Example Question:

How many drinks do you have in a sitting?

Finding:

Reports no more than 1 or 2 nights a week drinking alcohol

(Available)

Pro Tip: Finding out how many nights a week your patient drinks alcohol gives insight into potential abuse and how it might affect the cardiovascular system.

Example Question:

How many nights a week do you drink?

Finding:

Asked about illicit drugs

Finding:

Reports history of smoking recreational marijuana

(Available)

Pro Tip: A patient’s use of illicit drugs can affect their cardiovascular health in numerous ways. Asking Tina about her history of marijuana use will help clarify your picture of her cardiac health.

Example Question:

Have you ever smoked marijuana?

Finding:

Denies current use of recreational marijuana

(Found)

Pro Tip: A patient’s use of illicit drugs can affect their cardiovascular health in numerous ways. Asking Tina about any current marijuana use will help clarify your picture of her cardiac health.

Example Question:

Do you currently smoke marijuana?

Finding:

Asked about tobacco use

Finding:

Denies tobacco use

(Found)

Pro Tip: Smoking tobacco can affect a patient’s cardiovascular health in numerous ways. Asking Tina about her use of any tobacco will help clarify your picture of her cardiac health.

Example Question:

Do you use tobacco?

Finding:

Denies vaping

(Available)

Pro Tip: Smoking tobacco can affect a patient’s cardiovascular health in numerous ways. Asking Tina about her use of any tobacco will help clarify your picture of her cardiac health.

Example Question:

Do you vape?

Finding:

Asked about secondhand smoke

Finding:

Denies exposure to secondhand smoke

(Found)

Pro Tip: A person’s exposure to secondhand smoke could be impacting their cardiovascular health in ways they may not recognize. Asking Tina if she is around secondhand smoke informs your understanding of her cardiac health.

Example Question:

Are you exposed to any secondhand smoke?

Relevant Family History

Finding:

Asked family history of high blood pressure

Finding:

Reports mother has high blood pressure

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s mother had hypertension might reveal a genetic predisposition.

Example Question:

Does your mother have hypertension?

Finding:

Reports father had high blood pressure

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s father had hypertension might reveal a genetic predisposition.

Example Question:

Did your father have hypertension?

Finding:

Reports maternal grandfather had high blood pressure

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s maternal grandfather had hypertension might reveal a genetic predisposition.

Example Question:

Did your maternal grandmother have hypertension?

Finding:

Reports paternal grandmother has high blood pressure

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s paternal grandfather had hypertension might reveal a genetic predisposition.

Example Question:

Did your paternal grandfather have hypertension?

Finding:

Reports maternal grandmother had high blood pressure

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s maternal grandmother had hypertension might reveal a genetic predisposition.

Example Question:

Did your maternal grandmother have hypertension?

Finding:

Reports paternal grandmother has high blood pressure

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s paternal grandmother had hypertension might reveal a genetic predisposition.

Example Question:

Did your paternal grandmother have hypertension?

Finding:

Asked family history of high cholesterol

Finding:

Reports mother has high cholesterol

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s mother has high cholesterol might reveal a genetic predisposition.

Example Question:

Does your mother have high cholesterol?

Finding:

Reports father had high cholesterol

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s father has high cholesterol might reveal a genetic predisposition.

Example Question:

Does your father have high cholesterol?

Finding:

Reports maternal grandfather had high cholesterol

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s maternal grandfather had high cholesterol might reveal a genetic predisposition.

Example Question:

Did your maternal grandfather have high cholesterol?

Finding:

Reports paternal grandfather had high cholesterol

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s paternal grandfather had high cholesterol might reveal a genetic predisposition.

Example Question:

Did your paternal grandfather have high cholesterol?

Finding:

Reports maternal grandmother had high cholesterol

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s maternal grandmother had high cholesterol might reveal a genetic predisposition.

Example Question:

Did your maternal grandmother have high cholesterol?

Finding:

Reports paternal grandmother has high cholesterol

(Available)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s paternal grandmother had high cholesterol might reveal a genetic predisposition.

Example Question:

Did your paternal grandmother have high cholesterol?

Finding:

Asked family history of stroke

Finding:

Reports maternal grandmother died of stroke

(Found)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of stroke might reveal her health literacy and predisposition to heart disease.

Example Question:

Does stroke run in your family?

Finding:

Asked about family history of heart attack

Finding:

Reports maternal grandfather died of heart attack

(Found)

Pro Tip: Family histories can suggest genetic predispositions to certain conditions. Asking if Tina’s family has a history of heart attacks might reveal her health literacy and predisposition to heart disease.

Example Question:

Did your maternal grandfather die of a heart attack?

Finding:

Asked about family history of obesity

Finding:

Reports some family members are overweight

Objective Data Collection: 16.67 of 17 (98.06%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed

 Inspected chest

1 of 1 point

 

Symmetry (1/2 point)

  •  Symmetric
  •  Asymmetric

Appearance (1/2 point)

  •  No visible abnormal findings
  •  Prominent pulsation
  •  Abnormal apical impulse
  •  Heaves or lifts

 Inspected for jugular venous distension

1 of 1 point

 

Height Of Venous Pressure (1/1 point)

  •  4 cm or less above the sternal angle
  •  More than 4 cm above the sternal angle

 Inspected hands and fingernails

1 of 1 point

 

Right: Nail Changes (1/3 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing

Left: Nail Changes (1/3 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing

Capillary Refill Time (1/3 point)

  •  3 seconds or less
  •  Greater than 3 seconds

 Inspected lower extremities and toenails

0.67 of 1 point

 

Right: Edema (No point)

  •  No edema
  •  Pitting
  •  Non-pitting

Right: Severity Of Edema (No point)

  •  No edema
  •  1+ Slight pitting
  •  2+ Deeper pit, disappears in 10 to 15 seconds
  •  3+ Noticeably deep pit that lasts more than a minute
  •  4+ Very deep pit that lasts 2 to 5 minutes

Right: Appearance (No point)

  •  No visible abnormal findings
  •  Visible distortion or swelling
  •  Discoloration
  •  Skin thickening
  •  Ulceration
  •  Varicose veins

Right: Nail Changes (1/9 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing

Left: Edema (1/9 point)

  •  No edema
  •  Pitting
  •  Non-pitting

Left: Severity Of Edema (1/9 point)

  •  No edema
  •  1+ Slight pitting
  •  2+ Deeper pit, disappears in 10 to 15 seconds
  •  3+ Noticeably deep pit that lasts more than a minute
  •  4+ Very deep pit that lasts 2 to 5 minutes

Left: Appearance (1/9 point)

  •  No visible abnormal findings
  •  Visible distortion or swelling
  •  Discoloration
  •  Skin thickening
  •  Ulceration
  •  Varicose veins

Left: Nail Changes (1/9 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing

Capillary Refill Time (1/9 point)

  •  3 seconds or less
  •  Greater than 3 seconds

 Palpated temporal arteries

1 of 1 point

 

Vibration (1/2 point)

  •  No thrill in either artery
  •  Thrill in right artery
  •  Thrill in left artery

Amplitude (1/2 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated carotid arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated PMI

1 of 1 point

 

Location (1/3 point)

  •  Present at midclavicular line and 5th intercostal space
  •  Displaced laterally

Amplitude (1/3 point)

  •  Brisk and tapping
  •  Increased amplitude (hyperkinetic)

Diameter (1/3 point)

  •  3 cm or less
  •  Greater than 3 cm

 Palpated radial arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated brachial arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated femoral arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated popliteal arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated tibial arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated dorsalis pedis arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Auscultated carotid arteries

1 of 1 point

 

Right (1/2 point)

  •  No bruit
  •  Bruit

Left (1/2 point)

  •  No bruit
  •  Bruit

 Auscultated heart sounds

1 of 1 point

 

Heart Sounds (1/2 point)

  •  S1 and S2 audible
  •  S1, S2, and S3 audible
  •  S1, S2, and S4 audible
  •  S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

  •  No extra sounds
  •  Gallops
  •  Murmur
  •  Friction rub
  •  Valve clicks

 Auscultated abdominal aorta

1 of 1 point

 

Sounds (1/1 point)

  •  No bruit
  •  Bruit

 Auscultated abdominal arteries

1 of 1 point

 

Right: Renal (1/6 point)

  •  No bruit
  •  Bruit

Right: Iliac (1/6 point)

  •  No bruit
  •  Bruit

Right: Femoral (1/6 point)

  •  No bruit
  •  Bruit

Left: Renal (1/6 point)

  •  No bruit
  •  Bruit

Left: Iliac (1/6 point)

  •  No bruit
  •  Bruit

Left: Femoral (1/6 point)

  •  No bruit
  •  Bruit

 

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Brian Foster Focused Exam: Chest Pain Health Assessment – January 2023

Brian Foster Focused Exam: Chest Pain Health Assessment – January 2023

Transcript

All Lines (144)Interview Questions (48)Statements (2)Exam Actions (94)

Hello!
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation?
Your patient is Brian Foster, a 58-year-old Caucasian man. He has been hospitalized in Shadow General Hospital for 3 days after a TURP, or Transurethral resection of the prostate. Today, he started having chest pain. Your role in this simulation is that of a healthcare provider who will conduct a focused history and physical examination of Mr. Foster in order to assess his condition and transfer his care. While Mr. Foster’s condition is critical, he will survive this exam.
What are my objectives in this assessment?
In your interview with Brian, you will ask about the history of his presenting illness and the functioning of relevant systems in order to obtain subjective data related to his chest pain. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Mr. Foster’s family so you can determine his genetic disposition to any diseases. In addition to collecting subjective data, you will perform a physical exam on Mr. Foster to gather objective data about his health and physiology. Throughout the conversation, you should educate and empathize with Mr. Foster when appropriate to increase his health literacy and sense of well-being. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve?
You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for your colleagues who will attend to the patient. You may record Mr. Foster’s vitals as you see fit, as they will fluctuate throughout the exam. If you believe Mr. Foster to be in danger, you may press the button reading Notify the Preceptor. Do not end the exam until you have collected all relevant subjective and objective data. After the exam, you will transfer care of the patient to me, Preceptor Diana, communicating key information about the Situation, Background, Assessment, and Recommendation, or SBAR. Activities other than Subjective and Objective Data Collection, and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
How will I be evaluated?
In this assignment, you will be evaluated on your Subjective and Objective Data Collection, as well as Education and Empathy. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. This assignment takes on average between 45 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world?
In this assessment, you will become familiarized with the structure and content of a chest pain focused exam so that with real-life patients, you can: º ask effective and comprehensive questions º educate and empathize with the patient º evaluate the patient’s risk of disease, infection, injury, and complications º obtain and assess objective data. º and transfer patient care using SBAR.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What are 3-5 common causes of chest pain?
Inflammation
Time to begin.
Hello, how are you? My name is Nukol I will be your nurse today.
Hi.
What is your name?
Brian Robert Foster.
What brings you here today?
I’m having a really uncomfortable pressure in my chest right now.
I am sorry for that
Thank you.
WHen did the problem start?
Only about five minutes ago.
where is the pain located?
I feel it mostly in the middle of my chest, over my heart. There’s a little bit of ache in my left shoulder, but it’s the chest pain that’s really worrying me.
 Measured vitals
 Tested blood pressure in left arm with cuff
 Tested blood pressure in right arm with cuff
 Measured vitals
how frequent is the chest pain?
It’s the first time. It’s terrible.
How severe is the pain?
It’s really tight and uncomfortable. Maybe like a 6 out of 10.
what are the aggravating factors of the pain?
I don’t really know, I only noticed it a few minutes ago. I tried to get up and walk around the room a little but I think that made it worse.
what are the relieving factors of the pain? (Clarified to What relieves your symptoms?.)
It seems like moving around makes it worse, or at least more noticeable. I felt a little better when I sat down to rest for a few minutes. (Clarified to what relieves my symptoms.)
what relieves the pain?
I’m not sure. I think lying still seems to help a little.
do you have allergies?
No, well…I’ve had a bad reaction to codeine before, but that is all I know of.
do you have any other medical conditions?
Well I thought it was just my prostate, and I hope this chest pain isn’t much of a problem. I take meds for blood pressure and cholesterol too.
do you monitor blood pressure?
Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.
monitoring blood pressure frequently is very important
Sure.
have you had cardiac test?
I’ve had…huh…well, I guess I’ve had the EKG a few times and they give me a stress test every two years or so.
what were the results of the cardiac test?
Everything was normal, they said.
have you taken any medications? (Clarified to Have you taken medication for the pain?.)
No, not yet. (Clarified to if I took medication for the pain.)
have you taken home medications?
Um…I think it’s on the chart, but this morning they gave me Lisinopril, some ibuprofen, some hydrocodone, and, um, the stool softener. Oh, and the Lovenox.
Is the high blood pressure medication helpful? (Clarified to What dose of medication do you take for high high blood pressure?.)
It’s 20 milligrams once a day. (Clarified to what the dosage of my high blood pressure medication is.)
do you use cholesterol medication?
I take Atorvastatin.
how is your access to healthcare?
Yes.
do you have stress?
Honestly, my life is pretty low stress. My job rarely stresses me out, my home life is great, and my kids generally behave. My only stress right now is this chest pain.
do you exercise?
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then…I want to get a new bike after I recover from this surgery.
what is your typical diet?
I think my diet’s alright. My wife says I should do better but I’m a meat man, what can I say.
do you take a lot of fluids? (Clarified to Do you drink a lot of fluids?.)
I usually drink water all day at work. At least a liter, probably more. (Clarified to if I drink a lot of fluids.)
do you use drugs?
Nope.
Do you drink alcohol?
Sure, but never more than two or three beers on a weekend.
How many drinks do you take?
I rarely drink during the week. If I drink at all it’s a couple beers on the weekend while I’m grilling or watching football. Maybe a little bourbon occasionally.
Do you have a family history of chest pain?
Now? In my immediate family? Not that I know of. I don’t think this is a . . . contagious condition.
how is your constitutional health?
I don’t think anything’s wrong besides this chest pain. . .
how is your respiratory system?
My breathing’s fine.
How is your mouth, nose, eyes and ears? (No matching questions found.)
do you have any headache?
I get headaches once in a blue moon, but it’s never anything that has concerned me.
how is your gastrointestinal system?
I think it’s okay.
how is your ears? (Clarified to How is your vision?.)
I think it’s still fine. I’ve never hd to wear glasses. (Clarified to how my vision is.)
how are your ears and nose? (Clarified to Do your ears hurt?.)
No. (Clarified to if I have ear pain.)
how is your cardiovascular system?
I don’t know–I thought fine, but my chest is hurting, so. . .
How is the systems for HEENT?
I think it’s okay.
do you take a lot of fluids? (Clarified to Do you take over the counter medications a lot?.)
I wouldn’t say a lot, no. (Clarified to if I take over the counter medication a lot.)
do you take a lot of fluids? (Clarified to Do you drink a lot of fluids?.)
I usually drink water all day at work. At least a liter, probably more. (Clarified to if I drink a lot of fluids.)
do you have any eye problem?
No, I don’t think so.
do you have any nose problem?
No.
 Inspected face
 Inspected for jugular venous distension: No jugular venous distention; JVP 1 cm above sternal angle
 Inspected anterior chest wall
 Inspected right side chest wall
 Inspected posterior chest wall
 Inspected left side chest wall
 Inspected anterior chest wall
 Inspected left side chest wall
 Inspected posterior chest wall
 Inspected right side chest wall
 Inspected anterior chest wall
 Inspected right hand
 Inspected left hand
 Inspected fingernails of left hand
 Inspected fingernails of right hand
 Inspected right leg
 Inspected left leg
 Inspected toenails on right foot
 Inspected toenails on left foot
 Inspected left leg for edema: No edema
 Inspected right leg for edema: No edema
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in fingernails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Checked capillary refill in toenails
 Palpated left carotid pulse: No thrill, 2+
 Palpated right carotid pulse: No thrill, 2+
 Palpated PMI: Displaced laterally; brisk and tapping; less than 3 cm
 Palpated right brachial pulse: No thrill, 2+
 Palpated left brachial pulse: No thrill, 2+
 Palpated right radial pulse: No thrill, 2+
 Palpated left radial pulse: No thrill, 2+
 Palpated right radial pulse: No thrill, 2+
 Palpated right femoral pulse: No thrill, 2+
 Palpated left femoral pulse: No thrill, 2+
 Palpated right popliteal pulse: No thrill, 2+
 Palpated left popliteal pulse: No thrill, 2+
 Palpated right tibial pulse: No thrill, 1+
 Palpated left tibial pulse: No thrill, 1+
 Palpated right dorsalis pedis pulse: No thrill, 1+
 Palpated left dorsalis pedis pulse: No thrill, 1+
 Auscultated right carotid pulse
 Auscultated left carotid pulse
 Auscultated aortic area with the bell
 Auscultated pulmonic area with the bell
 Auscultated Erb’s point with the bell
 Auscultated Erb’s point with the diaphragm
 Auscultated tricuspid area with the diaphragm
 Auscultated tricuspid area with the bell
 Auscultated mitral area with the bell
 Auscultated mitral area with the diaphragm
 Auscultated aorta in abdomen
 Auscultated right renal pulse
 Auscultated left renal pulse
 Auscultated right iliac pulse
 Auscultated left iliac pulse
 Auscultated right femoral pulse
 Auscultated left femoral pulse
 Auscultated breath sounds in anterior right upper lobe
 Auscultated breath sounds in anterior left upper lobe
 Auscultated breath sounds in anterior right middle lobe
 Auscultated breath sounds in anterior left mid-chest (upper lobe)
 Auscultated breath sounds in anterior right lower lobe
 Auscultated breath sounds in anterior left lower lobe
 Auscultated breath sounds in posterior left upper lobe
 Auscultated breath sounds in posterior right upper lobe
 Auscultated breath sounds in posterior left mid-back (lower lobe)
 Auscultated breath sounds in posterior right mid-back (lower lobe)
 Auscultated breath sounds in posterior left lower lobe
 Auscultated breath sounds in posterior right lower lobe
 Auscultated breath sounds in posterior right lower lobe on side
 Auscultated breath sounds in posterior right lower lobe near spine
 Auscultated breath sounds in posterior left lower lobe near spine
 Auscultated breath sounds in posterior left lower lobe on side
 Performed EKG
What is your recent meal?
My wife brought me some buffalo wings last night around eight.
Do you have any throat problem?
Nope.

 

Subjective Data Collection: 23 of 23 (100.0%)

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 chest pain

(Found)

Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source.

Example Question:

Do you have chest pain?

History of Presenting Illness

Finding:

Asked about onset and duration of chest pain

Finding:

Reports chest pain started about five minutes ago

(Found)

Pro Tip: Establishing the onset of a patient’s chest pain is essential in diagnosing its severity as well as the comfort of the patient.

Example Question:

When did the chest pain start?

Finding:

Reports chest pain has been constant since it began

(Available)

Pro Tip: Knowing the duration of a patient’s pain gives you a more complete picture of its severity and potential impact on the patient’s health.

Example Question:

How long does the chest pain last?

Finding:

Reports sitting in bed when pain began

(Available)

Pro Tip: A patient’s position and posture when their pain began can inform you as to the nature of the pain, as pain upon exertion often has different causes than pain upon resting.

Example Question:

Were you sitting when the pain began?

Finding:

Asked to rate chest pain on a scale

Finding:

Reports current pain is 6/10

(Found)

Pro Tip: For many patients, it is difficult to clearly describe pain. Asking Brian to rate his pain on a scale from 0 to 10 develops a consistent measure of pain severity.

Example Question:

On a scale of 0 to 10 how would you rate the chest pain?

Finding:

Asked about on characteristics of the pain

Finding:

Describes pain as tight and uncomfortable

(Found)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Can you describe your pain?

Finding:

Denies crushing pain

(Available)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Is the pain crushing?

Finding:

Denies gnawing or tearing pain

(Available)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Is the pain gnawing?

Finding:

Denies burning pain

(Available)

Pro Tip: Asking Brian to describe his pain helps identify the cause and the severity of his discomfort. Patients may not know how to answer, so you may need to suggest words like sharp, dull, crushing, gnawing, or burning.

Example Question:

Is the pain burning?

Finding:

Asked about location of the pain

Finding:

Reports pain location is in middle of the chest

(Found)

Pro Tip: Identifying the location of a patient’s pain is essential in determining which body systems are affected, the underlying cause of the pain, and how best to treat it.

Example Question:

Where is the pain?

Finding:

Reports slight pain in left shoulder

(Found)

Pro Tip: Pain radiation is an important symptom that can be helpful in understanding the cause of pain and narrowing the diagnosis.

Example Question:

Does the pain radiate?

Finding:

Denies arm pain

(Available)

Pro Tip: When combined with chest pain, arm pain can be a telling sign that the complaint may be cardiac in nature.

Example Question:

Do you have arm pain?

Finding:

Denies back pain

(Available)

Pro Tip: When combined with chest pain, back pain can be a telling sign that the complaint may be cardiac in nature.

Example Question:

Do you have back pain?

Finding:

Denies jaw pain

(Available)

Pro Tip: When combined with chest pain, jaw pain can be a telling sign that the complaint may be cardiac in nature.

Example Question:

Do you have jaw pain?

Finding:

Denies neck pain

(Available)

Pro Tip: When combined with chest pain, neck pain can be a telling sign that the complaint may be cardiac in nature.

Example Question:

Do you have neck pain?

Finding:

Asked about pain triggers

Finding:

Reports pain is aggravated by exertion

(Found)

Pro Tip: Aggravating factors reveal further information about the nature of the pain and the body systems affected.

Example Question:

What makes the pain worse?

Finding:

Asked about stress and anxiety

Finding:

Reports generally low stress lifestyle

(Found)

Pro Tip: Stress can have a profound effect on the patient’s health and wellness. Asking about stress is an important part of any health assessment.

Example Question:

What is your usual stress level?

Finding:

Denies history of anxiety

(Available)

Pro Tip: Symptoms such as chest pain can be caused or exacerbated by episodes of anxiety. Asking Brian if he’s ever suffered from anxiety can point to underlying stressors or triggers.

Example Question:

Do you have a history of anxiety?

Finding:

Denies history of panic attacks

(Available)

Pro Tip: Symptoms such as chest pain can be caused or exacerbated by episodes of anxiety. Asking Brian if he’s ever had a panic attack can point to underlying stressors or triggers.

Example Question:

Have you ever had a panic attack?

Past Medical History

Finding:

Asked relevant health history

Finding:

Reports high blood pressure

(Found)

Pro Tip: Hypertension is the most important risk factor for stroke. Soliciting a health history from Brian will allow you to assess his risk of cardiovascular disease.

Example Question:

Do you have high blood pressure?

Finding:

Reports high cholesterol

(Found)

Pro Tip: High cholesterol can lead to cardiovascular disease. Asking Brian whether he’s had a history of high cholesterol reveals important details about his cardiovascular health.

Example Question:

Do you have high cholesterol?

Finding:

Denies history of pulmonary embolism

(Available)

Pro Tip: Pulmonary embolism is one of many cardiac risk factors to ask about that can help you form a more complete picture of Brian’s cardiovascular health.

Example Question:

Have you ever had a pulmonary embolism?

Finding:

Denies history of angina

(Available)

Pro Tip: A history of angina can weaken the heart and lead to further cardiovascular complications. Asking Brian about angina helps you understand his overall cardiovascular health.

Example Question:

Do you have a history of angina?

Finding:

Denies history of rheumatic fever

(Available)

Pro Tip: Rheumatic fever early in life can cause fibrosis of the heart valves and can weaken the cardiovascular system. Finding out if Brian has a history of rheumatic fever is crucial to understanding his complete heart health.

Example Question:

Do you have a history of rheumatic fever?

Finding:

Denies history of heart murmur

(Available)

Pro Tip: Heart murmurs can be harmless or a sign of ongoing heart disease. Learning if Brian has a heart murmur is an important component of understanding his complete cardiovascular health.

Example Question:

Do you have a history of heart murmur?

Finding:

Followed up on high blood pressure treatment

Finding:

Reports taking high blood pressure medication

(Found)

Pro Tip: The medication that a patient takes for their high blood pressure will indicate how well controlled their condition is and how well they comply with treatment regimens.

Example Question:

Do you take medication for high blood pressure?

Finding:

Reports high blood pressure medication is Lisinopril

(Available)

Pro Tip: Discovering what specific high blood pressure medication a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions.

Example Question:

What medication do you take for high blood pressure?

Finding:

High blood pressure medication dose is 20mg

(Found)

Pro Tip: The current dose of any patient’s high blood pressure medication is important to learn about because it provides useful information about the patient’s treatment plan as well as potential medication interactions.

Example Question:

What dose of medication do you take for high blood pressure?

Finding:

High blood pressure medication is taken once daily

(Found)

Pro Tip: The frequency with which a patient takes his high blood pressure medications is an essential element of the complete picture of his medication treatment plan.

Example Question:

How frequently do you take medication for high blood pressure?

Finding:

Followed up on high cholesterol treatment

Finding:

Reports taking high cholesterol medication

(Found)

Pro Tip: The medication that a patient takes for their high cholesterol will indicate how well controlled their condition is and how well they comply with treatment regimens.

Example Question:

Do you take medication for cholesterol?

Finding:

Reports high cholesterol medication is Atorvastatin (Lipitor)

(Found)

Pro Tip: Discovering what specific high cholesterol medication a patient takes helps you assess his health conditions, effectiveness of treatment, and guards against unwanted medication interactions.

Example Question:

What medication do you take for cholesterol?

Finding:

Reports high cholesterol medication dose is 20mg

(Available)

Pro Tip: The current dose of any patient’s high cholesterol medication is important to learn about because it provides useful information about the patient’s treatment plan as well as potential medication interactions.

Example Question:

What dose of medication do you take for cholesterol?

Finding:

Reports high cholesterol medication is taken once daily

(Available)

Pro Tip: The frequency with which a patient takes his high cholesterol medications is an essential element of the complete picture of his medication treatment plan.

Example Question:

How frequently do you take medication for cholesterol?

Finding:

Asked history of cardiac tests

Finding:

Reports recent EKG test

(Found)

Pro Tip: An EKG test checks for electrical problems with the heart. Asking Brian whether he’s had an EKG will reveal his recent medical history, cardiac health, and medical literacy.

Example Question:

Have you recently had an EKG test?

Finding:

Reports undergoing a stress test within last two years

(Found)

Pro Tip: A stress test can illustrate the amount of stress a patient’s heart can handle before developing irregular rhythm. Asking Brian if he’s recently had a stress test will indicate a treatment plan, cardiac health, and health literacy.

Example Question:

Have you recently had a stress test?

Finding:

Asked about results of cardiac tests

Finding:

Reports belief that EKG was normal

(Available)

Pro Tip: An EKG test checks for electrical problems with the heart. Asking Brian whether he’s had an EKG will reveal his recent medical history, cardiac health, and medical literacy.

Example Question:

What were the results of your last EKG?

Finding:

Reports belief that stress test was normal

(Available)

Pro Tip: A stress test can illustrate the amount of stress a patient’s heart can handle before developing irregular rhythm. Asking Brian if he’s recently had a stress test will indicate a treatment plan, cardiac health, and health literacy.

Example Question:

What were the results of your last stress test?

Finding:

Asked about substance use

Finding:

Denies illicit drug use

(Found)

Pro Tip: Many drugs affect the central nervous system or can cause cardiovascular complications. Asking Brian if he uses illicit drugs will indicate whether drug use puts him at risk for health complications.

Example Question:

Do you use illicit drugs?

Finding:

Denies tobacco use

(Available)

Pro Tip: Tobacco affects the heart by reducing the amount of oxygen the blood is able to carry. Asking Brian if he uses tobacco will allow you to assess whether the condition is caused, in part, by tobacco use.

Example Question:

Do you use tobacco?

Finding:

Reports moderate alcohol consumption

(Found)

Pro Tip: Chronic alcohol use can result in cardiomyopathy. Asking Brian whether he drinks alcohol will allow you to assess whether he has any indicators of alcoholism.

Example Question:

How much alcohol do you consume?

Finding:

Followed up on alcohol consumption

Finding:

Reports drinking only on weekends

(Found)

Pro Tip: Asking the patient to describe his drinking habits can identify indicators of alcoholism. It may also be helpful to ask about the context and reasons for the patient’s alcohol intake. Heavy drinkers will often underestimate their drinking habits.

Example Question:

How frequently do you drink alcohol?

Finding:

Reports drinking 2-4 alcoholic drinks per week

(Found)

Pro Tip: Consumption of alcohol can impact a patient’s health and is considered a risk factor for many medical conditions. Asking Brian about his drinking habits will help you determine his risk for disease linked to alcohol consumption.

Example Question:

How many alcoholic drinks do you have in a week?

Finding:

Reports 2-3 drinks in a single sitting

(Found)

Pro Tip: Asking the patient to quantify his drinking is helpful because it elicits objective data on a subject that patients may otherwise downplay.

Example Question:

How many alcoholic drinks do you consume at a time?

Finding:

Asked about exercise

Finding:

Denies having a regular exercise routine

(Found)

Pro Tip: Activity levels have an important impact on cardiovascular health. Asking Brian about his exercise patterns can help you understand how his lifestyle might affect his health.

Example Question:

What kind of exercise do you get?

Finding:

Asked about most recent meal

Finding:

Reports most recent meal was previous night at 8 p.m.

(Found)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his most recent meal will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications, and can reveal if the food he ate may be affecting his complaint.

Example Question:

What time was your last meal?

Finding:

Reports meal consisted of buffalo wings

(Found)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his most recent meal will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications, and can reveal if the food he ate may be affecting his complaint.

Example Question:

What did you eat last night?

Finding:

Asked about typical diet

Finding:

Reports typical breakfast is granola bar and instant breakfast shake

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his typical breakfast will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications.

Example Question:

What is a typical breakfast for you?

Finding:

Reports typical lunch is turkey sub

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his typical lunch will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications.

Example Question:

What is a typical lunch for you?

Finding:

Reports typical dinner is grilled meat and vegetables

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Asking Brian about his typical dinner will allow you to assess whether his eating habits put him at risk of cardiovascular disease or other health complications.

Example Question:

What is a typical dinner for you?

Finding:

Denies moderating salt intake

(Available)

Pro Tip: A healthy and balanced diet is crucial for maintaining good health. Salt intake in particular can have a detrimental effect on blood pressure, which is why it is important to ask a patient like Brian, who suffers from hypertension, about his salt consumption.

Example Question:

Do you moderate your salt intake?

Review of Systems

Finding:

Asked about review of cardiovascular system

Finding:

Denies palpitations

(Available)

Pro Tip: Discovering palpitations can be an important clue into the patient’s cardiovascular history and current condition.

Example Question:

Do you have palpitations?

Finding:

Denies swelling

(Available)

Pro Tip: Swelling can be a major indicator of cardiovascular and peripheral vascular health. Asking the patient about swelling is an important part of a thorough cardio exam.

Example Question:

Do you have any swelling?

Finding:

Denies circulation problems

(Available)

Pro Tip: Circulation is an important indicator of peripheral vascular and cardiovascular health. Asking Brian about his circulation can help diagnose vascular conditions.

Example Question:

Do you have any problems with circulation?

Finding:

Denies blood clots

(Available)

Pro Tip: Blood clots can be a sign of serious cardiovascular or related illnesses. Asking Brian about blood clots can provide valuable information about the state of his health.

Example Question:

Have you ever had a blood clot?

Finding:

Denies easy bleeding

(Available)

Pro Tip: Bleeding can be a sign of serious cardiovascular or related illnesses. Asking Brian about bleeding can provide valuable information about the state of his cardiovascular health.

Example Question:

Have you noticed any unusual bleeding?

Finding:

Denies easy bruising

(Available)

Pro Tip: Ease of bruising can be a sign of serious cardiovascular or related illnesses. Asking Brian about bruising can provide valuable information about the state of his cardiovascular health.

Example Question:

Have you noticed any unusual bruising?

Finding:

Asked about constitutional health

Finding:

Denies fever

(Available)

Pro Tip: Fever can signify infection and other complications, so it is important to determine the presence of a fever and treat it if there is.

Example Question:

Do you have a fever?

Finding:

Denies chills

(Available)

Pro Tip: Chills can be a sign of circulation issues, fever, and more. Discovering a patient’s chills will reveal more about the cause of his complaint.

Example Question:

Do you have chills?

Finding:

Denies fatigue

(Available)

Pro Tip: Fatigue can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Do you feel tired?

Finding:

Denies sleep issues

(Available)

Pro Tip: Sleep issues can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Have you had problems sleeping?

Finding:

Denies recent weight changes

(Available)

Pro Tip: Weight changes can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Has your weight changed?

Finding:

Denies night sweats

(Available)

Pro Tip: Night sweats can be an indicator of serious cardiovascular problems, and it is important to ask the patient about it in order to narrow your diagnosis.

Example Question:

Do you have night sweats?

Finding:

Denies dizziness or lightheadedness

(Available)

Pro Tip: Patients exhibiting dizziness may be at risk for several conditions as well as a fall risk. It is important to ask about dizziness to keep your patient safe.

Example Question:

Do you have dizziness?

Finding:

Asked about review of respiratory system

Finding:

Denies cough

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. A cough in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have a cough?

Finding:

Denies shortness of breath while lying down

(Found)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the respiratory system. Orthopnea in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have difficulty breathing when lying down?

Finding:

Denies blue skin

(Available)

Pro Tip: Cyanosis can be a symptom of troubling cardiovascular illness, though patients may not be aware of its connection to respiratory health. Asking Brian if he has noticed any cyanosis is important in ruling out certain cardiac risk factors.

Example Question:

Has your skin ever turned blue?

Finding:

Asked about throat problems

Finding:

Denies sore throat

(Found)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the throat. A sore throat in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have a sore throat?

Finding:

Denies difficulty swallowing

(Found)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the throat. Painful or difficult swallowing in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have difficulty swallowing?

Finding:

Asked about review of gastrointestinal system

Finding:

Denies diarrhea

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Diarrhea in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have diarrhea?

Finding:

Denies constipation

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Constipation in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have constipation?

Finding:

Denies flatus

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Excessive gas in a patient complaining of chest pain is a symptom worth investigating.

Example Question:

Do you have flatulence?

Finding:

Denies bloating

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. A patient complaining of bloating in addition to chest pain is a symptom worth investigating.

Example Question:

Do you have bloating?

Finding:

Denies heartburn or GERD

(Available)

Pro Tip: The cardiovascular system is inextricably balanced with many other body systems, including the gastrointestinal system. Heartburn and GERD are of particular importance to ask about, since their symptoms closely follow the symptoms of cardiac pain.

Example Question:

Do you have heartburn or GERD?

Finding:

Reports earlier nausea

(Available)

Pro Tip: Nausea can be an urgent symptom and sign of distress in more than one body symptom. Assessing and treating a patient’s nausea is important in a cardiovascular exam.

Example Question:

Do you have nausea?

Finding:

Denies vomiting

(Available)

Pro Tip: Vomiting can be a major indicator of multiple health problems. Asking the patient about vomiting is an important part of a thorough cardio exam.

Example Question:

Have you vomited recently?

Family History

Finding:

Asked relevant family history

Finding:

Reports family history of heart attack

(Available)

Pro Tip: Family health history is an important genetic indicator of a patient’s predisposition to certain medical conditions. Asking Brian if anyone in his family has suffered a heart attack helps you develop a more complete picture of his cardiovascular health.

Example Question:

Has anyone in your family had a heart attack?

Finding:

Denies family history of stroke

(Available)

Pro Tip: Family health history is an important genetic indicator of a patient’s predisposition to certain medical conditions. Asking Brian if anyone in his family has suffered a stroke helps you develop a more complete picture of his cardiovascular health.

Example Question:

Do you have a family history of stroke?

Finding:

Denies family history of pulmonary embolism

Objective Data Collection: 21 of 21 (100%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed

 Inspected face

1 of 1 point

 

Appearance (1/1 point)

  •  No visible abnormal findings
  •  Rash or lesion
  •  Cyanosis
  •  Pallor
  •  Redness or flushing
  •  Evidence of trauma (scar, laceration, or bruising)

 Inspected for jugular venous distension

1 of 1 point

 

Height Of Venous Pressure (1/1 point)

  •  4 cm or less above the sternal angle
  •  More than 4 cm above the sternal angle

 Inspected chest

1 of 1 point

 

Symmetry (1/2 point)

  •  Symmetric
  •  Asymmetric

Appearance (1/2 point)

  •  No visible abnormal findings
  •  Rash or lesion
  •  AP diameter abnormal
  •  Intercostal retraction while breathing
  •  Excessive use of accessory muscles while breathing
  •  Pectus excavatum
  •  Skin growths (freckles or moles)
  •  Evidence of skin trauma (scar, laceration, or bruising)

 Inspected hands and fingernails

1 of 1 point

 

Right: Appearance (1/4 point)

  •  No visible abnormal findings
  •  Redness
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Rash

Left: Appearance (1/4 point)

  •  No visible abnormal findings
  •  Redness
  •  Moles or skin tags
  •  Masses (warts, cysts, or tumors)
  •  Freckles, birthmark, or other discoloration
  •  Excessive dry or flaking skin
  •  Purpura
  •  Scarring
  •  Laceration, lesion, or wound
  •  Bruising
  •  Rash

Right: Nail Changes (1/4 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing

Left: Nail Changes (1/4 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing

 Inspected lower extremities and toenails

1 of 1 point

 

Right: Appearance (1/4 point)

  •  No visible abnormal findings
  •  Visible distortion or swelling
  •  Brownish pigmentation
  •  Skin thickening
  •  Ulceration
  •  Varicose veins

Right: Nail Changes (1/4 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing

Left: Appearance (1/4 point)

  •  No visible abnormal findings
  •  Visible distortion or swelling
  •  Brownish pigmentation
  •  Skin thickening
  •  Ulceration
  •  Varicose veins

Left: Nail Changes (1/4 point)

  •  No visible abnormal findings
  •  Pallor
  •  Cyanosis
  •  Splinter hemorrhages
  •  Clubbing

 Inspect lower extremities for edema

1 of 1 point

 

Right: Edema (1/4 point)

  •  No edema
  •  Pitting
  •  Non-pitting

Right: Severity Of Edema (1/4 point)

  •  No edema
  •  1+ Slight pitting
  •  2+ Deeper pit, disappears in 10 to 15 seconds
  •  3+ Noticeably deep pit that lasts more than a minute
  •  4+ Very deep pit that lasts 2 to 5 minutes

Left: Edema (1/4 point)

  •  No edema
  •  Pitting
  •  Non-pitting

Left: Severity Of Edema (1/4 point)

  •  No edema
  •  1+ Slight pitting
  •  2+ Deeper pit, disappears in 10 to 15 seconds
  •  3+ Noticeably deep pit that lasts more than a minute
  •  4+ Very deep pit that lasts 2 to 5 minutes

 Tested capillary refill time

1 of 1 point

 

Fingers (1/2 point)

  •  Less than 3 seconds
  •  Greater than 3 seconds

Toes (1/2 point)

  •  Less than 3 seconds
  •  Greater than 3 seconds

 Palpated carotid arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated PMI

1 of 1 point

 

Location (1/3 point)

  •  Present at midclavicular line and 5th intercostal space
  •  Displaced laterally

Diameter (1/3 point)

  •  Less than 3 cm
  •  Greater than 3 cm

Amplitude (1/3 point)

  •  Brisk and tapping
  •  Increased amplitude (hyperkinetic)

 Palpated brachial arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated radial arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated femoral arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated popliteal arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated tibial arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Palpated dorsalis pedis arteries

1 of 1 point

 

Right: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Right: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

Left: Vibration (1/4 point)

  •  No thrill
  •  Thrill

Left: Amplitude (1/4 point)

  •  0 Absent
  •  1+ Diminished or barely palpable
  •  2+ Expected
  •  3+ Increased
  •  4+ Bounding pulse

 Auscultated carotid arteries

1 of 1 point

 

Right (1/2 point)

  •  No bruit
  •  Bruit

Left (1/2 point)

  •  No bruit
  •  Bruit

 Auscultated heart sounds

1 of 1 point

 

Heart Sounds (1/2 point)

  •  S1 and S2 audible
  •  S1, S2, and S3 audible
  •  S1, S2, and S4 audible
  •  S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

  •  No extra sounds
  •  Gallops
  •  Murmur
  •  Friction rub
  •  Valve clicks

 Auscultated abdominal aorta

1 of 1 point

 

Sounds (1/1 point)

  •  No bruit
  •  Bruit

 Auscultated abdominal and lower extremity arteries

1 of 1 point

 

Right: Renal (1/6 point)

  •  No bruit
  •  Bruit

Right: Iliac (1/6 point)

  •  No bruit
  •  Bruit

Right: Femoral (1/6 point)

  •  No bruit
  •  Bruit

Left: Renal (1/6 point)

  •  No bruit
  •  Bruit

Left: Iliac (1/6 point)

  •  No bruit
  •  Bruit

Left: Femoral (1/6 point)

  •  No bruit
  •  Bruit

 Auscultated breath sounds

1 of 1 point

 

Breath Sounds (1/3 point)

  •  Present in all areas
  •  Diminished in some areas
  •  Absent in some areas

Adventitious Sounds (1/3 point)

  •  No adventitious sounds
  •  Wheezing
  •  Fine crackles
  •  Stridor
  •  Rhonchi
  •  Rales

Location (1/3 point)

  •  All areas clear
  •  Adventitious sounds in anterior right upper lobe
  •  Adventitious sounds in anterior right middle lobe
  •  Adventitious sounds in anterior right lower lobe
  •  Adventitious sounds in anterior left upper lobe
  •  Adventitious sounds in anterior left lower lobe
  •  Adventitious sounds in posterior right upper lobe
  •  Adventitious sounds in posterior right lower lobe
  •  Adventitious sounds in posterior left upper lobe
  •  Adventitious sounds in posterior left lower lobe

 Performed EKG

1 of 1 point

 

Sinus Rhythm (1/2 point)

  •  Regular
  •  Irregular

St Changes (1/2 point)

  •  No ST elevation
  •  ST elevation present

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

 1 Family Medical History

Not Encountered

 

 Description: Mr. Foster shares his emotions over his family history of illness and death.
 Model Statement: “Thank you for telling me about your family’s health. It’s clear you care for your family and hate to see them suffer, especially as it indicates your own risk factors. This medical history will help us develop a care plan for your own health.”

 2 Exercise

Not Followed Up

 

 Description: Mr. Foster reports that he does not exercise regularly.
do you exercise?
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then…I want to get a new bike after I recover from this surgery.
what is your typical diet?
 Model Statement: “Exercise can lead to health improvements for everyone, and is helpful for people with high blood pressure and cholesterol. We can help you consider some healthy forms of exercise that you might be interested in trying.”

 3 Pain and Discomfort

Followed Up

 

 Description: Mr. Foster describes the symptoms that have been distressing him.
WHen did the problem start?
Only about five minutes ago.
where is the pain located?
I feel it mostly in the middle of my chest, over my heart. There’s a little bit of ache in my left shoulder, but it’s the chest pain that’s really worrying me.
how frequent is the chest pain?
It’s the first time. It’s terrible.
How severe is the pain?
It’s really tight and uncomfortable. Maybe like a 6 out of 10.
what are the aggravating factors of the pain?
I don’t really know, I only noticed it a few minutes ago. I tried to get up and walk around the room a little but I think that made it worse.
what are the relieving factors of the pain? (Clarified to: What relieves your symptoms?)
It seems like moving around makes it worse, or at least more noticeable. I felt a little better when I sat down to rest for a few minutes. (Clarified to: what relieves my symptoms)
what relieves the pain?
I’m not sure. I think lying still seems to help a little.
do you have allergies?
No, well…I’ve had a bad reaction to codeine before, but that is all I know of.
do you have any other medical conditions?
Well I thought it was just my prostate, and I hope this chest pain isn’t much of a problem. I take meds for blood pressure and cholesterol too.
do you monitor blood pressure?
Not usually. They check it when I get checkups. My doctor has never seemed overly concerned about it.
monitoring blood pressure frequently is very important
Sure.
 Model Statement: “I share your concern for these symptoms, and I’m sorry you’re under so much discomfort and stress. We’re going to assess what’s going on so we can develop a quick and appropriate treatment plan.”

 4 Nutrition

Not Followed Up

 

 Description: Mr. Foster describes his dietary habits and reveals gaps in nutrition.
What is your recent meal?
My wife brought me some buffalo wings last night around eight.
Do you have any throat problem? Question
05:27 AM MST
Nope.
 Model Statement: “Because your diet can impact your health in many ways, it’s best to eat veggies, fruits, and whole grains, and lean proteins like fish or chicken. Reducing your intake of red meat, refined sugars, and fried foods could help increase your overall well-being.”

 

 

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Tina Jones – Respiratory Results Health Assessment – January 2023

Tina Jones – Respiratory Results Health Assessment – January 2023

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Transcript

Started: Feb 17, 2023 | Total Time: 44 min

All Lines (104)Interview Questions (39)Statements (0)Exam Actions (65)

Hello!
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation?
It’s noon on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full respiratory exam on Ms. Jones given her history of asthma.
What are my objectives in this assessment?
In your interview with Ms. Jones, you will ask about her respiratory system and identify any risk factors so that you can determine any current and potential issues. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to the respiratory system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her respiratory system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ respiratory system to gather objective data about the system’s health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve?
You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
How will I be evaluated?
In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 40 and 50 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world?
In this assessment, you will become familiarized with the structure and content of respiratory exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Based on your current knowledge, explain the pathophysiology of asthma.
airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness.
Time to begin.
Hi, my name is Nukol. I will be your nurse today? (No matching questions found.)
Hi, my name is Nukol. I will be your nurse today (Clarified to Hello, and I’ll be taking care of you today..)
Hi. (Clarified to to say hello and that you will be taking care of me.)
My name is Nukol
Hey, I’m Tina Jones. [AUDIO COMING SOON]
What brings you here today
I came in last night because of my foot. It just wasn’t healing, and it’s been hurting.
How can I help you today?
I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!
Do you have any respiratory issue?
My breathing’s fine right now, but I do have asthma.
How severe is the asthma?
I haven’t had a full attack in years, but I have trouble breathing sometimes.
When was the last asthma exacerbation?
I was at my cousin’s house three days ago, and my asthma acted up while I was there because of her cats.
What triggers the asthma?
Being around cats is the worst, but dust and running up stairs can make my breathing bad, too.
how do you manage your asthma?
I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
Do you take asthma medication?
I just use my inhaler.
Do you use inhalers?
Yeah, I use it when my asthma acts up.
What are the exacerbation symptoms?
Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though.
How is your breathing?
My breathing is okay right now.
Do you have any cough?
I don’t have a cough, no.
Do you have sputum?
I haven’t been coughing anything up or anything.
do you have any other respiratory illness? (Clarified to Do you have a history of respiratory illnesses besides asthma?.)
No, just the asthma. (Clarified to If I have a history of respiratory illnesses besides asthma.)
When were you diagnosed with asthma?
My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.
Have you seen an asthma specialist?
I saw Dr. DeWitt for my asthma starting when I was diagnosed, but she moved away about two years ago.
have you ever been hospitalized?
Well, before this I went to the hospital a bunch of times when I was little, for asthma attacks. This is the first time I’ve been in the hospital since I was probably sixteen, though.
Do you have allergies?
Yeah, I’m allergic to cats.
Have taken any allergy treatment?
I’ve just been given an inhaler is all.
do you smoke tobacco?
No. I think it’s gross.
how many puffs do you take when using inhaler?
I usually use two puffs from my albuterol inhaler, but sometimes I need three. I think it’s 90 mcg per puff. [AUDIO COMING SOON]
Do you cough during asthma exacerbation?
No, I don’t cough when it’s happening.
Do you have any allergy symptoms? (Clarified to Do you have other allergy symptoms?.)
My allergies mostly just act up around cats. I start sneezing, my eyes get itchy. . . and my asthma starts to go crazy. (Clarified to if I have any other allergy symptoms.)
Do you use marijuana?
Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
Are you exposed to secondhand smoke?
Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes.
When did you last smoke?
I haven’t smoked pot since I was twenty or twenty-one.
Do you have a family history of asthma?
My baby sister has asthma like me, but she’s pretty healthy. She almost never has trouble with it.
Do you have a family history of respiratory illness?
My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think.
Do you have family history of tobacco use?
No, nobody at home smokes.
Do you have a family history of lung cancer?
Nobody in my family has had lung cancer and, Lord willing, no one ever will. [AUDIO COMING SOON]
 Checked vitals
 Tested lung capacity with spirometer
 Inspected anterior chest wall
 Inspected left side chest wall
 Inspected posterior chest wall
 Inspected right side chest wall
 Inspected anterior chest wall
 Inspected right side chest wall
 Inspected posterior chest wall
 Inspected left side chest wall
 Inspected anterior chest wall
 Palpated chest expansion: Both sides rise symmetrically
 Palpated fremitus in anterior upper chest wall: Present and equal bilaterally
Ninety-nine.
 Palpated fremitus in anterior lower chest wall: Present and equal bilaterally
 Palpated fremitus in posterior upper chest wall: Present and equal bilaterally
Ninety-nine.
 Palpated fremitus in posterior middle chest wall: Present and equal bilaterally
 Palpated fremitus in posterior lower chest wall: Present and equal bilaterally
Ninety-nine.
 Percussed anterior right upper lobe
 Percussed anterior left upper lobe
 Percussed anterior left mid-chest (upper lobe)
 Percussed anterior right middle lobe
 Percussed anterior right lower lobe
 Percussed anterior left lower lobe
 Percussed posterior left upper lobe
 Percussed posterior right upper lobe
 Percussed posterior left mid-back (lower lobe)
 Percussed posterior right mid-back (lower lobe)
 Percussed posterior left lower lobe
 Percussed posterior right lower lobe
 Percussed posterior left lower lobe on side
 Percussed posterior left lower lobe near spine
 Percussed posterior right lower lobe near spine
 Percussed posterior right lower lobe on side
 Auscultated breath sounds in anterior right upper lobe
 Auscultated breath sounds in anterior left upper lobe
 Auscultated breath sounds in anterior right middle lobe
 Auscultated breath sounds in anterior left mid-chest (upper lobe)
 Auscultated breath sounds in anterior right lower lobe
 Auscultated breath sounds in anterior left lower lobe
 Auscultated breath sounds in posterior left upper lobe
 Auscultated breath sounds in posterior right upper lobe
 Auscultated breath sounds in posterior left mid-back (lower lobe)
 Auscultated breath sounds in posterior right mid-back (lower lobe)
 Auscultated breath sounds in posterior left lower lobe
 Auscultated breath sounds in posterior right lower lobe
 Auscultated breath sounds in posterior left lower lobe on side
 Auscultated breath sounds in posterior left lower lobe near spine
 Auscultated breath sounds in posterior right lower lobe near spine
 Auscultated breath sounds in posterior right lower lobe on side
 Auscultated voice sounds in anterior right upper lobe
 Auscultated voice sounds in anterior left upper lobe
 Auscultated voice sounds in anterior right middle lobe
 Auscultated voice sounds in anterior left mid-chest (upper lobe)
 Auscultated voice sounds in anterior left lower lobe
 Auscultated voice sounds in anterior right lower lobe
 Auscultated voice sounds in posterior left upper lobe
 Auscultated voice sounds in posterior right upper lobe
 Auscultated voice sounds in posterior left mid-back (lower lobe)
 Auscultated voice sounds in posterior left lower lobe
Ninety-nine.
 Auscultated voice sounds in posterior right mid-back (lower lobe)
 Auscultated voice sounds in posterior right lower lobe
 Auscultated voice sounds in posterior right lower lobe on side
 Auscultated voice sounds in posterior right lower lobe near spine
 Auscultated voice sounds in posterior left lower lobe near spine
 Auscultated voice sounds in posterior left lower lobe on side
Ninety-nine.

Subjective Data Collection: 27 of 27 (100.0%)

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:

Asked about asthma

Finding:

Reports having asthma

(Found)

Pro Tip: Asking whether Tina has had asthma will elicit information regarding any previous respiratory diagnosis.

Example Question:

Do you have asthma?

Finding:

Reports asthma exacerbations

(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 asthma attacks?

Relevant Medical History

Finding:

Asked about severity of asthma

Finding:

Reports asthma is intermittent

(Found)

Pro Tip: Establishing the severity classification of Tina’s asthma is important for understanding the impact on her life and the functioning of her respiratory system, as well as assessing the appropriateness of her medication.

Example Question:

What is the severity of your asthma?

Finding:

Asked about asthma frequency and duration

Finding:

Reports asthma exacerbations occur up to 2 times a week

(Found)

Pro Tip: Establishing a timeline for how often Tina’s asthma attacks occur will help in treatment and in understanding the severity of her asthma.

Example Question:

How many times a week do you have an asthma attack?

Finding:

Reports asthma exacerbations last around five minutes

(Available)

Pro Tip: Establishing a timeline for how long Tina’s asthma attacks last will help in treatment and in understanding the severity of her asthma.

Example Question:

How long do your asthma attacks last?

Finding:

Asked about most recent asthma exacerbation

Finding:

Reports last exacerbation was three days ago

(Found)

Pro Tip: Establishing a timeline for Tina’s asthma attacks will help in treatment and in understanding the severity of her asthma.

Example Question:

When is the last time you had an asthma attack?

Finding:

Reports last exacerbation around cats at cousin’s house

(Found)

Pro Tip: Questions about what factors might have caused an illness can point to a patient’s environmental stressors, habits, and general wellbeing. Asking Tina what caused her asthma attacks might indicate her health literacy and understanding of what factors impact her breathing.

Example Question:

What caused your last asthma attack?

Finding:

Asked about asthma triggers

Finding:

Reports cat allergy as asthma trigger

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such trigger.

Example Question:

Do cats trigger your asthma?

Finding:

Reports dust as asthma trigger

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such trigger.

Example Question:

Does dust trigger your asthma?

Finding:

Denies asthma problems at work

(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:

Does anything at work make your asthma worse?

Finding:

Denies asthma problems at home

(Available)

Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at home might indicate a relevant factor in her recent exacerbation.

Example Question:

Have you had problems with your asthma at home?

Finding:

Asked about asthma management

Finding:

Reports inhaler

(Found)

Pro Tip: Tina’s response to a question about asthma management 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 manage your asthma?

Finding:

Asked about asthma medication

Finding:

Reports albuterol inhaler (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:

Reports last inhaler use was three days ago

(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 using inhaler no more than 2 times per week

(Available)

Pro Tip: After an asthma exacerbation, patients often will become more reliant on medical tools like inhalers. Asking Tina how many times a week she uses her inhaler will point to the severity of her recent exacerbation.

Example Question:

How many times a week are you using your inhaler?

Finding:

Asked about number of puffs when using asthma inhaler

Finding:

Reports recommended dose is 1-3 puffs as needed

(Found)

Pro Tip: Tina’s response to a question about asthma medicine dosing will reveal the severity of her symptoms, her health literacy, and the way she’s complied with her treatment plans.

Example Question:

What is the recommended dose of your asthma medication?

Finding:

Reports typically taking 2 puffs

(Found)

Pro Tip: Tina’s response to a question about asthma medicine dosing will reveal the severity of her symptoms, her health literacy, and the way she’s complied with her treatment plans.

Example Question:

How many puffs do you normally take?

Finding:

Reports sometimes needing 3 puffs to control symptoms

(Found)

Pro Tip: Tina’s response to a question about asthma medicine dosing will reveal the severity of her symptoms, her health literacy, and the way she’s complied with her treatment plans.

Example Question:

What is the most puffs you ever take?

Finding:

Asked about exacerbation symptoms

Finding:

Reports chest tightness during exacerbation

(Available)

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s had chest tightness since exacerbation can indicate the severity of her symptoms since exacerbation.

Example Question:

Have you had chest tightness?

Finding:

Reports wheezing during exacerbation

(Available)

Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she’s been wheezing illustrates how her asthma is presenting.

Example Question:

Have you been wheezing?

Finding:

Reports shortness of breath during exacerbation

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences shortness of breath during an attack will indicate how her individual symptoms manifest.

Example Question:

Do you have shortness of breath during an asthma attack?

Finding:

Denies coughing during exacerbation

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences coughing during an attack will indicate how her individual symptoms manifest.

Example Question:

Do you cough during an asthma attack?

Finding:

Denies chest pain during exacerbation

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences chest pain during an attack will indicate how her individual symptoms manifest.

Example Question:

Do you have chest pains when you have asthma attacks?

Finding:

Denies painful breathing

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences painful breathing during an attack will indicate how her individual symptoms manifest.

Example Question:

Is it painful for you to breathe?

Finding:

Asked about current breathing

Finding:

Denies current breathing problems

(Found)

Pro Tip: Asking about how Tina is currently breathing can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns or conditions.

Example Question:

Are you having breathing problems now?

Review of Systems

Finding:

Asked about cough history

Finding:

Reports only coughing when she has a cold

(Available)

Pro Tip: When a cough occurs can be indicative of its cause. Asking Tina when she coughs will allow you to determine the reason behind it and what treatment plans are appropriate.

Example Question:

When are you coughing?

Finding:

Denies coughing up blood

(Found)

Pro Tip: Coughing up blood can be indicative of a major health concern. Asking Tina if she has been coughing up blood solicits an important health history.

Example Question:

Have you been coughing up blood?

Finding:

Asked about sputum

Finding:

Denies sputum

(Found)

Pro Tip: Asthma symptoms may vary from one attack to the next. Determining which other symptoms Tina has experienced since exacerbation will more specifically illustrate the ways in which Tina’s asthma manifests.

Example Question:

Are you coughing up phlegm or sputum?

Risk Factors

Finding:

Asked about respiratory illness history besides asthma

Finding:

Denies history of bronchitis

(Available)

Pro Tip: Asking whether Tina has had bronchitis will elicit information regarding any previous respiratory diagnosis.

Example Question:

Have you had bronchitis?

Finding:

Denies history of pneumonia

(Available)

Pro Tip: Asking whether Tina has had pneumonia will elicit information regarding any previous respiratory diagnosis.

Example Question:

Have you had pneumonia?

Finding:

Denies history of emphysema

(Found)

Pro Tip: Asking whether Tina has had emphysema will elicit information regarding any previous respiratory diagnosis.

Example Question:

Have you had emphysema?

Finding:

Followed up on asthma diagnosis

Finding:

Reports specific age of diagnosis is 2.5 years old

(Found)

Pro Tip: By determining the onset of asthma you can get a sense for Tina’s asthma history, instance, and frequency of exacerbation.

Example Question:

When were you diagnosed with asthma?

Finding:

Asked about seeing an asthma specialist

Finding:

Reports not seeing asthma doctor in two years

(Found)

Pro Tip: Seeing a specialist, like an asthma doctor, can help patients to manage symptoms. Asking when Tina last saw an asthma doctor will allow you to assess her current treatment plan and healthcare access.

Example Question:

When did you last see a doctor for asthma?

Finding:

Asked about past hospitalizations

Finding:

Reports past hospitalizations for asthma

(Found)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina if she’s been hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

Have you been hospitalized for asthma in the past?

Finding:

Reports five past hospitalizations for asthma

(Available)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina how many times she was hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

How many times have you been hospitalized for asthma?

Finding:

Reports most recent hospitalization at age 16

(Found)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina when she was last hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

When was your most recent hospitalization for asthma?

Finding:

Reports hospital treatment was usually steroids and a nebulizer

(Available)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina how she was treated when she was hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

How were you treated at the hospital for asthma?

Finding:

Asked about general allergies

Finding:

Reports allergy to cats

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such trigger.

Example Question:

Are you allergic to cats?

Finding:

Followed up on allergy symptoms

Finding:

Reports sneezing, itchy eyes, and wheezing

(Found)

Pro Tip: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening.

Example Question:

What are your allergy symptoms?

Finding:

Asked about allergy treatment

Finding:

Reports avoiding cats when possible

(Available)

Pro Tip: Tina’s response to a question about avoiding allergy triggers will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Do you stay away from cats?

Finding:

Reports using inhaler

(Found)

Pro Tip: Tina’s response to a question about recent allergy management 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 cat allergy?

Finding:

Reports showering

(Available)

Pro Tip: Tina’s response to a question about recent allergy management 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 cat allergy?

Finding:

Asked about tobacco use

Finding:

Denies currently smoking tobacco

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she currently smokes can help you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.

Example Question:

Do you use tobacco products?

Finding:

Denies history of smoking tobacco

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she has a history of smoking can help you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.

Example Question:

Have you ever used tobacco?

Finding:

Denies vaping

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she vapes can help you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.

Example Question:

Do you vape?

Finding:

Asked about marijuana use

Finding:

Reports past recreational marijuana smoking

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked marijuana can help you to discern whether smoking was an exacerbating factor for Tina’s asthma.

Example Question:

Have you ever smoked marijuana?

Finding:

Followed up on marijuana

Finding:

Reports smoking marijuana for 5 or 6 years

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina how long she smoked marijuana can help you to discern whether smoking exacerbated Tina’s asthma.

Example Question:

How long did you smoke marijuana?

Finding:

Reports stopped smoking marijuana 6 or 7 years ago

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina when she quit smoking marijuana can help you to discern whether smoking exacerbated Tina’s asthma.

Example Question:

When did you stop smoking marijuana?

Finding:

Reports stopping because of health reasons and waning interest

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina why she quit smoking marijuana can help you to discern whether smoking exacerbated Tina’s asthma.

Example Question:

Why did you stop smoking marijuana?

Finding:

Asked about secondhand smoke

Finding:

Denies secondhand smoke exposure

(Found)

Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking how often Tina is around people who smoke might indicate a proximate environmental trigger.

Example Question:

Are you exposed to secondhand smoke?

Relevant Family History

Finding:

Asked about family history of asthma

Finding:

Reports sister has asthma

(Found)

Pro Tip: Soliciting a family history helps you to determine which, if any, conditions are inherited. In asking Tina whether anyone in her family has asthma, you’re ascertaining whether Tina’s condition is inherited.

Example Question:

Does anyone else in your family have asthma?

Finding:

Asked about family history of other respiratory illness

Finding:

Denies family history of respiratory illness

(Found)

Pro Tip: People with a family history of respiratory illness are often at a higher risk for asthma. If Tina has a family history of respiratory illness, this could suggest inherited sensitivity.

Example Question:

Does respiratory illness run in your family?

Finding:

Asked about family tobacco use

Finding:

Denies family history of tobacco use

(Found)

Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking whether anyone in Tina’s household smokes might indicate a proximate environmental trigger.

Example Question:

Does anyone in your family use tobacco products?

Finding:

Asked about family history of lung cancer

Finding:

Denies family history of lung cancer

Objective Data Collection: 6 of 6 (100%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed

 Inspected chest

1 of 1 point

 

Symmetry (1/2 point)

  •  Symmetric
  •  Asymmetric

Appearance (1/2 point)

  •  No visible abnormal findings
  •  Rash or lesion
  •  AP diameter abnormal
  •  Intercostal retraction while breathing
  •  Excessive use of accessory muscles while breathing
  •  Pectus excavatum
  •  Evidence of trauma (scar, laceration, or bruising)

 Palpated chest expansion

1 of 1 point

 

Symmetry (1/1 point)

  •  Equal bilaterally
  •  Unequal bilaterally

 Palpated tactile fremitus

1 of 1 point

 

Symmetry (1/2 point)

  •  Equal bilaterally
  •  Unequal bilaterally

Vibration (1/2 point)

  •  Expected fremitus
  •  Decreased fremitus
  •  Absent fremitus

 Percussed chest wall

1 of 1 point

 

Observations (1/2 point)

  •  All areas resonant
  •  Some areas of dullness

Location (1/2 point)

  •  No areas of dullness
  •  Dullness, anterior right upper lobe
  •  Dullness, anterior right middle lobe
  •  Dullness, anterior right lower lobe
  •  Dullness, anterior left upper lobe
  •  Dullness, anterior left lower lobe
  •  Dullness, posterior right upper lobe
  •  Dullness, posterior right lower lobe
  •  Dullness, posterior left upper lobe
  •  Dullness, posterior left lower lobe

 Auscultated breath sounds

1 of 1 point

 

Breath Sounds (1/3 point)

  •  Present in all areas
  •  Diminished in some areas
  •  Absent in some areas

Adventitious Sounds (1/3 point)

  •  No adventitious sounds
  •  Wheezing
  •  Fine crackles
  •  Stridor
  •  Rhonchi
  •  Rales

Location (1/3 point)

  •  All areas clear
  •  Adventitious sounds in anterior right upper lobe
  •  Adventitious sounds in anterior right middle lobe
  •  Adventitious sounds in anterior right lower lobe
  •  Adventitious sounds in anterior left upper lobe
  •  Adventitious sounds in anterior left lower lobe
  •  Adventitious sounds in posterior right upper lobe
  •  Adventitious sounds in posterior right lower lobe
  •  Adventitious sounds in posterior left upper lobe
  •  Adventitious sounds in posterior left lower lobe

 Auscultated for bronchophony

1 of 1 point

 

Bronchophony (1/1 point)

  •  Positive
  •  Negative

Documentation / Electronic Health Record

  • Flowsheets
  • Nursing Progress Notes

Vitals

Vitals 22:00 00:00 02:00 04:00 06:00 08:00 10:00 12:00
Temp (<38° C) 38.7 C / 101.7 F 39.1 C / 102.4 F 38.6 C / 101.5 F 37.9 C / 100.2 F 37.1 C / 98.8 F 36.7 C / 98.1 F 37 C / 98.6 F 36.7 C
BP (<120/80) 138/90 138/88 136/88 138/90 134/88 138/90 136/88
HR (60-100) 90 72 68 69 70 68 70
RR (12-20) 18 16 16 18 18 16 18
O2 Sat (>94%) 98% 98% 98% 98% 98% 98% 98%
Pain Scale 10 7 asleep asleep 9 6 8 6
Pain Reassessment after Intervention 7

@23:00

asleep 5

@07:00

4

@11:00

4
FVC 1.78 L
FEV1

 

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Danny Rivera Focused Exam: Cough Results – Health Assessment – January 2023

Danny Rivera Focused Exam: Cough Results – Health Assessment – January 2023

Transcript

All Lines (141)Interview Questions (37)Statements (2)Exam Actions (102)

Hello!
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation?
Your patient is Danny Rivera, an 8-year-old Puerto Rican boy presenting with a cough in the Shadowville Elementary nurse’s office. Your role in this simulation is that of a healthcare provider who will perform a focused history and physical examination in order to collect data, assess Danny’s condition, and transfer care. In this simulation, you will be able to perform procedures not always typical to a school setting so you can gather as much data as possible.
What are my objectives in this assessment?
Danny is very health literate and a good historian of his own health history; he can answer questions that not every child may be able to. In your interview with Danny, you will ask about the history of his presenting illness and the functioning of relevant systems in order to obtain subjective data related to his cough. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Danny’s family so you can determine his genetic predisposition to any diseases. In addition to collecting subjective data, you will perform a physical exam on Danny to gather objective data about his health and physiology. Throughout the conversation, you should educate and empathize with Danny when appropriate to increase his health literacy and sense of well-being. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve?
Because Danny is a pediatric patient, you will also be required to make a phone call to his guardian’s home to gather additional information. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. After the exam, you will transfer care of the patient to me, Preceptor Diana, communicating key information about the Situation, Background, Assessment, and Recommendation, or SBAR. Activities other than Subjective and Objective Data Collection, and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
How will I be evaluated?
In this assignment, you will be evaluated on your Subjective and Objective Data Collection, as well as Education and Empathy. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. This assignment takes on average between 40 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world?
In this assessment, you will become familiarized with the structure and content of a cough focused exam so that with real-life patients, you can: º ask effective and comprehensive questions º educate and empathize with the patient º evaluate the patient’s risk of disease, infection, injury, and complications º obtain and assess objective data. º and transfer patient care using SBAR.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What strategies can you use to develop rapport with a pediatric patient?
Being friendly to the patient by being an active listener, repeating what the patient said and showing the patient you understand what they mean.
Time to begin.
 Washed hands.
Hello, my name is Nukol. I will be your nurse today.
Hi.
What brings you here today?
My music teacher Mr. Hillman sent me here because he said I look sick. I have been coughing a lot. . . and I feel kinda tired.
I am sorry to hear that
Thanks.
When did the cough start?
I think the cough started two . . . No, it started three days ago.
How frequent is the cough?
I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.
What is the characteristics of the cough?
My cough seems kind of gurgly and watery.
What aggravates the cough?
I don’t think anything makes my cough be worse.
What relieves the cough?
My mom gave me some medicine this morning. . . that helped my cough a little. I don’t remember what it was called though, sorry.
What are the nasal symptoms?
My nose is runny. It’s runny a lot of the time.
Do you have nasal discharge?
My nose is always a little bit runny. . .but ever since I started coughing it’s been worse, I think.
what colour is the nasal discharge?
You mean like when I blow my nose? It’s clear.
Do you have any ear discharge?
No, nothing comes out of my ears.
Do you have any ear pain?
My ears are okay. They don’t hurt or anything.
Do you have throat problem?
My throat is a little bit sore, but just a little bit.
Do you have any allergies?
I don’t think I have any allergies.
Have you sort any medication? (Clarified to Do you have medical problems?.)
Oh, well, I have been sick before and I’m sick now . . . I had pneumonia once. Last year. My mom was really scared. She says I used to get earaches a lot too. (Clarified to if I have medical problems.)
Have you taken any medication?
My mom gave me some medicine this morning. . . that helped my cough a little. I don’t remember what it was called though, sorry.
What colour was the medicine?
Um, it was purple-ish. It tasted gross.
Have you taken any home medications? (Clarified to Have you taken medicine for your cough?.)
My mom gave me some medicine this morning. . . that helped my cough a little. I don’t remember what it was called though, sorry. (Clarified to if I have taken medicine for my cough.)
Do you have any medical history?
Oh, well, I have been sick before and I’m sick now . . . I had pneumonia once. Last year. My mom was really scared. She says I used to get earaches a lot too.
Are you exposed to secondhand smoke?
Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it’s not all the time or anything. I don’t like how it smells, and I don’t like that he is hurting himself. He could get sick.
Secondhand smoke exposure can be harmful to you
OK.
How is your living condition?
My cough seems kind of gurgly and watery.
Where do you live?
I live in Shadowville.
do you have breathing problem?
I breathe OK, but my nose is always kinda runny.
Have you exposed yourself to germs? (No matching questions found.)
Were you exposed to germs?
Um… no… [AUDIO COMING SOON]
Do you wash hands frequently?
Not a lot. I only wash them if they’re really dirty, or Abuela says we’re about to eat.
How is your cough etiquette?
My cough seems kind of gurgly and watery.
Do you cover your mouth while coughing? (Clarified to Do you cover your mouth when you cough?.)
When I cough, I like to let it all out. (Clarified to if I cover my mouth when I cough.)
Did you play with an ill child?
Cindy was coughing when she was at my house the other day. But she still beat me at checkers.
Do you take vitamins?
Oh yeah, I take vitamins every day! The gummy dinosaur kind. I don’t think I’m supposed to, but sometimes I sneak extra ones to be super healthy!
Do you play in school? (Clarified to Do you do a lot of playing?.)
I don’t play any sports on a team, but Tony and I play outside. We like to skateboard and shoot hoops. (Clarified to if I do a lot of playing.)
Any relevant family history?
My mom’s got diabetes, cholesterol, and high blood pressure. Papi talks about his cholesterol sometimes, and he smokes cigars. I know that’s bad, especially because mom says he had asthma when he was little. Probably my age. Uch, it sounds like a lot when I say it altogether like that. . .
 Measured blood pressure
 Measured heart rate
 Measured pulse oximetry
 Measured respiratory rate
 Measured temperature
 Tested lung capacity with spirometer: FEV1: 1.549 L, FVC 1.78 L (FEV1/FVC: 87%)
 Inspected right orbital area and sclera
 Inspected left orbital area and sclera
 Inspected upper conjunctiva
 Inspected lower conjunctiva
 Performed otoscopic examination of right ear
 Performed otoscopic examination of left ear
 Performed otoscopic examination of right naris
 Performed otoscopic examination of left naris
 Inspected mouth
 Inspected front of neck
 Inspected left side of neck
 Inspected front of neck
 Inspected right side of neck
 Inspected back of neck
 Inspected left side of neck
 Inspected back of neck
 Inspected right side of neck
 Inspected front of neck
 Inspected anterior chest wall
 Inspected posterior chest wall
 Inspected anterior chest wall
 Palpated frontal sinuses: No tenderness reported
 Palpated frontal sinuses: No tenderness reported
 Palpated maxillary sinuses: No tenderness reported
 Palpated lymph nodes of head and neck: Enlarged and reported tenderness on the right side
 Palpated supraclavicular lymph nodes: Not palpable
 Palpated axillary lymph nodes: Not palpable
 Palpated supraclavicular lymph nodes: Not palpable
 Palpated fremitus in anterior upper chest wall: Present and equal bilaterally
Ninety-nine.
 Palpated fremitus in anterior lower chest wall: Present and equal bilaterally
Ninety-nine.
 Palpated fremitus in posterior upper chest wall: Present and equal bilaterally
Ninety-nine.
 Palpated fremitus in posterior middle chest wall: Present and equal bilaterally
Ninety-nine.
 Palpated fremitus in posterior lower chest wall: Present and equal bilaterally
Ninety-nine.
 Palpated chest expansion: Both sides rise symmetrically
 Auscultated breath sounds in anterior right upper lobe
 Auscultated breath sounds in anterior left upper lobe
 Auscultated breath sounds in anterior right upper lobe
 Auscultated breath sounds in anterior left middle lobe
 Auscultated breath sounds in anterior right middle lobe
 Auscultated breath sounds in anterior left middle lobe
 Auscultated breath sounds in anterior right lower lobe
 Auscultated breath sounds in anterior left lower lobe
 Auscultated breath sounds in posterior left upper lobe
 Auscultated breath sounds in posterior right upper lobe
 Auscultated breath sounds in posterior left mid-back (lower lobe)
 Auscultated breath sounds in posterior right mid-back (lower lobe)
 Auscultated breath sounds in posterior left lower lobe near spine
 Auscultated breath sounds in posterior right lower lobe near spine
 Auscultated breath sounds in posterior left lower lobe on side
 Auscultated breath sounds in posterior left lower lobe
 Auscultated breath sounds in posterior right lower lobe
 Auscultated breath sounds in posterior right lower lobe on side
 Auscultated voice sounds in anterior right upper lobe
 Auscultated voice sounds in anterior left upper lobe
 Auscultated voice sounds in anterior right upper lobe
 Auscultated voice sounds in anterior left mid-chest (upper lobe)
Ninety-nine.
Ninety-nine.
 Auscultated voice sounds in anterior right middle lobe
 Auscultated voice sounds in anterior left mid-chest (upper lobe)
 Auscultated voice sounds in anterior left lower lobe
 Auscultated voice sounds in anterior right lower lobe
 Auscultated voice sounds in posterior left upper lobe
Ninety-nine.
 Auscultated voice sounds in posterior right upper lobe
 Auscultated voice sounds in posterior left mid-back (lower lobe)
 Auscultated voice sounds in posterior right mid-back (lower lobe)
Ninety-nine.
Ninety-nine.
 Auscultated voice sounds in posterior right lower lobe near spine
Ninety-nine.
 Auscultated voice sounds in posterior left lower lobe near spine
Ninety-nine.
 Auscultated voice sounds in posterior left lower lobe on side
 Auscultated voice sounds in posterior left lower lobe
Ninety-nine.
 Auscultated voice sounds in posterior right lower lobe
Ninety-nine.
 Auscultated voice sounds in posterior right lower lobe on side
Ninety-nine.
 Auscultated aortic area with the bell
 Auscultated pulmonic area with the bell
 Auscultated pulmonic area with the diaphragm
 Auscultated Erb’s point with the diaphragm
 Auscultated tricuspid area with the diaphragm
 Auscultated tricuspid area with the bell
 Auscultated mitral area with the bell
 Auscultated mitral area with the diaphragm
 Percussed anterior right upper lobe
 Percussed anterior left upper lobe
 Percussed anterior right middle lobe
 Percussed anterior left mid-chest (upper lobe)
 Percussed anterior right lower lobe
 Percussed anterior left lower lobe
 Percussed posterior left upper lobe
 Percussed posterior right upper lobe
 Percussed posterior left mid-back (lower lobe)
 Percussed posterior right mid-back (lower lobe)
 Percussed posterior left lower lobe
 Percussed posterior right lower lobe
 Percussed posterior left lower lobe on side
 Percussed posterior left lower lobe near spine
 Percussed posterior right lower lobe near spine
 Percussed posterior left right lobe on side
 Measured diaphragmatic excursion: 3 cm

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Subjective Data Collection: 22 of 22 (100.0%)

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 cough

(Found)

Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source.

Example Question:

Do you have a cough?

History of Presenting Illness

 

Finding:

Asked about onset of cough

 

Finding:

Reports cough started 3 days ago

(Found)

Pro Tip: Whenever you are assessing a symptom or a health condition, in this case the patient’s cough, inquiring about onset assesses the severity and the progression of the problem.

Example Question:

How long have you had a cough?

 

Finding:

Asked about characteristics of cough

 

Finding:

Reports cough is wet

(Found)

Pro Tip: The characteristics of a cough, such as whether it is dry or wet, can indicate key information about the type of illness the patient has.

Example Question:

Is your cough a wet cough?

 

Finding:

Reports clear sputum with cough

(Found)

Pro Tip: The characteristics of a cough, such as whether it is productive, can indicate key information about the type of illness the patient has.

Example Question:

Do you produce any phlegm or sputum with your cough?

 

Finding:

Asked about frequency and duration of cough

 

Finding:

Reports coughing every few minutes

(Found)

Pro Tip: Establishing how frequently Danny coughs will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

How frequently are you coughing?

 

Finding:

Reports coughs last a few seconds

(Available)

Pro Tip: Establishing how long Danny’s coughs last will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

How long do your coughs last?

 

Finding:

Asked about aggravating factors for cough

 

Finding:

Reports cough is worse at night

(Found)

Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.

Example Question:

Is the cough worse at night?

 

Finding:

Denies smoking

(Available)

Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking even young patients about whether they consume tobacco products helps you assess this risk factor.

Example Question:

Do you smoke?

 

Finding:

Reports being exposed to secondhand smoke through father

(Found)

Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking about whether a patient is exposed to secondhand smoke allows you to assess this risk factor.

Example Question:

Are you ever around cigarette smoke?

 

Finding:

Reports he doesn’t know what triggers the cough

(Found)

Pro Tip: Asking about aggravating factors of Danny’s cough will allow you to determine potential causes and educate the patient on what to avoid.

Example Question:

What makes your cough worse?

 

Finding:

Asked about exposure to germs

 

Finding:

Reports playing with an ill classmate

(Found)

Pro Tip: Asking about Danny’s exposure to illnesses will allow you to counsel him on effective hygiene, as well as potentially determine the cause of his current symptoms.

Example Question:

Have you come in contact with anyone sick?

 

Finding:

Asked about hand hygiene

 

Finding:

Reports infrequent hand washing

(Found)

Pro Tip: Asking about Danny’s hand washing practices will allow you to counsel him on effective hygiene.

Example Question:

How often do you wash your hands?

 

Finding:

Reports occasionally putting fingers in eyes, nose, or mouth

(Available)

Pro Tip: Asking about Danny’s hand washing practices will allow you to counsel him on effective hygiene.

Example Question:

Do you ever touch your eyes, nose, or mouth?

 

Finding:

Asked about cough etiquette

 

Finding:

Denies covering mouth when coughing

(Found)

Pro Tip: Asking about Danny’s cough etiquette will allow you to counsel him on effective hygiene and reduce the risk of him infecting other people.

Example Question:

Do you cover your mouth when you cough?

 

Finding:

Asked about relieving factors for cough

 

Finding:

Reports cough is temporarily relieved by cough medicine

(Found)

Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.

Example Question:

Have you done anything to treat your cough?

 

Finding:

Followed up on cough medicine

 

Finding:

Reports cough medicine was purple

(Found)

Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the cough medicine’s color may help you identify the type of medication it is.

Example Question:

What color was the cough medicine?

 

Finding:

Reports taking one spoonful of cough medicine

(Available)

Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the dose of cough medicine allows you to determine whether it is being taken correctly.

Example Question:

How much medicine did you take?

 

Finding:

Reports mother gave him the medicine

(Found)

Pro Tip: Children should only take medication under the supervision of an adult who can assure it is taken as directed. You should ask younger patients whether the medicine was given to them and by whom.

Example Question:

Who gave you the medicine for your cough?

 

Finding:

Reports only took the medicine this morning

(Found)

Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the frequency Danny took cough medicine allows you to determine whether it is being taken correctly.

Example Question:

How many times have you taken the cough medicine?

 

Finding:

Denies home remedies

(Available)

Pro Tip: Patients sometimes try non-medicinal home remedies to treat coughs, such as breathing steam, or drinking tea with honey. Not all home remedies are effective or advisable, so it’s important to find out what remedies the patient has tried.

Example Question:

Have you tried any home remedies for your cough?

 

Finding:

Asked about typical medication use

 

Finding:

Denies taking medication

(Available)

Pro Tip: Knowing a patient’s current medication regimen helps you determine if any future treatments will be safe and effective.

Example Question:

Do you take any medications from a doctor?

 

Finding:

Reports taking daily vitamin

(Found)

Pro Tip: Some symptoms can occur as a result of a vitamin deficiency, and others as a result of vitamin excess. Vitamins can also interfere with some treatments, so it’s important to know what your patient is taking.

Example Question:

Do you take vitamins?

 

Finding:

Asked about activity level

 

Finding:

Reports typical high activity level

(Found)

Pro Tip: Establishing a patient’s typical activity level is an important baseline to help you determine how an illness is affecting his life.

Example Question:

Are you usually active?

 

Finding:

Reports activity level low since getting sick

(Available)

Pro Tip: Establishing a patient’s activity level, and whether it has been impacted since becoming ill, is an important baseline to help you determine how an illness is affecting his life.

Example Question:

Have you been less active since getting sick?

 

Finding:

Reports still able to run or play

(Available)

Pro Tip: Ability to remain active indicates that the patient’s breathing is not dangerously affected, and that the patient isn’t seriously fatigued.

Example Question:

Are you able to keep up when you play with your classmates?

 

Finding:

Reports focusing in class is difficult

(Available)

Pro Tip: Mental lethargy and difficulty concentrating are common symptoms when a patient is sick.

Example Question:

Are you able to focus in class?

 

Finding:

Asked about nasal symptoms

 

Finding:

Reports current runny nose

(Found)

Pro Tip: Asking your patient if his nose is running will allow you to determine the symptoms he is experiencing and possible triggers.

Example Question:

Do you currently have a runny nose?

 

Finding:

Denies sneezing

(Available)

Pro Tip: Asking your patient if he has been sneezing will allow you to determine the symptoms he is experiencing and possible triggers.

Example Question:

Have you been sneezing?

 

Finding:

Followed up on nasal discharge

 

Finding:

Reports nasal discharge is clear

(Found)

Pro Tip: The color of a patient’s nasal discharge can provide you key information as to the type of condition the patient has.

Example Question:

What color is your snot?

 

Finding:

Reports nasal discharge is thin

(Available)

Pro Tip: The consistency of a patient’s nasal discharge can provide you key information as to the type of condition the patient has.

Example Question:

What is the consistency of your nasal discharge?

 

Finding:

Asked about ear symptoms

 

Finding:

Denies ear pain

(Found)

Pro Tip: Ear pain is often coincident with coughs and sinus problems. Asking about them allows you to ascertain if Danny needs follow-up care for his ears.

Example Question:

Do you have any ear pain?

 

Finding:

Reports history of frequent ear infections

(Found)

Pro Tip: Asking about Danny’s history of ear infections allows you to ascertain his risk for current and future ear infections.

Example Question:

Have you ever had ear infections?

 

Finding:

Denies ear discharge

(Found)

Pro Tip: Asking Danny about ear discharge, which are often coincident with of ear infections, allows you to ascertain his risk for current and future ear infections.

Example Question:

Do you have any ear discharge?

 

Finding:

Denies hearing problems

(Available)

Pro Tip: Simply talking with the patient assesses his hearing; however, some types of hearing loss are only apparent in specific settings such as noisy environments. Asking the patient about hearing problems identifies conditions that may not be readily apparent.

Example Question:

Do you have any hearing problems?

 

Finding:

Asked about throat symptoms

 

Finding:

Reports sore throat

(Found)

Pro Tip: Sore throats are often coincident with coughs and sinus problems. Asking about them allows you to ascertain if Danny needs follow-up care for his throat.

Example Question:

Is your throat sore?

 

Finding:

Reports a little pain with swallowing

(Available)

Pro Tip: Pain when swallowing helps you understand how severe the patient’s sore throat is.

Example Question:

Does it hurt when you swallow?

Past Medical History

 

Finding:

Asked about relevant medical history

 

Finding:

Reports frequent runny noses

(Found)

Pro Tip: Asking how often Danny experiences runny noses like the one he has now may help you determine the source of the problem.

Example Question:

Do you get runny noses often?

 

Finding:

Reports past frequent coughs

(Available)

Pro Tip: A patient experiencing a cough should be asked about their history of coughs so you can determine whether their current condition fits into a recurring pattern.

Example Question:

Do you have coughs very often?

 

Finding:

Reports past pneumonia

(Found)

Pro Tip: Pneumonia is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.

Example Question:

Have you had pneumonia?

 

Finding:

Denies asthma diagnosis

(Available)

Pro Tip: Asthma is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.

Example Question:

Do you have asthma?

 

Finding:

Reports immunizations as current

(Available)

Pro Tip: A health assessment should include an evaluation of the patient’s immunization status in order to identify diseases to which the patient is vulnerable.

Example Question:

Do you have current immunizations?

 

Finding:

Asked about allergies

 

Finding:

Denies seasonal allergies

(Found)

Pro Tip: Seasonal allergies can cause symptoms like runny nose, cough, and discomfort. Asking Danny if he has seasonal allergies can help you to ascertain possible triggers for symptoms.

Example Question:

Do you have seasonal allergies?

 

Finding:

Denies food allergies

(Found)

Pro Tip: Knowing if your patient has food allergies is important and relevant medical history. Asking your patient about food allergies will allow you to most effectively treat him.

Example Question:

Do you have food allergies?

 

Finding:

Denies medication allergies

(Found)

Pro Tip: Knowing if your patient has allergies to medicine is important and relevant medical history. Asking your patient about medicine allergies will allow you to most effectively treat him.

Example Question:

Are you allergic to any medication?

 

Finding:

Asked relevant family history

 

Finding:

Reports father has history of asthma

(Found)

Pro Tip: Medical problems such as asthma that are present in a patient’s immediate family can represent increased risk factors to respiratory conditions such as the ones the patient currently has.

Example Question:

Do you have a family history of asthma?

 

Finding:

Denies family history of allergies

(Available)

Pro Tip: Medical problems such as allergies that are present in a patient’s immediate family can represent increased risk factors to respiratory conditions such as the ones the patient currently has.

Example Question:

Do you have a family history of allergies?

Review of Systems

 

Finding:

Asked about constitutional health

 

Finding:

Denies chills

(Available)

Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has chills will illustrate the way his symptoms manifest.

Example Question:

Do you have chills?

 

Finding:

Denies fever

(Available)

Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has a fever will illustrate the way his symptoms manifest.

Example Question:

Do you have a fever?

 

Finding:

Reports feeling somewhat fatigued

(Found)

Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has fatigue will illustrate the way his symptoms manifest.

Example Question:

Do you have fatigue?

 

Finding:

Denies night sweats

(Available)

Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has night sweats will illustrate the way his symptoms manifest.

Example Question:

Do you have night sweats?

 

Finding:

Reports cough makes it difficult to sleep

(Available)

Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has had difficulty sleeping will illustrate the way his symptoms manifest.

Example Question:

Have you been sleeping okay?

 

Finding:

Denies swelling

(Available)

Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has had swelling will illustrate the way his symptoms manifest.

Example Question:

Have you noticed any swelling?

 

Finding:

Asked about additional review of systems for HEENT

 

Finding:

Reports frequent colds

(Available)

Pro Tip: A patient such as Danny who is presenting with a cough and a runny nose may have a cold, so you should ask about his history of colds to determine whether this is part of a larger pattern.

Example Question:

Do you have unusually frequent colds?

 

Finding:

Denies headaches

(Available)

Pro Tip: Headaches are a common complaint that can be caused by a variety of benign conditions. However, headaches can be an indicator of serious underlying neurological conditions such as cerebral hemorrhage, meningitis, or brain tumors. They may also be a symptom of sinus infection.

Example Question:

Do you get headaches?

 

Finding:

Denies nosebleeds

(Found)

Pro Tip: When a patient presents with symptoms that are often seen with respiratory infections, you should ask about similar signs of respiratory infections such as nosebleeds.

Example Question:

Do you have nosebleeds?

 

Finding:

Denies vision difficulty

(Available)

Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.

Example Question:

Do you have any problems with your vision?

 

Finding:

Denies dizziness

(Available)

Pro Tip: Asking about dizziness helps you assess the risk for inner ear, neurological, or cardiovascular problems.

Example Question:

Do you have any dizziness?

 

Finding:

Denies watery eyes

(Available)

Pro Tip: Whether a patient has watery eyes may help you indicate the type of sinus problem he is experiencing.

Example Question:

Do you have watery eyes?

 

Finding:

Denies eye redness

(Available)

Pro Tip: Whether a patient has eye redness may help you indicate the type of sinus problem he is experiencing.

Example Question:

Do you have eye redness?

 

Finding:

Denies eye pain

(Available)

Pro Tip: Eye pain can lower one’s ability to function and can be a major safety risk.

Example Question:

Do you have any eye pain?

 

Finding:

Denies sinus pain

(Available)

Pro Tip: Patients with sinus problems such as a runny nose may be at greater risk for sinus pain.

Example Question:

Do you have any sinus pain?

 

Finding:

Asked about review of systems for respiratory

 

Finding:

Denies chest tightness

(Available)

Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest tightness is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.

Example Question:

Do you have chest tightness?

 

Finding:

Denies chest pain

(Available)

Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest pain is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.

Example Question:

Do you have any chest pain?

 

Finding:

Denies difficulty breathing

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Objective Data Collection: 15 of 15 (100%)

Correct

Partially correct

Incorrect

Missed

 Inspected eyes and orbital area

1 of 1 point

 

Orbital Area (1/4 point)

No visible abnormal findings

Ptosis

Eyelid

Lesion

Sclera (1/4 point)

White

Yellow tint

Redness

Conjunctiva (1/4 point)

Moist and pink

Dry appearance

Redness

Swelling

Conjunctival Discharge (1/4 point)

No discharge

Clear, watery discharge

Purulent discharge

 Inspected nasal cavities

1 of 1 point

 

Color (1/4 point)

Pink

Red

Bluish

Discharge (1/4 point)

No discharge

Clear discharge

Bloody discharge

Purulent discharge

Turbinate Patency (1/4 point)

Patent

Decreased patency

Not patent

Observations (1/4 point)

No additional visible abnormal findings

Foreign body present

Polyp

Septum perforated

Septum deviated

Lesion

 Inspected ears

1 of 1 point

 

Right: Auditory Canal Color (1/10 point)

Pink

Red

Pallor

Right: Tympanic Membrane Color (1/10 point)

Pearly gray

Red

Opaque

Yellow

Not visible because of cerumen

Right: Tympanic Membrane Appearance (1/10 point)

No visible abnormal findings

Fluid observed

Visible scars

Bulging

Perforation

Retraction

Right: Cone Of Light (1/10 point)

5:00

Cone of light distorted

Right: Discharge (1/10 point)

No discharge

Cerumen

Clear discharge

Bloody discharge

Purulent discharge

Left: Auditory Canal Color (1/10 point)

Pink

Red

Pallor

Left: Tympanic Membrane Color (1/10 point)

Pearly gray

Red

Opaque

Yellow

Not visible because of cerumen

Left: Tympanic Membrane Appearance (1/10 point)

No visible abnormal findings

Fluid observed

Visible scars

Bulging

Perforation

Retraction

Left: Cone Of Light (1/10 point)

7:00

Cone of light distorted

Left: Discharge (1/10 point)

No discharge

Cerumen

Clear discharge

Bloody discharge

Purulent discharge

 Inspected mouth and throat

1 of 1 point

 

Oral Mucosa (1/5 point)

Moist and pink

Dry appearance

Redness

Tonsils (1/5 point)

No visible abnormal findings

Swelling

Redness

Throat Color (1/5 point)

Pink

Red

Throat Texture (1/5 point)

No abnormal findings

Cobblestoning

Exudate

Post Nasal Drip (1/5 point)

No discharge

Clear discharge

Purulent discharge

 Inspected neck

1 of 1 point

 

Symmetry (1/2 point)

Symmetric

Asymmetric

Appearance (1/2 point)

No visible abnormal findings

Swelling

Visible pulsation

Visible mass

Discoloration

 Inspected chest

1 of 1 point

 

Symmetry (1/2 point)

Symmetric

Asymmetric

Appearance (1/2 point)

No visible abnormal findings

Rash

Barrel chest

Intercostal retraction while breathing

Excessive use of accessory muscles while breathing

Skin growths (freckles or moles)

 Auscultated breath sounds

1 of 1 point

 

Breath Sounds (1/3 point)

Present in all areas

Diminished in some areas

Absent in some areas

Adventitious Sounds (1/3 point)

No adventitious sounds

Wheezing

Fine crackles

Stridor

Rhonchi

Rales

Location (1/3 point)

All areas clear

Adventitious sounds in anterior right upper lobe

Adventitious sounds in anterior right middle lobe

Adventitious sounds in anterior right lower lobe

Adventitious sounds in anterior left upper lobe

Adventitious sounds in anterior left lower lobe

Adventitious sounds in posterior right upper lobe

Adventitious sounds in posterior right lower lobe

Adventitious sounds in posterior left upper lobe

Adventitious sounds in posterior left lower lobe

 Auscultated for bronchophony

1 of 1 point

 

Bronchophony (1/1 point)

Positive

Negative

 Auscultated heart sounds

1 of 1 point

 

Heart Sounds (1/2 point)

S1 and S2 audible

S1, S2, and S3 audible

S1, S2, and S4 audible

S1, S2, S3, and S4 audible

Extra Heart Sounds (1/2 point)

No extra sounds

Gallops

Murmur

Friction rub

Valve clicks

 Percussed chest wall

1 of 1 point

 

Observations (1/2 point)

All areas resonant

Some areas dull, some resonant

Some areas hyperresonant, some resonant

Location (1/2 point)

No areas of dullness

Dullness, anterior right upper lobe

Dullness, anterior right middle lobe

Dullness, anterior right lower lobe

Dullness, anterior left upper lobe

Dullness, anterior left lower lobe

Dullness, posterior right upper lobe

Dullness, posterior right lower lobe

Dullness, posterior left upper lobe

Dullness, posterior left lower lobe

 Measured diaphragmatic excursion

1 of 1 point

 

Range (1/1 point)

3-5 cm

Greater than 3-5 cm

Less than 3-5 cm

 Palpated sinuses

1 of 1 point

 

Frontal (1/2 point)

None reported

Tenderness reported

Maxillary (1/2 point)

None reported

Tenderness reported

 Palpated lymph nodes

1 of 1 point

 

Head And Neck (1/3 point)

No palpable nodes

Palpable nodes on right side

Palpable nodes on left side

Supraclavicular (1/3 point)

No palpable nodes

Palpable nodes on right side

Palpable nodes on left side

Axillary (1/3 point)

No palpable nodes

Palpable nodes on right side

Palpable nodes on left side

 Palpated fremitus

1 of 1 point

 

Symmetry (1/2 point)

Equal bilaterally

Unequal bilaterally

Vibration (1/2 point)

Expected fremitus

Decreased fremitus

 Palpated chest expansion

1 of 1 point

 

Symmetry (1/1 point)

Equal bilaterally

Unequal bilaterally

Education & Empathy : 2 of 3 (66.7%)

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

 1 Symptoms

Followed Up

 

 Description: Danny describes the symptoms that have been bothering him.
What brings you here today?
My music teacher Mr. Hillman sent me here because he said I look sick. I have been coughing a lot. . . and I feel kinda tired.
I am sorry to hear that
Thanks.
 Model Statement: “I’m sorry you’ve not been feeling well these past few days. Being sick isn’t fun, especially when it affects lots of different parts of your body. Let’s talk about what’s been happening, and we’ll figure out how to make you better.”

 2 Family Medical History

Followed Up

 

 Description: Danny describes what he knows about his family’s health and indicates his distress over their various health issues.
Are you exposed to secondhand smoke?
Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it’s not all the time or anything. I don’t like how it smells, and I don’t like that he is hurting himself. He could get sick.
Secondhand smoke exposure can be harmful to you
OK.
 Model Statement: “Thank you for telling me about your family’s health. It’s completely understandable that you care for your family and don’t like hearing that their health isn’t perfect, especially with how your Papi smokes. You were really brave to tell us about that.”

 3 Vitamins

Not Followed Up

 

 Description: Danny describes taking vitamins and occasionally sneaking extras.
Do you take vitamins?
Oh yeah, I take vitamins every day! The gummy dinosaur kind. I don’t think I’m supposed to, but sometimes I sneak extra ones to be super healthy!
Do you play in school? (Clarified to: Do you do a lot of playing?)
I don’t play any sports on a team, but Tony and I play outside. We like to skateboard and shoot hoops. (Clarified to: if I do a lot of playing)
Any relevant family history?
 Model Statement: “You’re right; taking vitamins can be good for you. However, sometimes taking too many vitamins can be bad for you. It’d be better if you don’t sneak extra vitamins — just take the amount that your mom gives you.”

 

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