Shadow Health Comprehensive SOAP Note Template

Patient Initials: _Tina Jones_ Age: _28_ Gender: _Female_

Subjective Data:

Chief Complaint (CC): “I need a physical exam for the health insurance as a requirement for my new job.”

History of Present Illness (HPI): Ms. Jones came for a general physical exam, a requirement for health insurance required for her new job as an accountant at Smith, Stevens, Silver, & Company. She denies current problems.

Medications: Oral metformin 850mg BID and 2 puffs of Flovent 88mcgs/spray the last morning. 2 puffs Proventil 90mcg/spray PRN during asthmatic attacks to alleviate sobs and wheezing- last taken 3 months ago. Oral Advil 200mg 3 tablets every 8 hours during menses for menstrual pain. She took Advil last six weeks ago.

Allergies:

She reports allergies to:

Penicillin; she develops rashes after taking penicillin
Allergy to cat fur and dust: she develops a runny nose, the eyes get itchy and swollen, and she develops an influx of asthma symptoms, including congestion

She denies:

Any food allergies
Latex allergy

Past Medical History (PMH):

Diagnosed with asthma at age 21/2. She was hospitalized secondary to an asthmatic attack while in high school but was never intubated

She has a positive history of hypertension which she manages through exercising and dieting

Diagnosed with type 2 diabetes at 24, 4 years ago. She has been on metformin for the last five months. She developed some gastrointestinal side effects, but they have subsided. She monitors her blood sugar every morning, and the average of the readings is around 90, meaning proper diabetes control

Past Surgical History (PSH):

No history of surgeries

Sexual/Reproductive History:

Menarche at eleven, first sexual encounter at 18. Attracted to the opposite gender, has a boyfriend, and is not sexually active but plans to begin soon and use condoms for protection.

Has no children or has ever been pregnant. Had a pap smear 4 months ago

Her last menses were 2 weeks ago. PCOS diagnosis four months ago, Initiated Yaz four months ago. Cycles are now regular, with four-week intervals lasting five days and with moderate bleeding

Personal/Social History:

She has no children and has never been married

Lives with her mother and sister but plans to move into her apartment

Will begin working as an accountant at Smith, Stevens, Stewart, Silver, & Company in two weeks

During her free time, she spends time with friends, reads, attends bible study, volunteers at church, and loves to go dancing

She has a strong social support system entailing her family and the local church and denies feeling depressed, anxious, and suicidal thoughts, ideations, or attempts.

She took cannabis from age 15 to 21 and denies abusing cocaine, methamphetamines, and heroin. She reports taking alcohol occasionally, about 2-3 per month, and about 3 drinks per episode when she goes out with friends.

For security reasons: she has smokers detectors installed at home, always uses seatbelts when driving or riding, and uses sunscreen to protect her skin

Health Maintenance:

She had an eye exam 3 months ago, a pap smear 4 months ago, and a dental exam 5 months ago.

Her typical meals are breakfast: frozen fruit smoothie with yogurt. Lunch: vegetables and brown rice or a sandwich on white bread. She takes roasted vegetables for supper in addition to protein. For snacks, she takes either an apple or carrot sticks

She reports taking 1-2 diet cokes after meals per day

She has not traveled recently and does not own a pet

Ms. Jones does mild to moderate exercises 4-5 times per week, and these exercises include walking, yoga

She reports that her stress has decreased, and her coping abilities have improved

Ms. Jones reported having quality 8-10 hours of sleep a night

Immunization History:

Her recent immunizations include a tetanus booster in the past year

Significant Family History:

Her mother, 50, is hypertensive and hypercholesterolemic. Her Father died at 58 in an RTA a year ago, and she was hypertensive hypercholesterolemic, and diabetic (type 2). Her brother, 25, is overweight. Her sister, 14, is asthmatic. Maternal grandmother died at 73 of a stroke, hypertensive, and hypercholesterolemic.

Maternal grandfather died at 78 after a stroke and was hypertensive and hypercholesterolemic. Paternal grandmother died at 65 from colon cancer and was diabetic (type 2 diabetes). Her paternal uncle has an alcoholic syndrome

Review of Systems:

General: Patient denies any illness characteristics and reporting feeling fine. She denies any recent weight gains and reports decreased stress and anxiety, better coping abilities, and denies anxiety, depression, or suicide.

HEENT: Head: denies current headache or hair loss. Eyes: denies eye pain, drainage, redness, or itching. She reports using contact lenses to increase visual acuity and help reduce headaches. Ears: Denies ear pain or any hearing changes. Nose: denies sneezing, nasal drainage, congestion, or pain. Throat: Denies sore throat, dysphagia, or any enlarged lymph nodes. Ms. Jones’s last dental visit was five months ago.

Respiratory: Ms. Jones denies current breathing difficulty. She reports experiencing shortness of breath accompanied by wheezing and chest tightness during asthmatic attacks.

Cardiovascular/Peripheral Vascular: She denies chest pain, palpitations, tachycardia, or edema

Gastrointestinal: She denies nausea, vomiting, constipation, diarrhea of abdominal distension, or food intolerances

Genitourinary: She denies pain urinating, nocturnal or any vaginal itching, pain, or discharge

Musculoskeletal: denies muscle pain, joint pain, swelling, or muscle weakness.

Neurological: Denies headaches, coordination loss, sensation loss, seizures, equilibrium loss, or lightheadedness

Psychiatric:

Skin/hair/nails: The patient had acne, which is improving after using Yaz. Her neck skin is lightening, and her facial hair and body hair is improving. She denies any current hair or nail changes, raising concerns.

Objective Data:

Physical Exam:

Vital signs:

HT- 170cm

WT:84

BM1 29

T: 37

P:78RR:16

BP:128/82

O2 Saturation: 99% on room air

RBS: 100mg/dl

General:

The patient appears happy, dressed to the occasion, well-groomed ad clean, neat, and well-oriented to time, place, and event. He denies any pain and reports a recent 10-pound weight loss due to exercise and diet.

HEENT: Head: Normocephalic, no hair loss, and atraumatic. Eyes: bilaterally symmetrical, no lesion on eyelids, no edema, no ptosis, the conjunctiva is pink, sclera white, PERRLA bilaterally, no nystagmus, mild visual changes in the right eye. On further observation, the left fundus has sharp disc margins with no visible bleeding. Eye acuity 20/20 on both eyes.

The left eye has a corrective lens. Ear: TMs are intact and grey in color with a pearly appearance, whisper test positive bilaterally. Nose: Nasal septum intact, pink nasal mucosal with no drainage, sores, and sinuses are non-palpable and non-tender. Throat: Moist oral mucosal with no ulcerations or lesions, gag reflex present, throat, uvula midline, and raises with phonation. The dentition is complete with no infection. Tonsils 2+ bilaterally

Neck: Thyroid glands non-palpable, trachea midline, no lymphadenopathy

Chest/Lungs: Symmetrical rising with breathing, resonant sound produced on percussion, no cough, crackles, or wheezes. Home spirometry results are FEV 1 1.549 L and FVC 1.78 L.

Heart/Peripheral Vascular: HR regular, S1 and S2 auscultated with no murmurs, gallops, or rub on auscultation. Carotid arteries equal bilaterally with no bruit. Capillary refill; <3 secs, peripheral pulses palpated and equal bilaterally. No edema

Abdomen: protuberant abdomen with no visible masses, scars, or lesions with course hair from the pubis to the umbilicus. No guarding or tenderness with no organomegaly or CVA tenderness. Normoactive bowel sounds are evenly distributed in all quadrants. Tympanic sound on percussion.

Genital/Rectal: No drainage, no lesions, rashes, or swellings

Musculoskeletal: Upper and lower extremities are bilaterally symmetrical with no swelling or masses. She exhibits a full range of motion on all extremities. No muscle or joint pain on movement

Neurological: She has a decreased monofilament sensation on bilateral plantar surfaces. Appreciable muscle tones. Cranial nerves are intact with normal cerebellar function tests. Bilaterally equal DYRs 2+ on all extremities.

Skin: Has scattered blemishes on the face with dark patches where some have healed, hair on the upper lip and posterior neck has acanthosis nigricans

Diagnostic results: There are no remarkable results from the physical examination; hence no diagnostic testing was done

ASSESSMENT: Ms. Tina is a 28-year-old African American who presents to the clinics with a need for a physical exam for her health contract, a requirement for her new job that she hopes to begin in two weeks. She is currently diagnosed with asthma, PCOS, diabetes, and hypertension, which are well-controlled. Her review of the systems reveals that she is regulating her anxiety and stress well.

She is in a new relationship and is planning on using condoms for protection. In addition, she has a strong social support system. From the physical assessment, health history, and review of systems, she has no acute problems or needs.

Diagnosis: None- pre-employment physical exam

PLAN: the plan is to continue with the current management therapy. The advice is that her health fits her new role/job.

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Transcript

All Lines (645) Interview Questions (210) Statements (41) Exam Actions (394)

Hello, my name is Tammy. I will be conducting an interview and a physical exam.
Greet
07/22/20 5:37 PM EDT

Hey.

What is your name?
Question
07/22/20 5:37 PM EDT

Tina Jones.

What is your date of birth?
Question
07/22/20 5:37 PM EDT

February 17th.

How old are you?
Question
07/22/20 5:43 PM EDT

I’m 28.

What brings you into the clinic today?
Question
07/22/20 5:43 PM EDT

I came in because I’m required to have a recent physical exam for the health insurance at my new job.

Do you have any current health problem?
Question
07/22/20 5:44 PM EDT

I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days.

What is your new job?
Question
07/22/20 5:44 PM EDT

I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks–I’m really excited!

That is great.
Empathize
07/22/20 5:45 PM EDT

Thanks.

When was your last physical exam?
Question
07/22/20 5:45 PM EDT

Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear.

What did your gynecologist say?
Question
07/22/20 5:45 PM EDT

She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things.

How often do you take birth control?
Question
07/22/20 5:48 PM EDT

I take it every morning, with breakfast.

What is the name of the birth control pill you took?
Question
07/22/20 5:49 PM EDT

They’re called Yaz.

Has your menstrual cycle improved since taking Yaz?
Question
07/22/20 5:50 PM EDT

Now that I’m on the pill I’m getting my period every month.

That is great. I am glad you are having your period every month.
Empathize
07/22/20 5:50 PM EDT

Thanks.

How long have you had asthma?
Question
07/22/20 5:51 PM EDT

I’ve had asthma a long time. . . since I was really little.

What age were you diagnosed with asthma?
Question
07/22/20 5:51 PM EDT

My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.

I am sorry about the experience.
Empathize
07/22/20 5:52 PM EDT

Thanks.

How do you manage your asthma?
Question
07/22/20 5:52 PM EDT

I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.

What are your triggers for asthma?
Question
07/22/20 5:53 PM EDT

Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though.

It is important to stay away from triggers.
Educate
07/22/20 5:54 PM EDT

Thanks for telling me.

What happens when you are around dust?
Question
07/22/20 5:54 PM EDT

I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler.

What inhaler do you use?
Question
07/22/20 5:59 PM EDT

The daily inhaler is Flovent, and the rescue inhaler is Proventil.

How often do you use Flovent?
Question
07/22/20 6:00 PM EDT

Twice a day.

When did you most recently use the Flovent inhaler?
Question
07/22/20 6:01 PM EDT

I use my Flovent inhaler two times a day.

When did you last use your inhaler?
Question
07/22/20 6:03 PM EDT

I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too.

How much Albuterol do you use?
Question
07

I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church.

What is your relationship like with your family?
Question
07/22/20 7:39 PM EDT

Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along.

That is great.
Empathize
07/22/20 7:39 PM EDT

Thanks.

Are you involved in church?
Question
07/22/20 7:39 PM EDT

Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too.

Are you feeling stressed?
Question
07/22/20 7:40 PM EDT

I’m actually feeling really good lately. . . not stressed at all.

How do you cope with stress?
Question
07/22/20 7:40 PM EDT

I’ve realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I’ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me.

That is good to hear.
Empathize
07/22/20 7:40 PM EDT

Thanks.

Are you feeling depressed?
Question
07/22/20 7:41 PM EDT

No, I’m actually feeling really good these days.

How do you feel about your life?
Question
07/22/20 7:41 PM EDT

Well, I’m starting my new job in two weeks, and I’m really excited about that. I’m going to be an Accounting Clerk at this really nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple years, I’ll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job.

Are you feeling anxious?
Question
07/22/20 7:41 PM EDT

I guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though.

Do you have sleeping problems?
Question
07/22/20 7:42 PM EDT

I’m sleeping a lot better now, which is a relief.

Good to hear.
Empathize
07/22/20 7:42 PM EDT

Thanks.

How many hours are you sleeping a night?
Question
07/22/20 7:42 PM EDT

I’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night.

That is great.
Empathize
07/22/20 7:42 PM EDT

Thanks.

Have you ever smoked tobacco?
Question
07/22/20 7:43 PM EDT

No. I think it’s gross.

Have you ever used cocaine?
Question
07/22/20 7:43 PM EDT

No way, I have no interest in that. That stuff can mess you up.

Have you ever used heroin?
Question
07/22/20 7:49 PM EDT

Uh, no.

Have you ever used illegal drugs?
Question
07/23/20 3:17 PM EDT

Well, I used to smoke pot. . . but I don’t do that anymore.

What was the last time you smoked pot?
Question
07/23/20 3:17 PM EDT

I haven’t smoked pot since I was twenty or twenty-one.

Do you have any family history of mental illness?
Question
07/23/20 3:18 PM EDT

No. They’re crazy, but nobody’s diagnosed with anything.

Have you had suicidal thoughts?
Question
07/23/20 3:19 PM EDT

No, I’ve never done that.

Any new family medical history report?
Question
07/23/20 3:20 PM EDT

My mom has some issues, and I think some of my grandparents did, too.

How old is your mom?
Question
07/23/20 3:21 PM EDT

Mom is 50.

What medical problems does your mum have?
Question
07/23/20 3:21 PM EDT

Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though.

What medical problems did your father have?
Question
07/23/20 3:22 PM EDT

He had high blood pressure and cholesterol, and diabetes too…the same kind as me.

How old is your brother?
Question
07/23/20 3:24 PM EDT

He’s almost 27.

Does he have any medical issue? (Clarified to Does your younger sister have health problems?.)
Question
07/23/20 3:25 PM EDT

She’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.)

Does your bother have health issues? (Clarified to Does your brother have medical problems?.)
Question
07/23/20 3:25 PM EDT

No, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.)

How old is your maternal grandmother?
Question
07/23/20 3:26 PM EDT

Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too.

How old is your maternal grandfather?
Question
07/23/20 3:27 PM EDT

Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too.

Any medical history for your paternal grandmother?
Question
07/23/20 3:30 PM EDT

She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82.

Does your dad’s father have health issues?
Question
07/23/20 3:30 PM EDT

Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes.

Have you had any recent illness?
Question
07/23/20 3:31 PM EDT

No. . . the last time I was sick was when I was having those heartburn problems a while ago.

Any fever?
Question
07/23/20 3:32 PM EDT

I haven’t had a fever.

Any chills?
Question
07/23/20 3:32 PM EDT

Nope, no chills.

Any acne?
Question
07/23/20 3:32 PM EDT

I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything special. But my zits have gotten better, and I think it’s because I’m on birth control now.

Has your body hair improved?
Question
07/23/20 3:32 PM EDT

I think I have a little less body hair than I used to.

Do your eyes feel itchy?
Question
07/23/20 3:33 PM EDT

They haven’t been itchy lately at all.

Are you having any redness in your eyes?
Question
07/23/20 3:33 PM EDT

My eyes haven’t been red lately. . . not since I came in with those allergies a while ago.

Are your eyes dry?
Question
07/23/20 3:34 PM EDT

My eyes don’t feel dry.

Do you have any pain in your eyes?
Question
07/23/20 3:34 PM EDT

I haven’t had any eye problems lately–I went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good.

Are you having any ear problems?
Question
07/23/20 3:34 PM EDT

My ears feel fine.

Any changes in your hearing?
Question
07/23/20 3:36 PM EDT

My hearing is good.

Any ear pain?
Question
07/23/20 3:36 PM EDT

My ears feel fine.

Ear drainage? (Clarified to Do you have drainage from your ears?.)
Question
07/23/20 3:36 PM EDT

Nothing is coming out of my ears. (Clarified to if I have ear drainage.)

Any changes in your sense of smell?
Question
07/23/20 3:46 PM EDT

No.

Any nose bleeds?
Question
07/23/20 3:47 PM EDT

Nope, my nose isn’t bleeding at all.

Any sinus pressures?
Question
07/23/20 3:47 PM EDT

My sinuses have been fine.

Has your sense of taste changed?
Question
07/23/20 3:47 PM EDT

No, I think my sense of taste is fine.

Are you having dry mouth?
Question
07/23/20 3:48 PM EDT

My mouth hasn’t been dry.

ANY pain in your mouth?
Question
07/23/20 3:48 PM EDT

No, my mouth feels fine.

ANY sore throat?
Question
07/23/20 3:49 PM EDT

No, it’s fine.

Any issue with your gums?
Question
07/23/20 3:49 PM EDT

My gums have been fine.

Any issue with your tongue?
Question
07/23/20 3:49 PM EDT

My tongue feels fine.

Any difficulties when swallowing?
Question
07/23/20 3:50 PM EDT

I can swallow fine.

SORE throat?
Question
07/23/20 3:50 PM EDT

No, it’s fine.

Any voice changes?
Question
07/23/20 3:50 PM EDT

My voice has been fine.

Any swollen lymph nodes?
Question
07/23/20 3:52 PM EDT

My lymph nodes seem fine.

Are you having any nausea?
Question
07/23/20 3:52 PM EDT

No, I haven’t been nauseous at all.

Any vomiting?
Question
07/23/20 3:53 PM EDT

No.

ANY pain in the abdomen?
Question
07/23/20 3:53 PM EDT

I haven’t really had any stomach problems since I came in with them a while ago.

Any constipation?
Question
07/23/20 3:53 PM EDT

I don’t have that problem.

Any diarrhea?
Question
07/23/20 3:54 PM EDT

I haven’t had any problems with diarrhea.

Excessive flatulence?
Question
07/23/20 3:54 PM EDT

I haven’t been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked.

flatulence is one of the side effect of metformin
Educate
07/23/20 3:55 PM EDT

Thanks for telling me.

Any food intolerance
Question
07/23/20 3:56 PM EDT

I can eat just about anything.

Any burning sensation when you urinate?
Question
07/23/20 3:56 PM EDT

No, it doesn’t burn when I pee.

Any blood in your urine?
Question
07/23/20 3:57 PM EDT

No! That doesn’t sound like it would be good.

Are you having any pain right now?
Question
07/23/20 3:57 PM EDT

I don’t have any pain anywhere.

Any vaginal discharge?
Question
07/23/20 3:58 PM EDT

My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish.

Any vaginal itching?
Question
07/23/20 3:58 PM EDT

No, it feels normal.

Do you have any problem with your breasts?
Question
07/23/20 3:59 PM EDT

No, my breasts feel fine.

Any pain in the breasts?
Question
07/23/20 3:59 PM EDT

No, my breasts feel fine.

Are you having any dizziness/
Question
07/23/20 3:59 PM EDT

I haven’t been getting dizzy at all.

Any lightheadedness?
Question
07/23/20 4:00 PM EDT

No, I don’t really get lightheaded.

Any tingling?
Question
07/23/20 4:00 PM EDT

Nope, no tingling.

Any loss of balance?
Question
07/23/20 4:00 PM EDT

My balance is fine.

Any changes in sensation?
Question
07/23/20 4:00 PM EDT

I haven’t noticed any changes.

Any seizures?
Question
07/23/20 4:01 PM EDT

No, I’ve still never had problems with seizures, fortunately.

Do you have memory problems?
Question
07/23/20 4:01 PM EDT

I think my memory has been fine.

Any muscle pain?
Question
07/23/20 4:01 PM EDT

My muscles have felt great, especially since I started exercising more.

Joint pain?
Question
07/23/20 4:02 PM EDT

My joints always seem fine.

Any muscle weakness?
Question
07/23/20 4:02 PM EDT

No, I haven’t felt weak at all.

Any swelling?
Question
07/23/20 4:03 PM EDT

Nothing is swollen.

Performed pulse oximetry
Exam Action
07/24/20 10:01 AM EDT

Performed spirometry
Exam Action
07/24/20 10:01 AM EDT

Inspected scalp
Exam Action
07/24/20 10:01 AM EDT

Inspected hair on scalp
Exam Action
07/24/20 10:01 AM EDT

Inspected scalp
Exam Action
07/24/20 10:01 AM EDT

Inspected right eyebrow and orbital area
Exam Action
07/24/20 10:02 AM EDT

Inspected left eyebrow and orbital area
Exam Action
07/24/20 10:02 AM EDT

Inspected mouth: Oral mucosa moist. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation
Exam Action
07/24/20 10:02 AM EDT

Subjective Data Collection: 50 of 50 (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

Current Health Status

Finding: Confirmed reason for visit

Finding: Reports needing a pre-employment physical

Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question: Can I confirm that you are here for a physical?

Finding: Reports no current acute health problems

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question: Do you have any current health problems?

Finding: Asked about last visit to a healthcare provider

Finding: Last visit to a healthcare provider was 4 months ago

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

Example Question: When did you see a healthcare provider?

Finding: Reason for last visit was annual gynecological exam

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems.

Example Question: Why did you see a healthcare provider?

Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler

Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history.

Example Question: When was your last physical exam? Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding: Asked about current prescription medications

Finding: Reports taking diabetes medication

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it.

Example Question: Have you been taking medication for your diabetes?

Finding: Reports using a daily inhaler

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it.

Example Question: Do you use a daily inhaler?

Finding: Reports taking prescription birth control pills

Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans.

Example Question: Are you taking any form of birth control?

Finding: Followed up about diabetes medication

Finding: Medication is metformin

Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history.

Example Question: What is the name of your diabetes medication?

Finding: Started taking metformin 5 months ago

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question: How long have you been taking metformin?

Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question: Have you noticed any side effects from the metformin?

Finding: Followed up on metformin frequency and dose

Finding: Reports taking metformin twice daily

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question: How many times a day do you take metformin?

Finding: Metformin dose is 850 mg

Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history.

Example Question: What is the dose of your metformin?

Finding: Asked about asthma medication

Finding: Reports using Flovent inhaler twice daily

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question: How often do you use your daily inhaler?

Finding: Has a Proventil rescue inhaler

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

Example Question: Do you have a rescue inhaler?

Finding: Last use of Proventil inhaler was three months ago

Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.

Example Question: When did you last use your rescue inhaler?

Finding: Has used Proventil inhaler twice in the last year

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she has been treating her symptoms since exacerbation.

Example Question: How often do you use your rescue inhaler?

Finding: Followed up about birth control prescription

Finding: Started taking birth control 4 months ago

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan.

Example Question: How long ago did you start taking birth control?

Finding: Reason for birth control was to manage PCOS symptoms

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words.

Example Question: Why did you decide to start taking birth control?

Finding: Birth control type is Yaz (Drospirenone and ethinyl estradiol)

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question: What type of birth control do you use?

Finding: Takes birth control pill daily

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question: How often do you take your birth control pill?

Finding: Takes birth control pill at the same time every day

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question: Do you take your pill at the same time every day?

Finding: Reports no skipped days

Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan.

Example Question: Have you missed any days of your birth control pill?

Finding: Asked about current non-prescription medications

Finding: Reports rare Advil use for cramps

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes nonprescription drugs will indicate her current treatment plan.

Example Question: Do you take Advil?

Finding: Reports no OTC herbal products

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan.

Example Question: Do you use any herbal products?

Finding: Reports no OTC vitamins

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan.

Example Question: Do you take any vitamins?

Finding: Reports no OTC supplements

Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan.

Example Question: Do you take any supplements?

Finding: Asked about allergies

Finding: Confirms allergies

Pro Tip: Discerning what is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina’s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina’s health literacy.

Example Question: Can you confirm your allergies?

Finding: Reports no new allergies

Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question: Have you noticed any new allergies?

Finding: Followed up on seasonal allergies

Finding: Reports no recent seasonal allergy symptoms

Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing.

Example Question: Have you been having seasonal allergies?

Finding: Reports no current medication for allergies

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

Example Question: Are you taking any medication for your allergies?

Finding: Asked about diabetes

Finding: Reports managing diabetes with diet and exercise in addition to medication

Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she is complied with previous treatment plans. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Example Question: How are you managing your diabetes?

Finding: Asked about blood glucose monitoring

Finding: Reports checking blood sugar once a day

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

Example Question: How often do you monitor your blood glucose?

Finding: Checks sugar in the morning

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

Example Question: When do you check your blood glucose?

Finding: Blood sugar number is usually around 90

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

Example Question: What is your average blood sugar number?

Finding: Reports having adequate supplies

Objective Data Collection: 70 of 73 (95.9%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips.

Found: Indicates an item that you found.

Available: Indicates an item that is available to be found.

Category

Scored Items

Experts selected these examinations as essential components of objective data collection for this patient.

Patient Data

Thorough examinations will yield better patient data. The following actions reveal the objective data of the patient’s case. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

HEENT

Finding: Inspected head and neck

Finding: Scattered pustules on face and facial hair on upper lip

Pro Tip: Inspecting the facial skin for the presence of discoloration, lesions, or abnormal hair growth assesses for underlying medical problems.

Finding: Head is normocephalic, atraumatic

Pro Tip: Because your patient may have unknowingly hit her head during her fall, giving special attention to your observation of the size and the shape of your patient’s head can identify any indications of trauma.

Finding: Normal scalp hair distribution

Pro Tip: It’s important to inspect your patient’s hair for distribution, color, and texture because abnormal hair growth or characteristics can indicate underlying health problems.

Finding: Acanthosis nigricans noted on neck

Pro Tip: Skin changes are common in patients with uncontrolled diabetes. A thorough inspection should be conducted of your patient’s skin, especially in folds around the neck, axilla, and groin.

Finding: Inspected eyebrows and orbital area

Finding: Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema

Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.

Finding: Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema

Pro Tip: Examining the external eye for hair distribution, coloration, edema, lesions, and ptosis identifies abnormalities that can indicate infection or underlying conditions.

Finding: Palpated scalp

Finding: No masses

Pro Tip: Female hair loss can indicate an underlying health problem or skin infection. Inspecting the scalp and hair for texture, distribution, and quantity helps to identify lesions or masses.

Finding: Palpated sinuses

Finding: No frontal sinus tenderness

Pro Tip: Palpating the frontal sinuses checks for sinusitis.

Finding: No maxillary sinus tenderness

Pro Tip: Palpating the maxillary sinuses checks for sinusitis.

Finding: Palpated jaw

Finding: No clicks, full ROM

Pro Tip: Palpating the jaw checks for crepitus can identify TMJ or injury.

Finding: Palpated lymph nodes

Finding: No axillary lymphadenopathy

Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy.

Finding: No supraclavicular lymphadenopathy

Pro Tip: Palpating the lymph nodes helps to identify characteristics relaying information about inflammation, infection, and malignancy. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding: Palpated thyroid

Finding: Thyroid smooth without nodules, no goiter

Pro Tip: Palpating the thyroid gland for size, shape, and consistency, and noting any nodules or tenderness, helps to identify signs of a thyroid disorder.

Finding: Inspected eyelids and conjunctiva

Finding: Upper eyelids: conjunctiva pink, no lesions, white sclera

Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.

Finding: Lower eyelids: conjunctiva pink, no lesions, white sclera

Pro Tip: Inspecting the conjunctiva and sclera for color changes, swelling, and increased vascularity helps to identify an infection or underlying condition.

Finding: Tested PERRL with penlight

Finding: Right pupil: equal, round, reactive to light

Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.

Finding: Left pupil: equal, round, reactive to light

Pro Tip: When inspecting the pupils for size, shape, symmetry, and reaction to light, unequal or unreactive pupils can indicate significant underlying health problems.

Finding: Tested eye movements

Finding: Normal convergence

Pro Tip: This test accommodation assesses the eye’s ability to focus on close objects.

Finding: EOMs intact bilaterally, no nystagmus

Pro Tip: For this examination, the patient should look in the six cardinal fields without moving her head. Lag, nystagmus, and deviations may indicate neurologic conditions.

Finding: Tested peripheral vision

Finding: Peripheral vision intact in both eyes, all fields

Finding: Inspected interior eyes with ophthalmoscope

Finding: Mild retinopathic changes on right

Pro Tip: Patients with diabetes are at risk for diabetic retinopathy. By visualizing the fundus, you can look for any retinopathic changes.

Finding: Left fundus with sharp disc margins, no hemorrhages

Finding: Palpated abdomen – deep

Finding: Right upper quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Right lower quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation

Finding: Left upper quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Left lower quadrant: no masses, guarding or rebound

Pro Tip: Performing deep palpation determines the shape, consistency, tenderness, and pulsations of abdominal masses.

Finding: Palpated organs

Finding: Liver: palpable 1 cm below right costal margin

Pro Tip: Palpating the liver identifies enlargement, displacement, tenderness, and consistency, which can indicate important health problems.

Finding: Spleen: not palpable

Pro Tip: Palpating the spleen identifies enlargement or displacement, which can indicate several serious health conditions.

Finding: Right kidney: not palpable, no masses

Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.

Finding: Left kidney: not palpable, no masses

Pro Tip: Healthy kidneys are not usually palpable. Attempting to palpate the kidney helps determine enlargement or tenderness.

Musculoskeletal

Finding: Inspected neck

Finding: Neck without swelling, masses, or deformity