NRS 434 Shadow Health: Comprehensive Assessment

Sample Answer for NRS 434 Shadow Health: Comprehensive Assessment Included After Question

Within the Shadow Health platform, complete the Comprehensive Assessment. The estimated average time to complete this assignment each time is 3 hours. Please note, this is an average time. Some students may need longer.

This clinical experience is a comprehensive exam. Students must score at the level of “Proficiency” in the Shadow Health Digital Clinical Experience. Students have three opportunities to complete this assignment and score at the Proficiency level. Upon completion, submit the lab pass through the assignment dropbox.

Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 150 points; students successfully scoring at the Proficiency level on the second attempt will earn a grade of 135 points; and students successfully scoring at the Proficiency level on the third attempt will earn a grade of 120 points. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (102 points).

If Proficiency is not achieved on the first attempt it is recommended that you review your answers with the correct answers on the Experience Overview page. Review the report by clicking on each tab to the left titled; Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. Reviewing this overview and course resources may help you improve your score.

Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion.

You are not required to submit this assignment to LopesWrite.

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT NRS 434 Shadow Health: Comprehensive Assessment

For the middle-aged adult, exercise can reduce the risk of various health problems. Choose two at-risk health issues that regular physical exercise and activity can help prevent and manage. Discuss the prevalence of each of these health problems in society today. Describe measures that you would take as a nurse to assist clients with health promotion measures to incorporate exercise and physical activity into their lives. Include the kind of activities you would recommend, the amount of exercise, and the approach you would use to gain cooperation from the client. Support your response with evidence-based literature.

Re: Topic 4 DQ 2

People who exercise regularly could reduce their risk of developing hypertension and diabetes and slow down how quickly their body deteriorates as they age. Hypertension is characterized by persistently high blood pressure in the systemic arteries (Oparil et al., 2018). Blood pressure is expressed in two categories. Systolic blood pressure is the pressure that the blood exerts on the arterial wall when the heart contracts and the diastolic blood pressure when the heart relaxes. A person is considered hypertensive when the systolic blood pressure is greater than or equal to 140 and diastolic blood pressure is greater than or equal to 90 (Oparil et al., 2018).

According to Klarroubi&Darwish (2015), diabetes mellitus is defined as “a group of metabolic diseases characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both.” There are different classes of diabetes mellitus. Type I diabetes also called juvenile diabetes; it is autoimmune due to destruction of the b cells of the pancreas, characterized by the absence of insulin secretion and is more dominant in children and adolescents (Klarroubi&Darwish, 2015). Type II diabetes commonly seen in adults, gestational diabetes in pregnant women, and other types. Fasting plasma glucose of greater than or equal to 126mg/dL. (7.0 mmol/L, plasma glucose after 2-h OGTT greater than or equal to 200mg/dL (11.1mmol/L), HgbA1C greater than or equal to 6.5%, or a random plasma glucose greater than or equal to 200 along with symptoms of hyperglycemia is diagnostic of diabetes mellitus (Klarroubi&Darwish, 2015).

Hypertension is a major risk factor for cardiovascular disease. According to Ostchega et al., 2020, the risk for hypertension increases with age: 22.4% (aged 18-39), 54.5% (40-59) and 74.5% (60 and over). Hypertension prevalence was higher among non-Hispanic black 57.1% than non-Hispanic white 43.6%, and Hispanic 43.7%. The prevalence of age adjusted hypertension was 45.4% among adults and was higher among men (51.0) than women (39.7%) (Centers for Disease Control and Prevention, 2020). Diabetes represents a burden to modern societies. According to the National Diabetes Statistics Report 2020, 34.2 million people of all ages which represent 10.5% of the US population had diabetes; 34.1 million adults aged 18 or older (13.0%) of all US adults had diabetes; 7.3 million adults aged 18 or older met laboratory criteria but did not aware they had diabetes. Among adults aged 65 and older the percentage increased to 26.8%.

Health promotion and education is critical for patients diagnosed with hypertension and diabetes. Regular physical activity is proven to help prevent and manage hypertension and diabetes. As a nurse, I will educate my patient on the importance of being active to prevent adverse consequences from hypertension and diabetes such as stroke with paralysis or other coronary artery diseases which can cause morbidity or even death. Therefore, I will educate my patient of the benefits of walking, swimming, hiking, and dancing etc. According to World Health Organization (2020), adults aged 18-64 years old should do at least 150-300 minutes of moderate- intensity of aerobic physical activity; or at least 75-150 minutes of vigorous – intensity aerobic physical activity. Physical exercise is the most effective methods to help prevent and manage hypertension and diabetes (Patel et al., 2017).

References:

Centers for Disease Control and Prevention (2020). National diabetes statistics report, 2020. www.cdc.gov/diabetes/library/features/diabetes-stat-report.html

Klarroubi, A.T., &Darwish, H.M. (2015). Diabetes mellitus: The epidemic of the century. World Journal of Diabetes, 6(6): 850-867. doi: 10.4239/wjd. v6.i6.850

Ostchega, Y., Fryar, C.D., Nwankwo, T., & Nguyen, D.T. (2020). Hypertension prevalence among adults aged 18 and over: United States, 2017-2018. National Center for Health Statistics. www.cdc.gov/nchs/products/databriefs/db364.html

Patel, H., Alkhawam, H., Madanieh, R., Shah, N., Kosmas, C.E., & Vittorio, T.J. (2017). Aerobic vs anaerobic exercise training effects on the cardiovascular system. World Journal of Cardiology, 9(2): 134-138. doi:10.4330/wjc. v9.i2.134

World Health Organization (2020). Physical activity. www.who.int/news-room/fact-sheets/detail/physical-activity

Subjective Data Collection: 33 of 33 (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.
Current Health Status

Finding:

• Asked about current health problems

Finding:

• Denies current acute health problems
  (Found)

Pro Tip: Determining if the patient has any current acute health problems is essential in conducting a productive exam and prioritzing the patient’s needs.
Example Question:
Are you having any health problems?
Finding:
Reports diabetes
(Found)
Pro Tip: Confirming a patient’s medical conditions, such as diabetes, will enable you to provide the best care possible.
Example Question:
Can you confirm your diabetes?
Finding:
Reports asthma
(Found)
Pro Tip: Confirming a patient’s medical conditions, such as asthma, will enable you to provide the best care possible.
Example Question:
Can you confirm your asthma?

Finding:
Asked about last visit to a healthcare provider

Finding:
Reports last visit to a healthcare provider was 4 months ago
(Found)
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:
Reports reason for last visit was annual gynecological exam
(Found)
Pro Tip: Establishing a timeline for Tina’s gynecological exams will allow you to develop a comprehensive health history.
Example Question:
Why did you see a healthcare provider?
Finding:
Reports last general physical examination was 5 months ago
(Found)
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?

Finding:
Asked about current prescription medications

Finding:
Reports taking diabetes medication
(Found)
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 having an inhaler
(Found)
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 have an inhaler?
Finding:
Reports taking prescription birth control pills
(Found)
Pro Tip: A patient’s use of birth control can impact the care plan, such as which medications are prescribed. Understanding a patient’s history of birth control can be an indicator of health literacy.
Example Question:
Are you taking any form of birth control?

Finding:
Followed up about diabetes medication

Finding:
Reports diabetes medication is metformin
(Found)
Pro Tip: Follow up questions about Tina’s diabetes medication will help you to understand her treatment plan and recent health history.
Example Question:
What is the name of your diabetes medication?
Finding:
Reports starting taking diabetes medication 5 months ago
(Found)
Pro Tip: Follow up questions about Tina’s diabetes 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 side effects of diabetes medication abated over time
(Found)
Pro Tip: Determining if Tina has experienced any side effects of her diabetes medication will help you determine the efficacy and appropriateness of her medication.
Example Question:
Have you noticed any side effects from the metformin?
Finding:
Reports taking diabetes medication twice daily
(Found)
Pro Tip: Follow up questions about Tina’s medication adherence will help you to understand her treatment plan and recent health history.
Example Question:
How many times a day do you take metformin?
Finding:
Reports diabetes medication dose is 850 mg
(Found)
Pro Tip: Follow up questions about the dosage of Tina’s diabetes medication will help you to understand her treatment plan and recent health history.
Example Question:
What is the dose of your metformin?
Finding:
Denies adverse effects of diabetes medication
(Found)
Pro Tip: Determining if Tina has experienced any adverse effects of her diabetes medication will help you determine the efficacy and appropriateness of her medication.
Example Question:
Are you experiencing adverse effects from your diabetes medication?

Finding:
Asked about asthma medication

Finding:
Reports asthma medication has not changed
(Found)
Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.
Example Question:
Has your asthma medication changed?
Finding:
Reports inhaler is albuterol (Proventil)
(Found)
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:
Reports using inhaler no more than 2 times per week
(Found)
Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking how frequently Tina uses her inhaler can indicate how she’s been treating her symptoms.
Example Question:
How often do you use your inhaler?
Finding:
Reports recommended dose is 1-3 puffs as needed
(Found)
Pro Tip: Asking Tina about the recommended dose of her inhaler can help you determine if the treatment is effective and appropriate for her health needs.
Example Question:
What is the recommended dosage for your inhaler?
Finding:
Reports typically taking 2 puffs
(Found)
Pro Tip: Asking Tina about how many puffs of her inhaler she typically takes can help you determine if the treatment is effective and appropriate for her health needs.
Example Question:
How many puffs of your inhaler do you typically take?
Finding:
Reports sometimes needing 3 puffs to control symptoms
(Found)
Pro Tip: Asking Tina about how many puffs of her inhaler she takes can help you determine if the treatment is effective and appropriate for her health needs.
Example Question:
What’s the most puffs you ever take?
Finding:
Denies adverse effects of asthma medication
(Found)
Pro Tip: Asking Tina if she experiences any adverse effects from her inhaler can help you determine if the treatment is effective and appropriate for her health needs.
Example Question:
Does your inhaler give you any adverse effects?

Finding:
Followed up about birth control prescription

Finding:
Reports starting birth control 4 months ago
(Found)
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:
Reports reason for birth control was to manage PCOS symptoms
(Found)
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:
What reason did you decide to start taking birth control?
Finding:
Reports birth control is drospirenone and ethinyl estradiol (Yaz)
(Found)
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.
Example Question:
What type of birth control do you use?
Finding:
Reports taking birth control pill daily
(Found)
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:
Reports taking birth control pill at the same time every day
(Found)
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:
Denies adverse side effects from birth control
(Found)
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 have side effects from your birth control?

Finding:
Asked about current non-prescription medications

Finding:
Reports occasional ibuprofen use
(Found)
Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes ibuprofen will indicate her current treatment plan.
Example Question:
Do you take Advil?
Finding:
Denies OTC herbals
(Found)
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:
Denies OTC supplements
(Found)
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:
Followed up on ibuprofen (Advil)

Finding:
Reports taking ibuprofen for cramps
(Found)
Pro Tip: Discovering the reason a patient has been taking pain medication is a crucial part of the history of her condition or injury.
Example Question:
Why do you take ibuprofen?
Finding:
Reports ibuprofen is regular strength
(Found)
Pro Tip: Determining the exact dose of pain medication your patient takes helps determine the severity of her condition or injury and will factor in to your care plan.
Example Question:
What strength ibuprofen do you take?
Finding:
Reports ibuprofen is effective
(Found)
Pro Tip: The efficacy of pain medication varies from patient to patient. Discovering a patient’s individual response to pain medication is an important factor in your overall treatment plan.
Example Question:
Does ibuprofen help your cramps?
Finding:
Reports last use of ibuprofen was six weeks ago
(Found)
Pro Tip: Discovering the last time your patient has taken pain medication is a crucial part of the history of her condition or injury.
Example Question:
When was the last time you took ibuprofen?

Finding:
Asked about allergies

Finding:
Reports allergies have not changed
(Found)
Pro Tip: In a comprehensive assessment, it is important to determine if any allergies have changed for the patient and determine how best to address those changes.
Example Question:
Can you confirm your allergies?
Finding:
Reports penicillin allergy
(Found)
Pro Tip: Asking specifically about allergies to medications, such as penicillin, is crucial to the patient’s safety while she is in your care, as it affects what medications will be safe and appropriate.
Example Question:
Are you allergic to penicillin?
Finding:
Reports cat allergy
(Found)
Pro Tip: Discovering occasional environmental triggers, such as animal allergies, is important in understanding a patient’s health. It is particularly important for Tina, as she suffers from asthma.
Example Question:
Do you have animal allergies?
Finding:
Reports dust allergy
(Found)
Pro Tip: Dust is a common allergen, and discovering its effect on asthmatic patients is particularly important.
Example Question:
Are you allergic to dust?

Finding:
Asked about diabetes management through lifestyle

Finding:
Reports recently beginning dieting to manage diabetes
(Found)
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 are you managing your diabetes?
Finding:
Reports recently beginning exercising to manage diabetes
(Found)
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:
Have you been exercising?

Finding:
Asked about blood glucose monitoring

Finding:
Reports checking blood sugar once a day
(Found)
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:
Reports checking sugar in the morning
(Found)
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:
When do you check your blood glucose?
Finding:
Reports using glucometer
(Found)
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:
Do you use a glucometer?
Finding:
Reports blood sugar number is usually around 90
(Found)
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
(Found)
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:
Do you have enough supplies to monitor your blood glucose?

Finding:
Asked about asthma symptoms

Finding:
Denies change in asthma symptoms
(Found)
Pro Tip: It is important to determine the severity of Tina’s asthma, as a worsening conditions indicates a need for further treatment.
Example Question:
Has your asthma changed at all?
Finding:
Reports belief that asthma is well-controlled
(Found)
Pro Tip: It is important to determine Tina’s perception of her asthma, as it may indicate a worsening condition that needs to be addressed.
Example Question:
Do you think your asthma is under control?
Finding:
Denies current asthma symptoms
(Found)
Pro Tip: It is important to solicit information about Tina’s current asthma symptoms, as this will allow you gain an up-to-date picture of her condition.
Example Question:
Do you have any difficulty breathing?
Finding:
Reports last use of Proventil inhaler was yesterday
(Found)
Pro Tip: Determining the last time Tina used her inhaler will help you gain an up-to-date picture of her condition and determine the efficacy of her current medication.
Example Question:
When was the last time you used your inhaler?

Finding:
Asked about vision

Finding:
Reports optometrist visit
(Found)
Pro Tip: Asking Tina if she has been to an eye doctor will indicate the degree to which she’s seen her vision as something that has needed medical attention.
Example Question:
Have you been to an eye doctor?
Finding:
Reports last optometrist visit was 3 months ago
(Found)
Pro Tip: Asking Tina when she last saw an eye doctor will indicate the degree to which she’s seen her vision as something that has needed medical attention.
Example Question:
When did you go to the eye doctor?
Finding:
Reports recently prescribed eyeglasses
(Found)
Pro Tip: Determining any outcomes from Tina’s last optometrist visit is important, as it may reveal treatments that you should follow-up on.
Example Question:
Did you get prescription eyeglasses?
Finding:
Reports that glasses improve overall vision
(Found)
Pro Tip: Once you uncover that Tina has recently been prescribed eyeglasses, it is important to follow-up on any effects, both positive and negative, that she may have noticed.
Example Question:
How do you like your glasses?

Finding:
Asked about reproductive system

Finding:
Reports last menstrual period was 2 weeks ago
(Found)
Pro Tip: Finding out when a patient’s LMP was indicates whether she might be pregnant (although this question alone can’t rule out pregnancy).
Example Question:
When was your last menstrual period?
Finding:
Reports menstrual cycle is normal
(Found)
Pro Tip: Asking about the frequency and duration of a patient’s periods, as well as the severity of cramps and heaviness of flow, will help you understand what it typical for the patient. Abnormalities may also point to underlying issues that should be addressed.
Example Question:
Is there anything unusual about your menstrual cycle?
Finding:
Reports rare cramping
(Found)
Pro Tip: Asking a patient for her subjective report on the heaviness of her cramps will help you understand her feelings about her menstrual symptoms.
Example Question:
Do you still have menstrual cramps?

Finding:
Asked about breast health

Finding:
Reports doing occasional breast exams
(Found)
Pro Tip: Asking if a patient perform breast self-examinations is important because it reveals a patient’s level of health literacy.
Example Question:
Do you perform breast self-exams?
Finding:
Denies having a mammogram
(Found)
Pro Tip: Inquiring into what breast screenings Tina has had can lead to a discussion about any test results and their implications for her cardiovascular health. If she has not had any screenings, it provides an opportunity for patient education.
Example Question:
Have you ever gotten a mammogram?
Finding:
Denies changes to breasts
(Found)
Pro Tip: It is important to determine any recent changes to breast, such as swelling, rashes, lumps, or nipple discharge, as it could be indicative of a serious underlying condition.
Example Question:
Have you noticed any changes to your breasts?
Finding:
Denies history of breast cancer
(Found)
Pro Tip: If a patient has a history of breast cancer, it is important that you look for signs of recurrence and engage in preventative care, as well as patient education. You may also need to provide further support and resources to the patient.
Example Question:
Do you have a history of breast cancer?

Finding:
Asked about weight changes

Finding:
Reports recent weight loss
(Found)
Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. Asking Tina if she’s lost weight might indicate recent changes in health.
Example Question:
Have you lost weight?
Finding:
Reports weight loss of about 10 pounds
(Found)
Pro Tip: Determining the exact amount of weight loss can indicate whether it’s within expected ranges, or extreme, which may indicate an underlying health problem.
Example Question:
How much weight did you lose?

Psychosocial History

Finding:
Asked about diet

Finding:
Reports a typical breakfast is smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for breakfast will illustrate her recent dietary patterns.
Example Question:
What is your typical breakfast?
Finding:
Reports a typical lunch is dinner leftovers or tuna or chicken sandwich on wheat bread
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns.
Example Question:
What is your typical lunch?
Finding:
Reports a typical dinner is vegetables with a protein and brown rice or quinoa
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for dinner will illustrate her recent dietary patterns.
Example Question:
What is your typical dinner?
Finding:
Reports a typical snack is carrot sticks or an apple
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for a snack will illustrate her recent dietary patterns.
Example Question:
What is a typical snack?

Finding:
Asked about caffeine intake

Finding:
Denies drinking coffee
(Found)
Pro Tip: Finding out specifically if a patient drinks coffee helps you understand what constitutes her typical caffeine intake.
Example Question:
Do you drink coffee?
Finding:
Reports only caffeine is diet Coke
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if she drinks soda will illustrate her recent dietary patterns.
Example Question:
Do you drink soda?
Finding:
Reports drinking 2 diet Cokes per day
(Found)
Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many diet cokes she drinks a day will illustrate her recent dietary patterns.
Example Question:
How much soda do you drink a day?

Finding:
Asked about alcohol intake

Finding:
Reports drinking 2-3 nights per month
(Found)
Pro Tip: Finding out how many nights per week/month your patient consumes alcohol gives insight into potential habits or abuse.
Example Question:
How many nights a month do you drink?
Finding:
Reports having 2 or 3 drinks when out with friends
(Found)
Pro Tip: Finding out how many alcoholic drinks a patient has in a single sitting is essential to uncover any binge-drinking habits that can be unhealthy for your patient.
Example Question:
How many drinks do you have in a sitting?

Finding:
Asked about tobacco use

Finding:
Denies tobacco use
(Found)
Pro Tip: Finding out if a patient uses tobacco products is important to understanding her overall health and identifying potential health risks.
Example Question:
Do you smoke?
Finding:
Denies vaping
(Found)
Pro Tip: Finding out if a patient uses tobacco products or inhales substances is important to understanding her overall health and identifying potential health risks.
Example Question:
Do you vape?

Finding:
Asked about illicit drugs

Finding:
Reports history of smoking recreational marijuana
(Found)
Pro Tip: Determining any recent or past history of drug use is essential to revealing any substance abuse issues, and if the patient is likely to seek drugs while admitted. It is also good practice to identify the purpose of drug use, such as recreation or pain management.
Example Question:
Do you smoke marijuana?

Finding:
Asked about exercise

Finding:
Reports walking for exercise
(Found)
Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how she exercises can help you to assess her current levels of health and nutrition.
Example Question:
What kind of exercise do you do?
Finding:
Reports swimming for exercise
(Found)
Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how she exercises can help you to assess her current levels of health and nutrition.
Example Question:
How do you exercise?
Finding:
Reports walking four or five times a week
(Found)
Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how many days a week she exercises can help you to assess her current levels of health and nutrition.
Example Question:
How many days a week do you exercise?
Finding:
Reports that a typical walk is thirty or forty minutes
(Found)
Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how long her walks are can help you to assess her current levels of health and nutrition.
Example Question:
How long are your walks?
Finding:
Reports swimming weekly
(Found)
Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina what exercise she does can help you to assess her current levels of health and nutrition.
Example Question:
What exercise do you do?

Finding:
Asked about sexual activity

Finding:
Denies sexual activity
(Found)
Pro Tip: Asking if Tina is currently sexually active will help you determine is she is practicing safe sex and has any potential health risks.
Example Question:
Are you sexually active right now?

Finding:
Asked about mental health

Finding:
Denies mental health issues
(Found)
Pro Tip: Asking about a patient’s mental health is important for understanding their overall well-being. It may also reveal problems not covered elsewhere in the exam.
Example Question:
Do you have any mental health problems?

Review of Systems

Finding:
Asked about constitutional health

Finding:
Denies fatigue
(Found)
Pro Tip: Asking Tina if she experiences unusual fatigue will help you better understand her general health.
Example Question:
Are you fatigued?
Finding:
Denies fever
(Found)
Pro Tip: Asking Tina if she experiences fevers will help you better understand her general health.
Example Question:
Have you had fevers?
Finding:
Denies chills
(Found)
Pro Tip: Asking Tina if she experiences chills will help you better understand her general health.
Example Question:
Have you had chills?
Finding:
Denies current sleep issues
(Found)
Pro Tip: Asking Tina if she experiences sleep issues will help you better understand her general health.
Example Question:
Do you sleep well?
Finding:
Denies night sweats
(Found)
Pro Tip: Asking Tina if she experiences night sweats will help you better understand her general health.
Example Question:
Have you had night sweats?
Finding:
Denies swelling
(Found)
Pro Tip: Asking Tina if she experiences swelling will help you better understand her general health.
Example Question:
Do you have swelling?

Finding:
Asked about HEENT

Finding:
Denies general HEENT issues
(Found)
Pro Tip: Broad, open questions about HEENT systems will allow Tina to describe, in her own words, any specific head conditions and symptoms that she is experiencing.
Example Question:
Have you noticed any problems with your head?

Finding:
Asked about review of systems for respiratory

Finding:
Denies current breathing problems
(Found)
Pro Tip: Determining if Tina has any current breathing problems is important for assessing her respiratory health and providing quality patient care.
Example Question:
Have you had breathing problems?
Finding:
Reports occasional shortness of breath
(Found)
Pro Tip: Determining if Tina has any current breathing problems is important for assessing her respiratory health and providing quality patient care.
Example Question:
Have you had shortness of breath?
Finding:
Reports occasional wheezing
(Found)
Pro Tip: Determining if Tina experiences wheezing is important for assessing her respiratory health and providing quality patient care.
Example Question:
Have you been wheezing?
Finding:
Reports occasional chest tightness
(Found)
Pro Tip: Determining if Tina experiences chest tightness is important for assessing her respiratory health and providing quality patient care.
Example Question:
Have you had chest tightness?
Finding:
Denies pain while breathing
(Found)
Pro Tip: Determining if Tina experiences pain while breathing is important for assessing her respiratory health and providing quality patient care.
Example Question:
Does it hurt when you breathe?
Finding:
Denies coughing
(Found)
Pro Tip: Determining if Tina has abnormal, persistent, or recurring coughs is important for assessing her respiratory health and providing quality patient care.
Example Question:
Have you been coughing?

Finding:
Asked about review of systems for cardiovascular

Finding:
Denies cardiovascular issues
(Found)
Pro Tip: Broad questions about the cardiovascular system will enable the patient to express any symptoms, concerns, or conditions concerning that she may have.
Example Question:
Do you have any heart problems?

Finding:
Asked review of systems for gastrointestinal

Finding:
Denies gastrointestinal issues
(Found)
Pro Tip: Broad questions about the gastrointestinal system will enable the patient to express any symptoms, concerns, or conditions that she may have.
Example Question:
Have you had any stomach or bowel problems?

Finding:
Asked review of systems for genitourinary

Finding:
Denies genitourinary issues
(Found)
Pro Tip: Broad questions about the genitourinary system will enable the patient to express any symptoms, concerns, or conditions that she may have.
Example Question:
Have you experienced any urinary problems?

Finding:
Asked review of systems for musculoskeletal

Finding:
Denies musculoskeletal issues
(Found)
Pro Tip: When doing a review of the musculoskeletal system, you will want to ask about general symptoms that will allow Tina to describe, in her own words, any specific bone or muscle problems that she is experiencing.
Example Question:
Do you have any bone problems?

Finding:
Asked review of systems for neurological

Finding:
Denies neurological issues
(Found)
Pro Tip: When doing a review of the neurological system, you will want to ask about general symptoms that will allow Tina to describe, in her own words, any specific neurological problems that she is experiencing.
Example Question:
Have you experienced any neurological problems?

Finding:
Asked review of systems for skin, hair and nails

Finding:
Denies integumentary issues

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

• Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
• Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
• One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
• I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

• Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
• In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
• Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
• Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

• Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
• Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
• I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

• I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
• As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
• It is best to paraphrase content and cite your source.

 LopesWrite Policy

• For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
• Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
• Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
• Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

• The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
• Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
• If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
• I do not accept assignments that are two or more weeks late unless we have worked out an extension.
• As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

• Communication is so very important. There are multiple ways to communicate with me: 
  • Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
  • Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

A Sample Answer For the Assignment:  NRS 434 Shadow Health: Comprehensive Assessment

Title: NRS 434 Shadow Health: Comprehensive Assessment

You are admitting a 19-year old female college student to the hospital for fevers.  Using the patient information provided, choose a culture unfamiliar to you and describe what would be important to remember while you interview this patient. Discuss the health care support systems available in your community for someone of this culture. If no support systems are available in your community, identify a national resource.

Cultural competence and cultural awareness is needed in nursing especially when gathering information and assessing a patient to effectively ” empower and promote health” (Grand Canyon University, 2018). This sensitivity and respect to the patients enables the nurse to have a therapeutic assessment and a trusting relationship with the patient. For example, when caring for a 19 year old female with Muslim faith, it is important to know the specifics of the culture to provide the appropriate care. Muslim faith with Islamic beliefs that women must only be seen by female health care providers to protect privacy and to minimize eye contact especially from the opposite sex (Attum, et. al. 2021). Also “for Muslims, the belief of illness is a test from God and it is a trial for removal of sin, therefore when ill they may call for spiritual intervention (Attum, et. al, 2021). For nurses unfamiliar with the culture, it may be a good advice to inquire with the patient or any accompanying family their cultural norms and how they can be treated with respect and without judgement. The Islamic Center of San diego and the Muslim community Services of San Diego are two community resources that provide valuable resources and information regarding the cultural norms.

Reference:

Attum B, Hafiz S, Malik A, et al. Cultural Competence in the Care of Muslim Patients and Their Families. [Updated 2021 Sep 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499933/

Grand Canyon University (Ed). (2018). Health promotion: Health & wellness across the continuum. Retrieved from https://lc.gcumedia.com/nrs429vn/health-promotion-health-and-wellness-across-the-continuum/v1.1/

Muslim Community Services of San DIego. Retrieved from: https://www.mcssd.org/

A Sample Answer 2 For the Assignment:  NRS 434 Shadow Health: Comprehensive Assessment

Title: NRS 434 Shadow Health: Comprehensive Assessment

When interviewing a 19-year-old female Iranian college student who has been taken to the hospital with fevers, some factors must be considered to enable successful communication and culturally appropriate care. Here are some key items to remember:

Religious Considerations: Understanding Muslims’ cultural and spiritual beliefs is essential while giving healthcare to them. Diet, modesty, privacy, touch limitation, and alcohol consumption restriction are all significant variations. The Muslim faith comprises various nationalities, each with a unique perspective on disease and treatment. As a result, many non-Muslim healthcare practitioners have difficulties in caring for Muslim patients. The Islamic faith can have an impact on decision-making, family dynamics, health behaviors, hazards, and healthcare utilization (Attum et al., 2023).

Religious Considerations: Healthcare practitioners should be especially culturally attentive and considerate during Ramadan, Islam’s Holy Month. Clinicians who understand Muslim religious traditions will be better positioned to give Muslim patients with appropriate, tailored treatment (Attum et al., 2023).

Gender Sensitivity: It is preferable for the healthcare provider to be of the same sex during a physical checkup. Obviously, there will be times when this will not be possible. In these cases, having a third person in the room of the same gender as the patient should provide comfort. If the physical exam must be performed by someone of the opposite gender, the typical rule of thumb is to warn the patient that a piece of clothing must be removed for the examination but will be returned promptly. This reduces exposure and informs the patient of the rationale for removing any garments (Attum et al., 2023).

National Resource:

American Muslim Health Professionals – they offer Muslim-run free clinics.

Documentation / Electronic Health Record

• Documentation

Vitals

Student Documentation	Model Documentation
Vitals Height: 170 cm Weight: 84 kg BMI: 29 Blood Glucose: 100 RR: 15 HR: 78 BP: 128/82 Pulse OX: 99 Temperature: 99.0 F	• Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F

Health History

Student Documentation	Model Documentation
Identifying Data & Reliability Tina Jones is a pleasant, 28-year-old African-American single woman who presents for a pre-employment physical examination. She is the primary source of the offered history. Ms. Jones gives information freely minus contradiction. Speech is clear and coherent. She maintains eye contact throughout the entire interview.	Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.
General Survey Ms. Tina Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-developed, well-nourshed and dressed appropriately with good hygiene.	Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
Reason for Visit ” I came in because I am required to have a recent physical examination for the health insurance at my new job. “	“I came in because I’m required to have a recent physical exam for the health insurance at my new job.”
History of Present Illness Ms. Jones reports that she recently was hired by Smith, Stevens, Stewart, Silver and Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynaecological exam at Shadow Health General Clinic. Ms. Jones states that the gynaecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is well-tolerating. She has type II diabetes, which she is controling with diet, exercise, and metformin, which she just started five months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.	Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre-employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.
Medications Fluticasone Propionate, 110 mcg, 2 puffs BID (last use: this morning) Metformin, 850 mg PO BID (last use this morning) Drospirenone and ethinyl estradiol PO QD (last use: this morning) Albuterol 90 mcg/ spray MDI 2 puffs, Q4H prn (last use three months ago) Acetaminophen 500-1000 mg PO PRN (FOR HEADACHES) Ibuprofen 600 mg PO TID prn (menstrual cramps; last used 6 weeks ago)	• Metformin, 850 mg PO BID (last use: this morning) • Drospirenone and ethinyl estradiol PO QD (last use: this morning) • Albuterol 90 mcg/spray MDI 1-3 puffs Q4H prn (last use: yesterday) • Acetaminophen 500-1000 mg PO prn (headaches) • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)
Allergies Penicillin: rash Denies food and latex allergy Allergic to dust and cats: When exposed to alkergens, Ms. Jones states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.	• Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.
Medical History Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved using her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and intially had some gastrointestinal side effects, which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension, which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months, after initiating Yaz, cycles regular with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.	Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she experiences exacerbations, such as around dust or cats. Her last asthma exacerbation was yesterday, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.
Health Maintenance Last papsmear 4 months ago. Last eye exam three months ago. Last dental exam 5 months ago. PPD negative – 2 years ago. Immunizations: Tetanus boster was received within the past year, influenza is not current. and human papillovirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meingoccocal vaccine for college. Safety: Has smoke detectors at home, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns having belonged to her dad are in the home, locked in the prent’s bedroom.	Last Pap smear 4 months ago. Last eye exam three months ago. Last dental exam five months ago. PPD (negative) ~2 years ago. Immunizations: Tetanus booster was received within the past year, influenza is not current, and human papillomavirus has been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine for college. Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike. Uses sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.
Family History Mother: age 50, hypertension, elevated cholesterol. Father: deceased in a car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes. Brother (Michael): 25, overweight. Sister (Brittany, 14); asthma. Maternal grandmother; died age 73 of a stroke, history of hypertension, high cholesterol. Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol. Paternal grandmother: still alive, age 82, hypertension. Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes. Paternal uncle: alcoholism Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems.	• Mother: age 50, hypertension, elevated cholesterol • Father: deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes • Brother (Michael, 25): overweight • Sister (Britney, 14): asthma • Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol • Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol • Paternal grandmother: still living, age 82, hypertension • Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes • Paternal uncle: alcoholism • Negative for mental illness, other cancers, sudden death, kidney disease, sickle cell anemia, thyroid problems
Social History Never married, no children. Lived independently since age 19, currently lives with mother and sister in single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible Study, volunteering in her church and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15-21. Reports no use of cocaine, metamphetamines, and heroine. Uses alcohol when out with friends2-3 times per month. Reports drinking more than three drinks per sitting. Typical breakfast is frozen fruit smoothie with unsweetened yoghurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks, or an apple. Denies coffe intake but does consume 1 or 2 diet sodas per day. No recent foreign travels. No pets. Participates in mild to moderate exercise 4 to 5 times per week consisting of yoga, walking, or swimming.	Never married, no children. Lived independently since age 19, currently lives with mother and sister in a single family home, but will move into own apartment in one month. Will begin her new position in two weeks at Smith, Stevens, Stewart, Silver, & Company. She enjoys spending time with friends, reading, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system. She states that family and church help her cope with stress. No tobacco. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin. Uses alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode. Typical breakfast is frozen fruit smoothie with unsweetened yogurt, lunch is vegetables with brown rice or sandwich on wheat bread or low-fat pita, dinner is roasted vegetables and a protein, snack is carrot sticks or an apple. Denies coffee intake, but does consume 1-2 diet sodas per day. No recent foreign travel. No pets. Participates in mild to moderate exercise four to five times per week consisting of walking, yoga, or swimming.
Mental Health History Reports decreased stress and improved coping abilities have improved sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to persons, place and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear.	Reports decreased stress and improved coping abilities have improved previous sleep difficulties. Denies current feelings of depression, anxiety, or thoughts of suicide. Alert and oriented to person, place, and time. Well-groomed, easily engages in conversation and is cooperative. Mood is pleasant. No tics or facial fasciculation. Speech is fluent, words are clear.
Review of Systems – General No recent or frequent illness, fatigue, fevers, chills or night sweats. States recent 10 pound loss due to diet change and exercise increase.	No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase.

HEENT

Student Documentation	Model Documentation
Subjective “I am doing well” Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visist to optometrist three months ago. Reports no general ear problems, no change in hearing, ear pain or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.	Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.
Objective Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eye brows, lids without lesions, no ptosis, or edema. Conjuctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMS intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemmorhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMS intact with pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxiallairy sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Denititon without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.	Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Respiratory

Student Documentation	Model Documentation
Subjective Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.	Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.
Objective Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV 1/ FVC ratio 80.56%.	Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Cardiovascular

Student Documentation	Model Documentation
Subjective Reports no palpitations, tachycardia, easy bruising, or edema.	Reports no palpitations, tachycardia, easy bruising, or edema.
Objective Heart rate is regular, S1, S2, withour murmurs, gallops, or rubs. Bilateral carotids equal bilaterally minus bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, liffts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refil less than 3 seconds. No peripheral edema.	Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves or lifts. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

Abdominal

Student Documentation	Model Documentation
Subjective Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge, or itching.	Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.
Objective Abdomen protuberant, no visible masses, scars or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or gurading to palpation. No organomegally. No CVA tenderness.	Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Musculoskeletal

Student Documentation	Model Documentation
Subjective Reports no msucle pain, joint pain, muscle weakness or swelling.	Reports no muscle pain, joint pain, muscle weakness, or swelling.
Objective Strength 5/5 bilaterall upper and lower extremities, without sweling, masses or deformity and with full range of motion. No pain with movement.	Bilateral upper and lower extremities without swelling, masses, or deformity and with full range of motion. No pain with movement.

Neurological

Student Documentation	Model Documentation
Subjective Reports no dizzinness, light-headeness, tingling, loss of cordination or sensation, seizures or sense of disequilibrium.	Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium.
Objective Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in lower and upper extremities. Decreased sensation in monofilament in bilateral plantar surfaces.	Strength 5/5 bilateral upper and lower extremities. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin, Hair & Nails

Student Documentation	Model Documentation
Subjective Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.	Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes.
Objective Scattered pustules on face and facial hair on upper lips, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities.	Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck.