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NURS 612 Shadow Health All Modules Cases Instructor Keys
Advnc Health Assessm (NURS 751.00)
Hunter College CUNY
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Health History - TINA JONES™
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Instructor Use Only
Ms. Jones is a pleasant, 28 -year- old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones off ers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview. Timeframe: 1 week after fall (Age: 28) Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.
Module 1 - Health History
Develop strong communication skills Interview the patient to elicit subjective health information about her health and health history Ask relevant follow-up questions to evaluate patient condition Demonstrate empathy for patient perspectives, feelings, and sociocultural background Identify opportunities to educate the patient
Document accurately and appropriately Document subjective data using professional terminology Organize appropriate documentation in the EHR
Demonstrate clinical reasoning skills Organize all components of an interview Assess risk for disease, infection, injury, and complications
After completing the assessment, you will refl ect on personal strengths, limitations, beliefs, prejudices, and values.
Learning Objectives
High Priority Acute pain of the foot Local infection of skin and subcutaneous tissue of the foot Uncontrolled type 2 diabetes mellitus
Low Priority: Acanthosis nigricans Asthma Dysmenorrhea Hirsutism Hypertension
Menorrhagia Obesity Oligomenorrhea Polycystic ovarian syndrome
Underlying ICD- 10 Diagnoses
Information Processing Activity Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective data categories include interview questions and patient data. Objective data categories include examination and patient data.
Module Features
I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking
“pretty nasty. And the pain is killing me!
Health History - TINA JONES™
© Shadow Health® 062015 || ShadowHealth For instructor use only
Instructor Use Only
One week after sustaining the cut, Tina Jones develops an infection in the cut on the bottom of her foot; she seeks treatment when the infection starts to swell and produce pus.
Day 1 (Onset): Tina was at home, going down the back steps, and she tripped. She turned her ankle and scraped the bottom of her foot. The wound bled, but she stopped the bleeding quickly and cleaned the wound. She worried that she had sprained her ankle, and her mom drove her to the ER. (“a week ago”)
The ER did an x ray (no broken bones), gave her a prescription for Tramadol, and sent her home. In the following days, her ankle seemed fi ne not as serious as she thought.
Day 2 - 4: She cleaned the wound dutifully, twice a day, with soap and water or hydrogen peroxide, let it dry, put Neosporin on it, and bandaged it. The wound wasn’t getting worse, but it wasn’t healing, either. She expresses that she “took really good care of it.” Tina was able to go to work and attend school.
Day 4: Tina went to her cousin’s house, where she encountered cats and experienced wheezing. She tried two puff s on her albuterol inhaler, and she had to do a third puff. (“three days ago”)
Day 5 - 6: Tina noticed pus in the wound, and swelling, redness and a warm feeling in her foot. Her pain increased to the point she was unable to walk. She began to take the Tramadol to try to manage the pain, but it didn’t resolve the pain completely. She missed class and work. (“two days ago”)
On the night of Day 6: Tina started to run a fever. They took her temperature at home, and it was 102. (“last night”)
Morning of Day 7: Tina fi nally recognizes that her foot infection is not going to get better, and her mom takes her to the nurse practitioner to get the foot looked at.
History of Present Illness
Medications
Acetaminophen 500- 1000 mg PO prn (headaches)
Ibuprofen 600 mg PO TID prn (menstrual cramps)
Tramadol 50 mg PO BID prn (foot pain)
Albuterol 90 mcg/spray MDI 2 puff s Q4H prn (last use: “a few months ago”)
Vitals
Weight (kg) - 88 BMI - 30. Heart Rate (HR) - 82 Respiratory Rate (RR) - 16
Pulse Oximetry - 99% Blood Pressure (BP) - 139/ Blood Glucose - 117 Temperature (F) - 98.
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.
Allergies
Printable “Answer Key” available within the Shadow Health DCE.
Subjective and Objective Model Documentation
Symptoms - Foot pain and discharge Diagnosis - Infected foot wound
Chief Complaint
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HEENT - TINA JONES™
Instructor Use Only
For the last week, Tina has experienced sore, itchy throat, itchy eyes, and runny nose. She states that these symptoms started spontaneously and have been constant in nature. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that her nose “runs all day” and has clear discharge. She denies cough and recent illness. She denies fevers, chills, and night sweats. Timeframe: 1 month after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of nose and throat symptoms.
Module 2 - HEENT
Develop strong communication skills Interview the patient to elicit subjective health information about her health and health history Ask relevant follow-up questions to evaluate patient condition Demonstrate empathy for patient perspectives, feelings, and sociocultural background Identify opportunities to educate the patient
Document accurately and appropriately Document subjective data using professional terminology Organize appropriate documentation in the EHR
Demonstrate clinical reasoning skills Organize all components of an interview Assess risk for disease, infection, injury, and complications
After completing the assessment, you will refl ect on personal strengths, limitations, beliefs, prejudices, and values.
Learning Objectives
“My throat has been sore and itchy for a week now, and my nose won’t stop running. It’s not getting
“worse, but it’s not going away either.
J30, Allergic rhinitis due to pollen
Underlying ICD- 10 Diagnoses
Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective data categories include interview questions and patient data. Objective data categories include examination and patient data.
Module Features
© Shadow Health® 072015 || ShadowHealth For instructor use only
HEENT - TINA JONES™
Instructor Use Only
Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week. She states that these symptoms started spontaneously and have been constant in nature. She does not note any specifi c aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10. She has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that she has some soreness when swallowing, but otherwise no other associated symptoms. She states that her nose “runs all day” and is clear discharge. She has not attempted any treatment for her nasal symptoms. She states that her eyes are constantly itchy and she has not attempted any eye specifi c treatment. She denies cough and recent illness. She has had no exposures to sick individuals. She denies changes in her hearing, vision, and taste. She denies fevers, chills, and night sweats. She has never been diagnosed with seasonal allergies, but does note that her sister has “hay fever”.
History of Present Illness
Medications
Albuterol 90 mcg/spray MDI 2 puff s Q4H prn (Wheezing: “when around cats,” last use in the past week)
Acetaminophen 5001000 mg PO prn (headaches
Ibuprofen 600 mg PO TID prn (cramps)
Vitals
Weight (kg) - 89 BMI - 30. Heart Rate (HR) - 80 Respiratory Rate (RR) - 16
Pulse Oximetry - 99% Blood Pressure (BP) - 141/ Blood Glucose - 199 Temperature (F) - 99.
General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. Head: Denies history of trauma. Denies current headache. Eyes: She does not wear corrective lenses, but notes that her vision has been worsening over the past few years. She complains of blurry vision after reading for extended periods. Denies increased tearing or itching prior to this past week. Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffi ness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week.
Review of Systems
Printable “Answer Key” available within the Shadow Health DCE.
Subjective and Objective Model Documentation
Symptoms - Sore and itchy throat, runny nose, itchy eyes Diagnosis - Allergic rhinitis
Chief Complaint
© Shadow Health® 072015 || ShadowHealth For instructor use only
Respiratory - TINA JONES™
Instructor Use Only
Tina had an asthma episode 2 days ago. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Tina presents with continued shortness of breath and wheezing. Timeframe: 3 months after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved.
Module 3 - Respiratory
Develop strong communication skills Interview the patient to elicit subjective health information about her health and health history Ask relevant follow-up questions to evaluate patient condition Demonstrate empathy for patient perspectives, feelings, and sociocultural background Identify opportunities to educate the patient
Document accurately and appropriately Document subjective data using professional terminology Organize appropriate documentation in the EHR
Demonstrate clinical reasoning skills Organize all components of an interview Assess risk for disease, infection, injury, and complications
After completing the assessment, you will refl ect on personal strengths, limitations, beliefs, prejudices, and values.
Learning Objectives
Two days ago, I had a kind of asthma attack. Since then, I’ve been using my inhaler a lot, and it’s not helping like it usually does. I want to get my asthma back under control.
“
J45, Asthma J45, Asthma with acute exacerbation with acute exacerbation
Underlying ICD- 10 Diagnoses
Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective data categories include interview questions and patient data. Objective data categories include examination and patient data.
Module Features
© Shadow Health® 072015 || ShadowHealth For instructor use only
Respiratory - TINA JONES™
Instructor Use Only
Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7-8/10 severity and lasted fi ve minutes. She did not experience any chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing, and has a nonproductive cough and episodes of shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying fl at, activity, and are accompanied by a non-productive cough. She awakens with night-time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities and she is concerned that her albuterol inhaler seems to be less eff ective than previous. Currently she states that her breathing is normal. Diagnosed with asthma at age 2 years. She has no recent use of spirometry, does not use a peak fl ow, does not record attacks, and does not have a home nebulizer or vaporizer. She has been hospitalized fi ve times for asthma, last at age 16. She has never been intubated for her asthma. She does not have a current pulmonologist or allergist.
History of Present Illness
Medications
Albuterol 90 mcg/spray MDI 2 puff s Q4H prn (Wheez- ing: “when around cats,” last use this morning). She does admit to needed an occasional third puff for symptom relief. She reports that the inhaler does not seem to be as eff ective in treating her symptoms recently.
Acetaminophen 500-1000 mg PO prn (headaches)
Ibuprofen 600 mg PO TID prn (cramps)
Vitals
Weight (kg) - 89 BMI - 30. Heart Rate (HR) - 89 Respiratory Rate (RR) - 20
Pulse Oximetry - 97% Blood Pressure (BP) - 140/ Blood Glucose - 224 Temperature (F) - 98.
General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. Nose/Sinuses: Denies rhinorrhea with this episode. Denies stuffi ness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16.
Review of Systems
Printable “Answer Key” available within the Shadow Health DCE.
Subjective and Objective Model Documentation
Symptoms - Shortness of breath, decreased inhaler eff ectiveness Diagnosis - Asthma exacerbation
Chief Complaint
For instructor use Focused Exam Case - G DRivera v1 || Copyright © 2014 ShadowHealth
FOCUSED EXAM CASE
Graduate - Cough (Daniel “Danny” Rivera™)
Daniel “Danny” Rivera is an 8-year-old boy who comes to the clinic with a cough. Students determine if Danny is in distress, explore the underlying cause of his cough, and look for related symptoms in other body systems.
Introduction
5 Perform a focused assessment of the respiratory system - Gather subjective and objective data - Select and use the appropriate tools and tests necessary for a focused exam - Consider and assess regional system involvement
5 Differentiate between variations of normal and abnormal assessment findings to determine the cause and severity of the event.
- Create a differential diagnosis
5 Practice patient-centered care
- Convey empathy with therapeutic communication
- Provide patient education on condition, diagnosis, or treatment while respecting variance in health literacy
- Express consideration and respect for patient perspectives, feelings, and sociocultural background 5 Evaluate, and document patient assessment data using information systems technology 5 Interview using communication techniques appropriate for a pediatric patient 5 Promote patient safety, privacy, and infection control 5 Communicate critical information effectively to another healthcare professional during the transfer of patient care. 5 Reflect on personal strengths, limitations, beliefs, prejudices, and values
Learning Objectives
“I’ve been coughing a lot the past four... no I’ve been coughing for five days.”
Chief Complaint
- Primary: Respiratory
- Secondary: HEENT, Cardiovascular
Body Systems of Study
Case Highlights
Ask about a variety of psychosocial factors related to home life, such as second-hand smoke exposure Observe non-verbal cues as Danny presents with intermittent coughing and visible breathing difficulty Rule out asthma, a common childhood affliction, by examining Danny
Abnormal Findings
INTERVIEW - Reports wet cough for several days - Cough is worse at night - Reports frequent cough as part of medical history - Father smokes indoors - Frequent ear infections when he was younger - Frequent rhinorrhea - Had pneumonia last year - Starting to feel pain in his right ear
EXAM - Rhinorrhea with clear mucus; inside nostril appearance red - Increased respiratory rate - Appears fatigued - Nasal discharge, boggy turbinate, and visible crease on nose from rubbing - Audible coarse crackles in upper airway; bronchovesicular on both sides, clears with cough - Mild tachycardia - Lymph nodes enlarged and tender on the right side - Right ear has erythematous; canal is clear and a little red. The tympanic membrane is red and inflamed - Fine bumps on tongue - Tenderness in throat; “cobble stoning” in back of throat
Danny Rivera, 8
© Shadow Health® 072015 || ShadowHealth For instructor use only
Cardiovascular - TINA JONES™
Instructor Use Only
Over the last month, Tina has experienced 3 -4 episodes of perceived rapid heart rate. She describes these episodes as “thumping in her chest” with a heart rate that is “way faster than usual”. She does not associate the rapid heart rate with a specifi c event, but notes that they usually occur about once per week in the morning on her commute to class. The episodes generally last between 5 and 10 minutes and resolve spontaneously. She denies chest pain during the episodes. Timeframe: 4 months after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of recent episodes of fast heartbeat.
Module 4 - Cardiovascular
Develop strong communication skills Interview the patient to elicit subjective health information about her health and health history Ask relevant follow-up questions to evaluate patient condition Demonstrate empathy for patient perspectives, feelings, and sociocultural background Identify opportunities to educate the patient
Document accurately and appropriately Document subjective data using professional terminology Organize appropriate documentation in the EHR
Demonstrate clinical reasoning skills Organize all components of an interview Assess risk for disease, infection, injury, and complications
After completing the assessment, you will refl ect on personal strengths, limitations, beliefs, prejudices, and values.
Learning Objectives
I’ve noticed my heart has been beating faster than usual lately, and I thought it was something I should
“get checked out.
R00, Palpitations
Underlying ICD- 10 Diagnoses
Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective data categories include interview questions and patient data. Objective data categories include examination and patient data.
Module Features
© Shadow Health® 072015 || ShadowHealth For instructor use only
Cardiovascular - TINA JONES™
Instructor Use Only
Abnormal Findings
Subjective (Reported by Tina) Experienced 3-4 episodes of fast heartbeat and a “thumping feeling” in the last month Episodes accompanied by mild anxiety Increased stress related to work and school Increased caff eine consumption from diet soda and energy drinks Risk factors for cardiovascular disease: type 2 diabetes, sedentary lifestyle and family history of high cholesterol and hypertension
Objective (Found by the student performing physical exam) Heart rate in the clinic is not tachycardic: 90 bpm Hypertensive blood pressure reading: 145 / 90 Risk factor for cardiovascular disease: Obesity (BSM 31)
Assessment
Palpitations related to caff eine and/or anxiety
Plan
- Encourage Ms. Jones to continue to monitor symptoms and log her episodes of palpitations with associated factors and bring log to next visit.
- Obtain EKG to rule out any cardiac abnormality and assess for symptom correlated EKG changes. If inconclusive, consider ambulatory EKG monitoring and referral to Cardiologist
- Encourage to decrease caff eine consumption and increase intake of water and other fl uids.
- Educate on anxiety reduction strategies including deep breathing, relaxation, and guided imagery. Continue to monitor and explore the need for possible referral to social work/psychiatry or pharmacologic intervention.
- Discuss the need to maintain a stable blood pressure. Encourage Ms. Jones to continue to monitor her blood pressure when a cuff or machine is available.
- Educate Ms. Jones on when to seek emergent care including episodes of chest pain unrelieved by rest, palpitations that do not dissipate after anxiety related strategies were implemented, changes in vision, loss of consciousness, and sense of impending doom.
- Revisit clinic in 2 4 weeks for follow up and evaluation.
FOCUSED EXAM CASE
For instructor use Focused Exam Case - G BFoster v1 || Copyright © 2014 ShadowHealth
Graduate - Chest Pain (Brian Foster ™)
This assignment provides the opportunity to conduct a focused exam on a patient presenting with recent episodes of chest pain. Interview the patient, assess the related body systems, produce a differential diagnosis, and then report to your preceptor.
Introduction
Develop strong communication skills - Interview the patient to elicit subjective health information about his symptoms - Ask relevant follow-up questions to evaluate patient condition - Demonstrate empathy for patient perspectives, feelings, and sociocultural background - Identify opportunities to educate the patient Develop strong physical assessment skills - Select and use the appropriate procedures for a focused cardiac exam - Differentiate between normal and abnormal assessment findings to determine the cause and severity of the event Document accurately and appropriately - Document subjective data using professional terminology - Document objective data using professional terminology Demonstrate clinical reasoning skills - Organize all components of a focused cardiac exam - Assess risk for disease, infection, injury, and complications - Create a differential diagnosis
After completing the assessment, you will communicate critical information effectively to another healthcare professional, and then reflect on personal strengths, limitations, beliefs, prejudices, and values.
Learning Objectives
“I have been having some troubling chest pain in my chest now and then for the past month.”
Chief Complaint
- Primary: Cardiovascular
- Secondary: Respiratory, Abdominal
Body Systems of Study
Abnormal Findings
INTERVIEW - Reports episodes of chest pain - Reports diagnosis of hypertension one year ago - Reports diagnosis of hyperlipidemia one year ago
EXAM - PMI displaced laterally - S3 noted at mitral area - Right side carotid bruit - Fine crackles/rales in posterior bases of L/R lungs
Case Highlights
Brian Foster, 58
Evaluate a cardiac complaint in a non-emergency setting
Learn about Mr. Foster’s personal and family history with heart disease
Identify lifestyle risk factors
Avg. 45 min. start to finish
© Shadow Health® 072015 || ShadowHealth For instructor use only
Gastrointestinal - TINA JONES™
Instructor Use Only
Ms. Jones is a pleasant 28 -year- old African American woman who presented to the clinic with complaints of upper stomach pain after eating. She noticed the pain about a month ago. She states that she experiences pain daily, but notes it to be worse 3 -4 times per week. Pain is a 5/10 and is located in her upper stomach. She describes it “kind of like heartburn” but states that it can be sharper. She notes it to increase with consumption of food and specifi cally fast food and spicy food make pain worse. She does notice that she has increased burping after meals. She states that time generally makes the pain better, but notes that she does treat the pain “every few days” with an over the counter antacid with some relief.
History of Present Illness
Medications
OTC antacid prn, last taken yesterday Fluticasone propionate, 110 mcg 2 puff s BID (last use: this morning)
Albuterol 90 mcg/spray MDI 2 puff s Q4H prn (last use: “a few months ago”)
Acetaminophen 500 1000 mg PO prn (headaches)
Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken a month ago)
Vitals
Weight (kg) - 85 BMI - 29. Heart Rate (HR) - 80 Respiratory Rate (RR) - 15
Pulse Oximetry - 98% Blood Pressure (BP) - 138/ Blood Glucose - 131 Temperature (F) - 99.
General: Denies changes in weight and general fatigue. She denies fevers, chills, and night sweats. Cardiac: Denies a diagnosis of hypertension, but states that she has been told her blood pressure was high in the past. She denies known history of murmurs, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or edema. Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16 Gastrointestinal: States that in general her appetite is unchanged, although she does note that she will occasionally experience loss of appetite in anticipation of the pain associated with eating. Denies nausea, vomiting, diarrhea, and constipation. Bowel movements are daily and generally brown in color. Denies any change in stool color, consistency, or frequency. Denies blood in stool, dark stools, or maroon stools. No blood in emesis. No known jaundice, problems with liver or spleen.
Review of Systems
Printable “Answer Key” available within the Shadow Health DCE.
Subjective and Objective Model Documentation
Symptoms - Recurrent stomach pain Diagnosis -GERD
Chief Complaint
© Shadow Health® 072015 || ShadowHealth For instructor use only
Gastrointestinal - TINA JONES™
Instructor Use Only
Abnormal Findings
Subjective (Reported by Tina) Reports daily occurring stomach pain, with 3 to 4 episodes a week that are more severe Pain begins right after fi nishing a meal and lasts a few hours Describes the pain as similar to heartburn, located in center of upper stomach Pain worsens with larger or spicy meals, and with supine body position Decreased appetite and increased burping
Objective (Found by the student performing physical exam) Abdominal exam results are normal (inspection, auscultation, percussion, and palpation), which allows students to eliminate diff erential diagnoses such as appendicitis or cholecystitis.
Assessment
Gastroesophageal refl ux disease without evidence of esophagitis
Plan
- Educate on lifestyle changes including weight loss, engagement in daily physical activity, and limitation of foods that may aggravate symptoms including chocolate, citrus, fruits, mints, coff ee, alcohol, and spicy foods.
- Ms. Jones may elevate the head of her bed or sleep on a wedge-shaped bolster for comfort or symptom reduc- tion.
- Encourage to eat smaller meals and to avoid eating 2- 3 hours before bedtime.
- Educate on dietary reduction in fat to decrease symptoms.
- Trial of ranitidine 150 mg by mouth daily for two weeks. If reduction in symptoms, Ms. Jones may continue therapy. If symptoms persist, consider testing for helicobacter pylori, trial of a proton pump inhibitor, or up- per endoscopy.
- Educate on when to seek emergent care including signs and symptoms of upper and lower gastrointestinal bleed, weight loss, and chest pain.
- Return to clinic in two weeks for evaluation and follow up.
© Shadow Health® 072015 || ShadowHealth For instructor use only
Musculoskeletal - TINA JONES™
Instructor Use Only
Three days ago, Ms. Jones injured (“tweaked”) her back lifting a box. The pain is in her low back and bilateral buttocks, is a constant aching with stiff ness, and does not radiate. The pain is aggravated by sitting and decreased by rest and lying fl at on her back. She presents today as the pain has continued and is interfering with her activities of daily living. Timeframe: 8 months after establishing primary care (Age: 28) Reason for visit: Patient presents complaining of lower back pain.
Module 6 - Musculoskeletal
Develop strong communication skills Interview the patient to elicit subjective health information about her health and health history Ask relevant follow-up questions to evaluate patient condition Demonstrate empathy for patient perspectives, feelings, and sociocultural background Identify opportunities to educate the patient
Document accurately and appropriately Document subjective data using professional terminology Organize appropriate documentation in the EHR
Demonstrate clinical reasoning skills Organize all components of an interview Assess risk for disease, infection, injury, and complications
After completing the assessment, you will refl ect on personal strengths, limitations, beliefs, prejudices, and values.
Learning Objectives
“I was helping my friend Selena move into the house she just bought, and I think I tweaked my back li ing
“a box. I’ve been having back pain ever since.”
M54, Muscle strain in low back
Underlying ICD- 10 Diagnoses
Student Performance Index - This style of rubric contains subjective and objective data categories. Subjective data categories include interview questions and patient data. Objective data categories include examination and patient data.
Module Features
© Shadow Health® 072015 || ShadowHealth For instructor use only
Musculoskeletal - TINA JONES™
Instructor Use Only
Ms. Jones presents to the clinic complaining of “horrible” back pain that began 3 days ago after she “tweaked it” while lifting a heavy box while helping a friend move. She states that she lifted several boxes before this event without incident and does not know the weight of the box that caused her pain. The pain is in her low back and bilateral buttocks, is a constant aching with stiff ness, and does not radiate. The pain is aggravated by sitting (rates a 7/10) and decreased by rest and lying fl at on her back (pain of 3-4/10). The pain has not changed over the past three days and she has treated with 2 over the counter ibuprofen tablets every 5- 6 hours. Her current pain is a 5/10, but she states that the ibuprofen can decrease her pain to 2-3/10. She denies numbness, tingling, muscle weakness, bowel or bladder incontinence. She presents today as the pain has continued and is interfering with her activities of daily living.
History of Present Illness
Medications
Ibuprofen 200 mg tablets, 1-2 tablets every 5-6 hours (last use: 5 hours ago)
Fluticasone propionate 110 mcg 2 puff s BID (last use: this morning)
Albuterol 90 mcg/spray MDI 2 puff s Q4H prn (last use: “a few months ago”)
Acetaminophen 500- 1000 mg PO prn (headaches)
Vitals
Weight (kg) - 87 BMI - 30. Heart Rate (HR) - 88 Respiratory Rate (RR) - 14
Pulse Oximetry - 99% Blood Pressure (BP) - 141/ Blood Glucose - 91 Temperature (F) - 99.
General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. Musculoskeletal: Denies muscle weakness, pain, joint instability, or swelling. She does state that she has diffi culties with range of motion. She does state that the pain in her lower back has impacted her comfort while sleeping and sitting in class. She denies numbness, tingling, radiation, or bowel/bladder dysfunction. She denies previous musculoskeletal injuries or fractures. Neurologic: Denies loss of sensation, numbness, tingling, tremors, weakness, paralysis, fainting, blackouts, or seizures.
Review of Systems
Printable “Answer Key” available within the Shadow Health DCE.
Subjective and Objective Model Documentation
Symptoms - Back pain Diagnosis - Muscle strain in lower back
Chief Complaint
NURS 612 Shadow Health All Modules Cases Instructor Keys
Course: Advnc Health Assessm (NURS 751.00)
University: Hunter College CUNY
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