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 – 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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Esther Park – Focused 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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