Shadow health tina jones musculoskeletal

Assess The Musculoskeletal System Of Tina Jones, A Digital Standardized Patient. Interview And Examine The Patient, And Document Your Findings

Please submit your post work to Canvas within 24 hours of the completion of your VCBC Experience. Please refer to the Experiential Learning Orientation for further questions and a reminder on how to ensure your assignment is properly saved.

Please complete the Concept Notebook (Map) for the concept of Assessment linked to your clients for the day.

Concept Notebook Template.docx download
205-225 Concept Notebook Rubric V2.docx download
Rubric
205/225 Concept Notebook Rubric205/225 Concept Notebook RubricCriteriaRatingsPtsThis criterion is linked to a Learning OutcomeRelated Concept1 ptsSatisfactoryDocumented at least 2 concepts, related to the client with a detailed explanation of each related concept and how the related concept is impacted by the main concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented at least 1 concept, 1 concept is related to the client, or only minimal explanation of each related concept and how the related concept is impacted by the main concept, or incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no related concept, did not relate the concept to the client, no explanation of each related concept and how the related concept is impacted by the main concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeExemplar1 ptsSatisfactoryDocumented at least 3 Exemplars, related to the client and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2 Exemplars, 1-2 concepts are related to the client, or incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no Exemplars , did not relate the concept to the client and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeAssessment1 ptsSatisfactoryDocumented at least 3 assessments used to find and rule out alterations with the main concept and are all related to the client, a detailed explanation of each assessment and why one would do that assessment relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2 assessments used to find and rule out alterations with the main concept and 1-2 relate to the client, minimal explanation of why one would do that assessment relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no assessments used to find and rule out alterations with the main concept and did not relate to the client, no explanation of why one would do that assessment relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeLab & Diagnostic1 ptsSatisfactoryDocumented at least 3 lab or diagnostic test used to find and rule out alterations with the main concept and all related to the client, a detailed explanation of each lab/test and why one would do that lab/test relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2 lab or diagnostic test used to find and rule out alterations with the main concept, 1-2 relate to the client, minimal explanation of each lab/test and why one would do that lab/test relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no lab or diagnostic test used to find and rule out alterations with the main concept and did not relate to the client, no explanation of each lab/test and why one would do that lab/test relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeInterventions1 ptsSatisfactoryDocumented at least 3 nursing interventions needed to care for clients with alterations to the main concept and all related to the client, a detailed explanation of each intervention and why one would perform the interventions relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2 nursing interventions needed to care for clients with alterations to the main concept, 1-2 relate to the client, minimal explanation of each intervention and why one would perform the interventions relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no nursing interventions needed to care for clients with alterations to the main concept and did not relate to the client, no explanation of each intervention and why one would perform the interventions relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeMedications1 ptsSatisfactoryDocumented at least 3 medications administered to clients to treat or prevent alterations to the main concept and all related to the client, a detailed explanation of each medication and why one would administer the medication relating o the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1-2medications administered to clients to treat or prevent alterations to the main concept, 1-2 relate to the client, minimal explanation of each medication and why one would administer the medication relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no medications administered to clients to treat or prevent alterations to the main concept and did not relate to the client, no explanation of each medication and why one would administer the medication relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomePotential Complications1 ptsSatisfactoryDocumented at least 2 potential problems that could occur if alterations to the main concept are not addressed/treated and all related to the client, a detailed explanation of each complication and how it could occur relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented 1 potential problem that could occur if alterations to the main concept are not addressed/treated, 1 concept is related to the client, minimal explanation of each complication and how it could occur relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no potential problems that could occur if alterations to the main concept are not addressed/treated, did not relate the concept to the client, no explanation of each complication and how it could occur relating to the concept, and incorrect APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeCollaborative Care1 ptsSatisfactoryDocumented at least 1 department/ancillary staff that may be needed to treat clients who have or are at risk for alterations with the main concept and is related to the client, a detailed explanation of each how that department/ancillary staff could assist the client relating to the concept, and correct APA in-text citations (if used).0.5 ptsNeeds ImprovementDocumented at least 1 department/ancillary staff that may be needed to treat clients who have or are at risk for alterations with the main concept and is related to the client, minimal explanation of each how that department/ancillary staff could assist the client relating to the concept, and incorrect APA in-text citations (if used).0 ptsUnsatisfactoryDocumented no department/ancillary staff that may be needed to treat clients who have or are at risk for alterations with the main concept, did not relate the concept to the client, no explanation of each how that department/ancillary staff could assist the client relating to the concept, and no APA in-text citations (if used).1 pts
This criterion is linked to a Learning OutcomeSpelling and Grammar1 ptsSatisfactory0- 2 mistakes in spelling or grammar.0.5 ptsNeeds Improvement3 -4 mistakes in spelling or grammar.0 ptsUnsatisfactory5 or more mistakes in spelling or grammar.1 pts
This criterion is linked to a Learning OutcomeReferences1 ptsSatisfactoryCorrect APA references.0.5 ptsNeeds ImprovementIncorrect APA references.0 ptsUnsatisfactoryNo APA references.1 pts
Total Points: 10PreviousNext

Musculoskeletal Results | Turned In Patient Assessment and

Experience Overview

Patient: Tina Jones

Digital Clinical Experience Score

100% This score measures your performance on the Student Performance Index in relation to other students in comparable academic programs. Your instructor has chosen to scale your Student Performance Index score so that the average score on the index is a 80.0%. This score may not be your final grade if your instructor chooses to include additional components, such as documentation or time spent.

Student Performance Index

50.6 out of

51 Proficiency Level:

Proficient

 Beginning

 Developing

 Proficient

Students rated as “beginning” are starting to develop their nursing competencies and clinical reasoning skills. In comparable nursing programs, 50% of students perform at the level of a beginning nurse. Review your results in the tabs on the left side of the page to identify areas for improvement. Students rated as “developing” demonstrate increasing clinical reasoning abilities as they apply their nursing knowledge. In comparable nursing programs, 25% of students perform at the level of a developing nurse. Review your results in the tabs on the left side of the page to identify areas for improvement. Students rated as “proficient” demonstrate entry­level expertise in nursing competencies and clinical reasoning skills. In comparable nursing programs, the top 25% of students perform at the level of a proficient nurse.

Subjective Data Collection

23 out of

https://app.shadowhealth.com/assignment_attempts/4721684#beginning-content
https://app.shadowhealth.com/assignment_attempts/4721684#proficient-content
https://app.shadowhealth.com/assignment_attempts/4721684#developing-content
23

Objective Data Collection

27.6 out of 28

Time

43 minutes total spent in assignment

Interaction with patient

35 minutes

Post-exam activities

8 minutes

Transcript

Started:Mar 29, 2019 | Patient Exam Time:35 min

All Lines (136)Interview Questions (56)Statements (0)Exam Actions (80)

Hello!

Question 03/29/19 2:22 PM EDT

Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam.At the end of this prebrief, you will answer a short question about the upcoming assignment.During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.

What is the situation?

Question 03/29/19 2:22 PM EDT

It's 8 a.m. on Tina Jones' second morning as a patient here at Shadow General Hospital. Ms. Jones has a physical therapy consultation later today. Your role in this simulation is that of healthcare provider who will perform a full musculoskeletal system exam on Ms. Jones so that her therapist can understand Ms. Jones' musculoskeletal health and customize therapy accordingly.

What are my objectives in this assessment?

Question 03/29/19 2:22 PM EDT

In your interview with Ms. Jones, you will ask about her musculoskeletal system and identify any risk factors or complications.If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. You will also inquire into the health history of Ms. Jones' family with regards to the musculoskeletal system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her musculoskeletal system.In addition to collecting subjective data, you will perform a physical exam on Ms. Jones' musculoskeletal system to gather objective data about the system's health and physiology.

While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes.You may complete the exam activities in any order and move between them as needed.

What else will this exam involve?

Question 03/29/19 2:23 PM EDT

You will complete nursing tasks to protect the patients safety, privacy, and health.You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real­world counterparts. However, they are not automatically graded by the simulation.

How will I be evaluated?

Question 03/29/19 2:24 PM EDT

In this assignment, you will be evaluated on your Subjective and Objective Data Collection.The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth.The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record.This assignment takes on average between 50 and 60 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.

How does this assignment prepare me for the real world?

Question 03/29/19 2:24 PM EDT

In this assessment, you will become familiarized with the structure and content of musculoskeletal exams so that with real­life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient's risk of disease, infection, injury, and complications º and obtain and assess objective data.

In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What precautions should you take with a patient that is a fall risk?

With a patient in a fall risk, you should have them only get up when there is someone with them, use bed alarm and have them wear a fall risk band.

Statement 03/29/19 2:26 PM EDT

Time to begin.

Good Morning Tina, My name is jenn i will be your nurse today

Greet 03/29/19 2:28 PM EDT

Hey.

Can you tell me your name and date of birth

Question 03/29/19 2:28 PM EDT

My name's Tina Jones, and my birthday's February 17th.

Vitals measured

Exam Action 03/29/19 2:29 PM EDT

ON a 0­10 scale, how would you rate your pain right now tina

Question 03/29/19 2:29 PM EDT

I'd give it a 5 or 6 out of 10 right now.

do you have any problems with your joints

Question 03/29/19 2:30 PM EDT

No, my joints are fine.

do you have any pain in your joints

Question 03/29/19 2:30 PM EDT

My joints don't hurt.

have you noticed any swelling in your joints

Question 03/29/19 2:31 PM EDT

No, I've never had joint problems.

do you have any muscle pain

Question 03/29/19 2:31 PM EDT

My muscles don't hurt.

do you have any muscle weakness

Question 03/29/19 2:31 PM EDT

No, I wouldn't say I feel weak.

do you have any bone pain

Question 03/29/19 2:31 PM EDT

My bones aren't hurting me, no.

have you had any recent injury or trauma to your bones

Question 03/29/19 2:32 PM EDT

I haven't had anything really serious before. I think my foot right now is the worst injury I've had!

are you able o bathe yourself normally (No matching questions found.)

Question 03/29/19 2:32 PM EDT

are you able to bathe yourself

Question 03/29/19 2:32 PM EDT

I've been stuck sitting on my butt for the last few days with my foot hurting so much. I could get out of bed, but my walk was basically a hobble so I stayed at home.

have you needed any help pto shower

Question 03/29/19 2:33 PM EDT

I don't need anything right now, thanks.

do you have chronic health issues

Question 03/29/19 2:33 PM EDT

I've had asthma since I was little, and I have sugar diabetes, too.

do you have family history of joint disease (Clarified to Any family member with degenerative joint disorder?.)

Question 03/29/19 2:34 PM EDT

No, I don't think so. (Clarified to if I have a family history of degenerative joint disease.)

do you have any history of arthritis (Clarified to Has anyone in your family had arthritis?.)

Question 03/29/19 2:34 PM EDT

No, I don't know about that. (Clarified to if anyone in my family has arthritis.)

do you have a history with arthritis

Question 03/29/19 2:35 PM EDT

No, I don't have arthritis! I'm a little young for that. . .

do you have any family history of hip replacements (Clarified to Does obesity run in your family?.)

Question 03/29/19 2:35 PM EDT

No, I don't think so. My brother and my dad are kind of big, but I wouldn't say they were obese or anything. (Clarified to if obesity runs in my family.)

Have you been able to function normally (Clarified to Can you change positions?.)

Question 03/29/19 2:36 PM EDT

I can sit up and everything, but I'd definitely need some help to stand up or walk since my foot is still hurting so bad. (Clarified to if I can change positions.)

have you been able to do normal activities on your own (Clarified to Have you been able to work?.)

Question 03/29/19 2:36 PM EDT

I've had to miss work for sure­­I'm on my feet all day for my job, and that obviously wouldn't work with my foot the way it is, if I could even get over there. (Clarified to if I have been able to work.)

Inspected front of neck

Exam Action 03/29/19 2:37 PM EDT

Inspected left side of neck

Exam Action 03/29/19 2:37 PM EDT

Inspected back of neck

Exam Action 03/29/19 2:37 PM EDT

Inspected right side of neck

Exam Action 03/29/19 2:37 PM EDT

Inspected front of neck

Exam Action 03/29/19 2:37 PM EDT

Inspected shoulders from the front

Exam Action 03/29/19 2:37 PM EDT

Inspected left shoulder

Exam Action 03/29/19 2:37 PM EDT

Inspected upper back

Exam Action 03/29/19 2:37 PM EDT

Inspected right shoulder

Exam Action 03/29/19 2:37 PM EDT

Inspected shoulders from the front

Exam Action 03/29/19 2:37 PM EDT

Inspected left arm

Exam Action 03/29/19 2:37 PM EDT

Inspected right arm

Exam Action 03/29/19 2:37 PM EDT

Inspected left elbow

Exam Action 03/29/19 2:38 PM EDT

Inspected right elbow

Exam Action 03/29/19 2:38 PM EDT

Inspected left wrist

Exam Action 03/29/19 2:38 PM EDT

Inspected both wrists

Exam Action 03/29/19 2:38 PM EDT

Inspected right wrist

Exam Action 03/29/19 2:38 PM EDT

Inspected both hands

Exam Action 03/29/19 2:38 PM EDT

Inspected left hand

Exam Action 03/29/19 2:38 PM EDT

Inspected right hand

Exam Action 03/29/19 2:38 PM EDT

Inspected front of hips

Exam Action 03/29/19 2:38 PM EDT

Inspected left side of hips

Exam Action 03/29/19 2:38 PM EDT

Inspected back of hips

Exam Action 03/29/19 2:38 PM EDT

Inspected right side of hips

Exam Action 03/29/19 2:38 PM EDT

Inspected front of thighs

Exam Action 03/29/19 2:39 PM EDT

Inspected left thigh

Exam Action 03/29/19 2:39 PM EDT

Inspected back of thighs

Exam Action 03/29/19 2:39 PM EDT

Inspected right thigh

Exam Action 03/29/19 2:39 PM EDT

Inspected front of knees

Exam Action 03/29/19 2:39 PM EDT

Inspected left knee

Exam Action 03/29/19 2:39 PM EDT

Inspected back of knees

Exam Action 03/29/19 2:39 PM EDT

Inspected right knee

Exam Action 03/29/19 2:39 PM EDT

Inspected front of legs

Exam Action 03/29/19 2:39 PM EDT

Inspected left leg

Exam Action 03/29/19 2:39 PM EDT

Inspected back of legs

Exam Action 03/29/19 2:39 PM EDT

Inspected right leg

Exam Action 03/29/19 2:39 PM EDT

Inspected left ankle

Exam Action 03/29/19 2:40 PM EDT

Inspected both ankles

Exam Action 03/29/19 2:40 PM EDT

Inspected right ankle

Exam Action 03/29/19 2:40 PM EDT

Inspected left foot

Exam Action 03/29/19 2:40 PM EDT

Inspected soles of feet: Right: Laceration and swelling, expected curvature. Left: No visible abnormal findings, expected curvature.

Exam Action 03/29/19 2:40 PM EDT

Inspected right foot

Exam Action 03/29/19 2:40 PM EDT

Tested ROM of neck ­ extension: Expected

Exam Action 03/29/19 2:41 PM EDT

Tested ROM of neck ­ flexion: Expected

Exam Action 03/29/19 2:41 PM EDT

Tested ROM of neck ­ lateral bending: Expected

Exam Action 03/29/19 2:41 PM EDT

Tested ROM of neck ­ rotation: Expected

Exam Action 03/29/19 2:41 PM EDT

Tested ROM of shoulders ­ adduction: Expected

Exam Action 03/29/19 2:41 PM EDT

Tested ROM of shoulders ­ extension: Expected

Exam Action 03/29/19 2:42 PM EDT

Tested ROM of shoulders ­ flexion: Expected

Exam Action 03/29/19 2:42 PM EDT

Tested ROM of elbows ­ flexion and extension: Expected

Exam Action 03/29/19 2:42 PM EDT

Tested ROM of elbows ­ supination and pronation: Expected

Exam Action 03/29/19 2:42 PM EDT

Tested ROM of wrists ­ ulnar and radial deviation: Expected

Exam Action 03/29/19 2:43 PM EDT

Tested ROM of wrists ­ extension: Expected

Exam Action 03/29/19 2:43 PM EDT

Tested ROM of wrists ­ flexion: Expected

Exam Action 03/29/19 2:43 PM EDT

Tested spinal ROM ­ extension: Expected

Exam Action 03/29/19 2:43 PM EDT

Tested spinal ROM ­ flexion: Expected

Exam Action 03/29/19 2:43 PM EDT

Tested spinal ROM ­ lateral bending: Expected

Exam Action 03/29/19 2:44 PM EDT

Tested spinal ROM ­ rotation to the left: Expected

Exam Action 03/29/19 2:44 PM EDT

Tested spinal ROM ­ rotation to the right: Expected

Exam Action 03/29/19 2:44 PM EDT

Tested ROM of hips ­ abduction: Expected

Exam Action 03/29/19 2:44 PM EDT

Tested ROM of hips ­ adduction: Expected

Exam Action 03/29/19 2:45 PM EDT

Tested ROM of hips ­ extension: Expected

Exam Action 03/29/19 2:45 PM EDT

Tested ROM of hips ­ flexion: Expected

Exam Action 03/29/19 2:45 PM EDT

Tested ROM of knees ­ extension: Expected

Exam Action 03/29/19 2:46 PM EDT

Tested ROM of knees ­ flexion: Expected

Exam Action 03/29/19 2:46 PM EDT

Tested ROM of ankles ­ inversion and eversion: Expected

Exam Action 03/29/19 2:46 PM EDT

Tested ROM of ankles ­ dorsiflexion and plantar flexion: Right, reduced dorsi­ and plantar flexion; Left, expected

Exam Action 03/29/19 2:47 PM EDT

Tested neck strength ­ head down: 5/5

Exam Action 03/29/19 2:47 PM EDT

Tested neck strength ­ head turned to the left: 5/5

Exam Action 03/29/19 2:47 PM EDT

Tested neck strength ­ head tilted to the left: 5/5

Exam Action 03/29/19 2:48 PM EDT

Tested neck strength ­ head turned to the right: 5/5

Exam Action 03/29/19 2:48 PM EDT

Tested neck strength ­ head tilted to the right: 5/5

Exam Action 03/29/19 2:48 PM EDT

Tested right and left shoulder strength: 5/5

Exam Action 03/29/19 2:48 PM EDT

Tested elbow strength during extension: 5/5

Exam Action 03/29/19 2:49 PM EDT

Tested wrist strength during extension ­ down: 5/5

Exam Action 03/29/19 2:49 PM EDT

Tested right and left hand strength with grip test: 5/5

Exam Action 03/29/19 2:49 PM EDT

Tested right and left hip strength: 5/5

Exam Action 03/29/19 2:50 PM EDT

Tested right and left knee strength: 5/5

Exam Action 03/29/19 2:50 PM EDT

Tested right and left ankle strength: Right 4/5, Left 5/5

Exam Action 03/29/19 2:50 PM EDT

Thank you for your time tina

Question 03/29/19 2:51 PM EDT

Alright, thanks.

Tina I have a few more question for you (Clarified to I would like to ask questions about your medical history?.)

Question 03/29/19 3:05 PM EDT

Ok. What about? (Clarified to you would like to ask about my medical history.)

Do you have any mobility issues

Question 03/29/19 3:05 PM EDT

I can walk on my foot now, but it still hurts a lot.

do you have a history of walking problems

Question 03/29/19 3:05 PM EDT

I could walk fine before I hurt my foot.

how have you been since being in the hospital ambulating (No matching questions found.)

Question 03/29/19 3:06 PM EDT

do you have any pain while walking

Question 03/29/19 3:06 PM EDT

I can walk on my foot now, but it still hurts a lot.

how much does it hurt when you walk

Question 03/29/19 3:07 PM EDT

It still hurts a lot to put weight on my foot, but I can do it now without help, at least.

can you stand on your own

Question 03/29/19 3:07 PM EDT

Last time I tried to stand normally it really hurt my foot, but at least I was able to stand on it. I'm hoping it'll be better soon.

on a scale 0­10 how bad does it hurt when you walk (Clarified to Can you rate the pain when walking on a scale from 1 to 10?.)

Question 03/29/19 3:07 PM EDT

It still hurts a lot to walk on. I'd say at least 7, maybe 8. (Clarified to how I would rate my pain when walking.)

Do you have any history of muscle soreness

Question 03/29/19 3:08 PM EDT

My muscles don't really get sore ever.

Do you have any ankle issues

Question 03/29/19 3:08 PM EDT

My ankles are fine.

IS your work dangerous?

Question 03/29/19 3:08 PM EDT

I never feel like I'm in danger at work. I'm mostly just walking around with a clipboard, anyway.

Have you ever had any difficulty bathing

Question 03/29/19 3:09 PM EDT

I was having trouble doing that stuff before, but my foot's getting better now, so I think I'm fine.

Do you have any difficulty going from a sitting position to a standing position (Clarified to Do you have trouble standing up?.)

Question 03/29/19 3:09 PM EDT

I was having trouble doing that stuff before, but my foot's getting better now, so I think I'm fine. (Clarified to if I have trouble standing up.)

DO you have any joint stiffness

Question 03/29/19 3:09 PM EDT

No, I'm not stiff anywhere now.

do you have back pain

Question 03/29/19 3:10 PM EDT

No, I don't usually have back pain.

do you have a history of back pain

Question 03/29/19 3:10 PM EDT

I don't usually have any back pain. Sometimes it aches a little, but nothing bad.

do you have any history of muscle injury

Question 03/29/19 3:10 PM EDT

No, I don't think so.

do you have any current muscle injuries (Clarified to Do you have any muscle injuries?.)

Question 03/29/19 3:10 PM EDT

No, I don't think so. (Clarified to if I have muscle injuries.)

do you ave any joint injuries

Question 03/29/19 3:11 PM EDT

No, not really.

Do you have a history of joint injury

Question 03/29/19 3:11 PM EDT

No, not really.

do you have any history of sprains?

Question 03/29/19 3:11 PM EDT

I can't remember spraining anything before. . . maybe in grade school? I did something to one of my fingers playing tether ball, I think. But nothing since then.

Do you have any history of bone problems?

Question 03/29/19 3:12 PM EDT

I don't know of any bone problems in the family.

do you have any neck injuries

Question 03/29/19 3:12 PM EDT

No.

do you have any range of motion issues (Clarified to Do you have limited movement?.)

Question 03/29/19 3:12 PM EDT

Well. . . my foot is maybe feeling a little better, but I still wouldn't want to put weight on it or try to walk anywhere just yet. (Clarified to if I have limited range of motion.)

Do you have any decreased range of motion anywhere in your body (Clarified to Do you have full range of motion of your legs?.)

Question 03/29/19 3:13 PM EDT

It hurts to move my foot, but I can do it. And everything else seems fine. [AUDIO COMING SOON] (Clarified to if I have full range motion of my legs.)

have you ever fallen

Question 03/29/19 3:13 PM EDT

I didn't fall onto the ground. . . it was like, my foot just slipped as I stepped onto the ladder, but I caught my balance before I could topple over or anything.

when did you last fall

Question 03/29/19 3:13 PM EDT

Well, I mean, I sort of fell on the ladder a week ago, but before that I can't remember the last time I fell or hurt myself.

do you have a family history of bone cancer

Question 03/29/19 3:14 PM EDT

Oh wow ­­ no, not that I know of.

do you have family history of osteoarthritis

Question 03/29/19 3:14 PM EDT

No one in the family has osteoporosis that I know of.

thank you for your time tina

Question 03/29/19 3:14 PM EDT

Alright, thanks.

Subjective Data Collection: 23 of 23 (100.0%) Hover To Reveal...

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

 Found:

Indicates an item that you found.

 Available:

Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.

Relevant Medical History  Finding:

Asked about joint problems

 Finding:

Denies joint pain

(Found)

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

Example Question:

Do you have joint pain?

 Finding:

Denies joint swelling

(Found)

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

Example Question:

Do you have swollen joints?

 Finding:

Asked about mobility

 Finding:

Denies history of walking problems

(Found)

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

Example Question:

Have you ever had problems walking?

 Finding:

Reports recent foot wound hindered mobility

(Found)

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

Example Question:

Has your wound affected your mobility?

 Finding:

Reports ability to walk on foot has recently improved

(Found)

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

Example Question:

Has your mobility changed lately?

 Finding:

Asked pain rating when walking

 Finding:

Reports pain as a 7 or 8/10 when walking

(Found)

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

Example Question:

How would you rate your pain when walking?

 Finding:

Asked about ability to stand

 Finding:

Denies trouble standing before foot problems

(Available)

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

Example Question:

Do you have a history of standing problems?

 Finding:

Reports recent foot wound hindered standing

(Found)

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

Example Question:

Has your wound affected your ability to stand?

 Finding:

Reports improved ability to stand on injured foot

(Found)

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

Example Question:

Are you able to stand on your foot?

 Finding:

Asked pain rating when standing

 Finding:

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

(Available)

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

Example Question:

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

 Finding:

Asked about muscle soreness

 Finding:

Denies history of muscle soreness

(Found)

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

Example Question:

Have you ever had muscle soreness?

 Finding:

Denies current muscle soreness

(Found)

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

Example Question:

Are you having muscle soreness?

 Finding:

Asked about joints in proximity of injury

 Finding:

Denies current ankle problems

(Found)

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

Example Question:

Are your ankles giving you trouble?

 Finding:

Asked about occupational impact on injury

 Finding:

Denies work being dangerous

(Found)

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

Example Question:

Is your work dangerous?

 Finding:

Denies work involving repetitive motion

(Available)

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

Example Question:

Does your work involve repetitive motion?

 Finding:

Reports foot wound prevented her from working

(Found)

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

Example Question:

Did your wound prevent you from working?

 Finding:

Asked about activities of daily living

 Finding:

Denies difficulty transferring from sitting to standing

(Found)

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

Example Question:

Are you able to go from sitting to standing?

 Finding:

Denies difficulty bathing

(Found)

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

Example Question:

Can you bathe yourself?

Review of Systems  Finding:

Asked about joint stiffness

 Finding:

Denies joint stiffness

(Available)

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

Example Question:

Do you feel stiff anywhere?

 Finding:

Asked about back pain

 Finding:

Denies history of back pain

(Found)

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

Example Question:

Have you had back pain before?

 Finding:

Denies current back pain

(Found)

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

Example Question:

Are you having back pain?

 Finding:

Asked about muscle injury

 Finding:

Denies history of muscle injury

(Found)

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

Example Question:

Have you ever had a muscle injury?

 Finding:

Denies current muscle injury

(Found)

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

Example Question:

Do you have a muscle injury?

 Finding:

Asked about joint injury

 Finding:

Denies past joint injury

(Found)

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

Example Question:

Have you experienced a joint injury in the past?

 Finding:

Denies current joint injury

(Found)

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

Example Question:

Do you have a joint injury?

 Finding:

Asked history of fracture

 Finding:

Denies history of fractures

(Found)

Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she's ever broken a bone might reveal relevant concerns she'd previously experienced.

Example Question:

Have you ever broken a bone?

 Finding:

Asked history of sprains

 Finding:

Denies history of sprains

(Found)

Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she has a history of getting sprains might reveal relevant concerns she'd previously experienced.

Example Question:

Do you have a history of getting sprains?

 Finding:

Asked about bone problems

 Finding:

Denies history of bone problems

(Available)

Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she ever had bone problems might reveal relevant concerns she'd previously experienced.

Example Question:

Have you ever had bone problems?

 Finding:

Denies current bone problems

(Found)

Pro Tip: Soliciting your patient's medical history can help you to understand the nature of a patient's chief complaint. Asking Tina whether she has bone problems might reveal relevant concerns she'd previously experienced.

Example Question:

Do you have bone problems?

 Finding:

Asked about neck

 Finding:

Denies history of neck problems

(Found)

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

Example Question:

Have you had neck problems?

 Finding:

Denies current neck problems

(Available)

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

Example Question:

Do you have neck problems?

 Finding:

Asked about range of motion of body parts

 Finding:

Reports normal range of motion

(Found)

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

Example Question:

Do you have full range of motion?

 Finding:

Asked about muscle problems

 Finding:

Denies muscle weakness

(Found)

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

Example Question:

Are you experiencing any muscle weakness?

 Finding:

Denies muscle cramping

(Available)

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

Example Question:

Are you experiencing any muscle cramping?

Risk Factors  Finding:

Asked fall history

 Finding:

Reports fall

(Found)

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