Samantha Monroe Adolescent Sports Evaluation shadow health

Samantha Monroe Adolescent Sports Evaluation shadow health

Transcript

Started: Mar 05, 2022 | Total Time: 306 min
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Hello. Am xxxx, I will interview you and later conduct a physical exam.\

Greet
03/05/22 5:41 AM EST

Samantha Monroe.
Hello.
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What is your relationship with the patient?

Question
03/05/22 5:42 AM EST

Samantha Monroe.
Oh, this is my mom.
Jackie Monroe.
Hey, I’m Jackie Monroe. This is my daughter, Samantha.
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Why are you here today?

Question
03/05/22 5:42 AM EST

Samantha Monroe.
I’m here for a sports physical. I’m gonna play on my school soccer team. We’re called the Nightingales, which is pretty cool. Samantha Monroe Adolescent Sports Evaluation shadow health
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Any medical issue?

Question
03/05/22 5:43 AM EST

Samantha Monroe.
Uh, nope. No health issues.
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Any history of surgery?

Question
03/05/22 5:43 AM EST

Samantha Monroe.
I had my tonsils removed when I was like 9, but that’s it.
Jackie Monroe.
Yeah, that was Samantha’s only surgery.
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Any missing organ? (No matching questions found.)

Question
03/05/22 5:45 AM EST

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Does your daughter have any missing organ? (No matching questions found.)

Question
03/05/22 5:46 AM EST

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Have you had any of your organs removed?

Question
03/05/22 5:46 AM EST

Samantha Monroe.
Uh . . . no. All my organs are 100% present.
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Any allergies?

Question
03/05/22 5:49 AM EST

Samantha Monroe.
No, I’ve never had any allergies before.
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Are your vaccinations current?

Question
03/05/22 5:50 AM EST

Samantha Monroe.
Yeah, I’ve had all my vaccines.
Jackie Monroe.
I always made sure she was up to date on her vaccinations.
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Are you using any medications?

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Question
03/05/22 5:50 AM EST

Samantha Monroe.
No, I don’t take anything.
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Are you using any vitamins or supplements?

Question
03/05/22 5:51 AM EST

Samantha Monroe.
I take a multivitamin. Plus, I drink apple cider vinegar, which is kinda like a supplement.
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Do you pass out during exercise? (Clarified to Have you passed out during exercise?.)

Question
03/05/22 5:52 AM EST

Samantha Monroe.
No way. I’ve never passed out while I was exercising. (Clarified to if I have passed out during exercise.)
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Any dizziness?

Question
03/05/22 5:53 AM EST

Samantha Monroe.
Oh, no. I feel totally fine right now.
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Have you ever been dizzy? (Clarified to Have you felt dizzy in the past?.)

Question
03/05/22 5:53 AM EST

Samantha Monroe.
I’ve only been dizzy like once or twice. And that was because I skipped lunch and then had to go to gym class. (Clarified to if I have felt dizzy in the past.)
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Am sorry about that

Educate
03/05/22 5:54 AM EST

Samantha Monroe.
Thanks for the heads-up.
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Any heart problems after exercising? (Clarified to Have you had heart problems after exercise?.)

Question
03/05/22 5:56 AM EST

Samantha Monroe.
No heart problems after exercise. (Clarified to if I have had heart problems after exercise.) Samantha Monroe Adolescent Sports Evaluation shadow health
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Have you had heart problems during exercise?

Question
03/05/22 5:57 AM EST

Samantha Monroe.
Nope. No problems during exercise.
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Have you been diagnosed with a heart problem?

Question
03/05/22 5:58 AM EST

Samantha Monroe.
No, I’ve never been diagnosed with any heart problems that I know of.
Jackie Monroe.
No, no heart problems.
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How is your breathing during and after exercise?

Question
03/05/22 5:59 AM EST

Samantha Monroe.
My breathing is fine during and after exercise.
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Any history of seizures?

Question
03/05/22 6:00 AM EST

Samantha Monroe.
Pretty sure I’ve never ever had a seizure.
Jackie Monroe.
That is correct. No seizures or anything like that.
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Any injuries?

Question
03/05/22 6:01 AM EST

Samantha Monroe.
Um, well I did sprain my ankle when I was like 10. That’s really it, though. I’m always good to play.
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Any rashes?

Question
03/05/22 6:01 AM EST

Samantha Monroe.
No rashes. Ew.
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Any history of head injuries?

Question
03/05/22 6:02 AM EST

Samantha Monroe.
Nope. My head’s fine.
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Have you had a concussion?

Question
03/05/22 6:03 AM EST

Samantha Monroe.
I’ve never had a concussion, but I did see my friend wipeout at the skatepark once. It was crazy. He was skating, then boom. I was filming, so it was, you know, pretty scarring.
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Any numbness or tingling?

Question
03/05/22 6:04 AM EST

Samantha Monroe.
No numbness or tingling. That sounds weird.
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Any weakness in your limbs?

Question
03/05/22 6:09 AM EST

Samantha Monroe.
Nope, no weakness.
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Do you exercise in the heat?

Question
03/05/22 6:14 AM EST

Samantha Monroe.
Sure. We do gym outside sometimes. When soccer season starts, practice and games are outside.
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Any eye problems?

Question
03/05/22 6:16 AM EST

Samantha Monroe.
My eyes are fine.
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Have you started your periods?

Question
03/05/22 6:17 AM EST

Samantha Monroe.
No, I haven’t started my period yet. It’s kind of weird because all my friends have? Whenever they talk about it, like the cramps or whatever, I just pretend like I’ve had mine, too. Just to fit in.
Jackie Monroe.
She asked how old I was when I got my first period. I told her I was about 12.
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I understand your concerns, but it’s normal for a person of your age to not have started their periods yet.

Educate
03/05/22 6:20 AM EST

Samantha Monroe.
Cool. Good to know.
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Tell me about your family medical history.

Question
03/05/22 6:21 AM EST

Samantha Monroe.
Wait, like the entire family medical history or do you mean something more specific?
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Any genetic conditions in your family? (Clarified to Does anyone in your family have a genetic heart condition?.)

Question
03/05/22 6:22 AM EST

Samantha Monroe.
I don’t know. Mom? (Clarified to if anyone in my family has a genetic heart condition.)
Jackie Monroe.
No, no one in the family has any genetic heart conditions.
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Any heart problems in your family?

Question
03/05/22 6:22 AM EST

Samantha Monroe.
I don’t think anyone has heart problems, but I’m not totally sure.
Jackie Monroe.
You know, I can’t think of anybody in the family who’s had heart problems.
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Any history of unexpected deaths in your family? (No matching questions found.)

Question
03/05/22 6:23 AM EST

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Any family history of unexpected deaths before the age of 35? (No matching questions found.)

Question
03/05/22 6:24 AM EST

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Has any of your family members had a pacemaker before age 35? (Clarified to Has anyone in your family had a pacemaker before 35?.)

Question
03/05/22 6:25 AM EST

Samantha Monroe.
I’m not sure about the pacemaker thing. (Clarified to if anyone in my family had a pacemaker before thirty five.)
Jackie Monroe.
To my knowledge, there isn’t anyone in the family who’s ever had a pacemaker.
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Do you feel your weight is okay? (Clarified to How do you feel about your weight?.)

Question
03/05/22 6:27 AM EST

Samantha Monroe.
Um, I mean, I wish I could lose this baby fat. All my friends wear one size smaller than me, so it’s super awkward when they’re swapping clothes . . . and talking about their periods . . . just hard not to compare. (Clarified to how I feel about my weight.)
Jackie Monroe.
I told her . . . middle school is tough, especially with all the social media they’re dealing with now. But luckily time goes by faster the older you get and one day you’re my age and it’s all in the rearview Samantha Monroe Adolescent Sports Evaluation shadow health.
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I understand your concerns but you should not try to fit in or compare yourself to others.

Educate
03/05/22 6:29 AM EST

Samantha Monroe.
Gotcha.
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Do you want to lose weight? (Clarified to Why do you think you need to lose weight?.)

Question
03/05/22 6:29 AM EST

Samantha Monroe.
Just . . . to look more athletic, you know. Like I fit in with everybody. (Clarified to why I think I need to lose weight.)
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You should not try to fit in. Everyone is unique.

Educate
03/05/22 6:30 AM EST

Samantha Monroe.
Um, that makes sense.
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Tell me about your diet.

Question
03/05/22 6:31 AM EST

Samantha Monroe.
I do the Mediterranean diet. It’s healthy. I try not to eat bad stuff. No candy, white carbs, processed food.
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Do you skip any meals?

Question
03/05/22 6:32 AM EST

Samantha Monroe.
Yeah, I skip lunch once or twice each week.
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It is not advisable to skip any meal at your age because you are still growing

Educate
03/05/22 6:33 AM EST

Samantha Monroe.
For sure. OK.
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How long have you been skipping your lunch? (Clarified to How long have you been skipping lunch?.)

Question
03/05/22 6:34 AM EST

Samantha Monroe.
I started skipping lunch maybe a month ago? (Clarified to how long I have been skipping lunch.)
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 Inspected weight and height growth chart

Exam Action
03/05/22 6:35 AM EST

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 Inspected Skin

Exam Action
03/05/22 6:48 AM EST

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 Assessed appearance

Exam Action
03/05/22 6:49 AM EST

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 Assessed Cervical Spine Range of Motion

Exam Action
03/05/22 6:52 AM EST

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 Assessed Spine Range of Motion: Full range of motion performed without discomfort

Exam Action
03/05/22 6:53 AM EST

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 Assessed wrist range of motion

Exam Action
03/05/22 7:01 AM EST

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 Assessed Elbow Range of Motion

Exam Action
03/05/22 7:03 AM EST

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 Assessed range of motion of shoulders – adduction and abduction: Strength equal bilaterally against full resistance

Exam Action
03/05/22 7:06 AM EST

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 Assessed Trapezius Strength: Strength equal bilaterally against full resistance

Exam Action
03/05/22 7:06 AM EST

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 Assessed deltoid strength and shoulder rotation

Exam Action
03/05/22 7:07 AM EST

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 Assessed Hand and Finger Range of Motion and Strength: Right and left hand strength equal bilaterally against resistance

Exam Action
03/05/22 7:08 AM EST

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 Assessed Symmetry of Extremities

Exam Action
03/05/22 7:09 AM EST

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 Assessed leg symmetry, knee and ankle effusion Samantha Monroe Adolescent Sports Evaluation shadow health

Exam Action
03/05/22 7:09 AM EST

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 Assessed Calf Symmetry and Leg Strength

Exam Action
03/05/22 7:10 AM EST

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 Tested Hip, Knee, and Ankle ROM

Exam Action
03/05/22 7:11 AM EST

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 Tested Cardinal Fields of Vision

Exam Action
03/05/22 7:14 AM EST

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 Tested peripheral vision

Exam Action
03/05/22 7:15 AM EST

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 Tested visual acuity

Exam Action
03/05/22 7:15 AM EST

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 Tested balance: Expected

Exam Action
03/05/22 7:16 AM EST

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 Auscultated lungs

Exam Action
03/05/22 7:17 AM EST

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 Auscultated abdomen

Exam Action
03/05/22 7:18 AM EST

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 Auscultated heart

Exam Action
03/05/22 7:18 AM EST

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 Screened Adam’s Forward Bend

Exam Action
03/05/22 7:20 AM EST

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Mrs. Monroe please step out so I can have a private conversation with your daughter.

Educate
03/05/22 7:34 AM EST

Jackie Monroe.
Sure, no problem.
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I will be asking you some personal questions and I need you to know that you are in a safe and a nonjudgmental environment.

Educate
03/05/22 7:36 AM EST

Samantha Monroe.
OK. That sounds alright.
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Tell me about your school life, friends and hobbies.

Question
03/05/22 7:38 AM EST

Samantha Monroe.
Everything’s fine. I mean . . . My grades are average. I get a lot of Bs. I feel like my friends used to be really chill but I don’t know what happened this year. It’s like everybody got super skinny and so many more followers on their social accounts. Soccer is gonna be fun, for sure, but . . . everything was easier before I turned 13.
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Am sorry about that. Everything will be fine.

Empathize
03/05/22 7:39 AM EST

Samantha Monroe.
Thanks. I’m glad you understand.
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Tell me about your support system.

Question
03/05/22 7:41 AM EST

Samantha Monroe.
Yeah, me and my mom are pretty close, and I have some friends who get it. We talk and stuff.
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Have you ever used tobacco?

Question
03/05/22 7:42 AM EST

Samantha Monroe.
Definitely not. I feel like I’ve heard smoking can help you lose weight, but I’m not ever gonna do it because it’s so bad for your lungs. That would ruin my soccer game.
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Have you used any drugs?

Question
03/05/22 7:43 AM EST

Samantha Monroe.
No. I wouldn’t ever do drugs.
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Have you used alcohol?

Question
03/05/22 7:44 AM EST

Samantha Monroe.
I don’t drink. No way.
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Are you interested in relationships and dating?

Question
03/05/22 7:45 AM EST

Samantha Monroe.
I’m not really interested in that yet.
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Are you sexually active?

Question
03/05/22 7:45 AM EST

Samantha Monroe.
No.
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I would like to know more about your feeling of nervousness or anxiety.

Question
03/05/22 7:54 AM EST

Samantha Monroe.
I mean . . . school’s a lot. Projects and tests and stuff. And I want to do really well in soccer. But I guess it’s mostly the whole “keeping up with appearances” thing. It’s like a full-time job.
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Am sorry about that.

Empathize
03/05/22 7:55 AM EST

Samantha Monroe.
Thanks.
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I noticed that you are concerned about your body image, weight, and diet.

Question
03/05/22 7:57 AM EST

Samantha Monroe.
Well, I’ve definitely started paying more attention to health stuff, but I thought that was a good thing. I just want to post a selfie and not have a double-chin, you know?
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Have you ever considered doing anything more extreme to manage your weight?

Question
03/05/22 7:58 AM EST

Samantha Monroe.
No, I wouldn’t do anything dangerous. I promise.
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Do you have any questions for me?

Question
03/05/22 7:59 AM EST

Samantha Monroe.
No, I don’t think so.
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 You will now discuss the appropriate non-pharmacological interventions with Samantha and her mother, Ms. Monroe. You will not be automatically scored on your choices or responses in this activity, but your instructor may choose to review your responses.

Exam Action
03/06/22 8:19 AM EST

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I am ready to begin the conversation with Samantha.

Question
03/06/22 8:20 AM EST

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 In your own words, discuss life-threatening health problems related to disordered eating with Samantha and Ms. Monroe.

Exam Action
03/06/22 8:20 AM EST

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Forcing yourself to diet or skip meals can make you very sick because strong bones teeth, and hair require adequate nutrition.

Question
03/06/22 8:23 AM EST

Samantha Monroe.
Oh, um yeah. That makes sense. I don’t want any of that to happen.
Jackie Monroe.
Thank you. This is pretty concerning so we’ll take this very seriously.
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 In your own words, discuss limiting media intake with Samantha and Jackie.

Exam Action
03/06/22 8:24 AM EST

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You should limit media exposure and remember that your body deserves to be fed, cared or, regardless of the size.

Question
03/06/22 8:30 AM EST

Samantha Monroe.
Yeah, I mean I don’t want an eating disorder or anything like that. I just thought thinking like that was pretty normal, but I guess not.
Jackie Monroe.
We’re just both going to have to rethink how we see our bodies and talk about nutrition. I don’t want to see my daughter struggle with her self-esteem.
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 In your own words, discuss increasing knowledge of coping mechanisms with Samantha and Jackie.

Exam Action
03/06/22 8:33 AM EST

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You can try journalling, relaxation and stress management techniques, and affirmations

Question
03/06/22 8:58 AM EST

Samantha Monroe.
Yeah, that make sense. It’s not like I want to feel this way, you know?
Jackie Monroe.
I’m just glad we figured out that this was an issue. I had no idea.
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 You have provided Samantha and her mother education on all appropriate non-pharmacological interventions.

 

Education & Empathy : 4 of 4 (100.0%)

During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.

  • Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
  • Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made
  • Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
 1 Fitting in
Followed Up

 Description: Samantha feels like she doesn’t fit in with her peers.

This is your avatar.

Do you want to lose weight? (Clarified to: Why do you think you need to lose weight?)

Question
06:29 AM EST

Samantha Monroe

Just . . . to look more athletic, you know. Like I fit in with everybody. (Clarified to: why I think I need to lose weight)

This is your avatar.

You should not try to fit in. Everyone is unique.

Educate
06:30 AM EST

Samantha Monroe

Um, that makes sense.

 Model Statement: “At age 13, there are a lot of social pressures, coming from your friends at school, teammates at soccer, and influencers on social media. It’s important to be a part of a community that accepts and supports you. If you don’t feel accepted or supported, then you should feel comfortable discussing these issues with people you do trust, because that environment might not be healthy for you. It’s also possible that you’re being hard on yourself. I know it’s tempting to compare yourself to others, but don’t let that damage your self-worth.”

 2 Body Image
Followed Up

 Description: Samantha has insecurities about her body image.

This is your avatar.

Do you feel your weight is okay? (Clarified to: How do you feel about your weight?)

Question
06:27 AM EST

Samantha Monroe

Um, I mean, I wish I could lose this baby fat. All my friends wear one size smaller than me, so it’s super awkward when they’re swapping clothes . . . and talking about their periods . . . just hard not to compare. (Clarified to: how I feel about my weight)

This is your avatar.

I understand your concerns but you should not try to fit in or compare yourself to others.

Educate
06:29 AM EST

Samantha Monroe

Gotcha.

 Model Statement: “Samantha, you’ve mentioned wanting to lose baby fat and look athletic. I’m really sorry you’re having a hard time with the way people see you and the way you see yourself, but there’s nothing wrong with how you look, and you’re in good health. I know it’s easy for me to say this here in the clinic and hard for you when you’re getting compared to other people, but there’s nothing you need to change about yourself.”

 3 Menstruation
Followed Up

 Description: Samantha has concerns that she should have had her first period already.

This is your avatar.

Have you started your periods?

Question
06:17 AM EST

Samantha Monroe

No, I haven’t started my period yet. It’s kind of weird because all my friends have? Whenever they talk about it, like the cramps or whatever, I just pretend like I’ve had mine, too. Just to fit in.

This is your avatar.

I understand your concerns, but it’s normal for a person of your age to not have started their periods yet.

Educate
06:20 AM EST

Samantha Monroe

Cool. Good to know.

 Model Statement: “Knowing that your classmates are having their periods when you haven’t had one yet can be frustrating, but you don’t have anything to worry about. It’s typical for someone your age to not have started menstruating yet, and we can expect it to happen before you are 15. Everyone’s experience is a little bit different—sometimes I have patients who are concerned at how early they started. You’re prepared for your first period when it happens, and you’re comfortable talking about it here. That’s the maturity that matters, so do your best not to worry about where your peers are.”

 4 Skipping Meals
Followed Up

 Description: Samantha says that she skips lunch once or twice a week to reduce her caloric intake.

This is your avatar.

Do you skip any meals?

Question
06:32 AM EST

Samantha Monroe

Yeah, I skip lunch once or twice each week.

This is your avatar.

It is not advisable to skip any meal at your age because you are still growing

Educate
06:33 AM EST

Samantha Monroe

For sure. OK.

 Model Statement: “It’s very important to eat lunch, along with the rest of your regular meals. You’re still growing, and that takes a lot of food and energy. You’re also a soccer player, and athletes need plenty of calories and nutrients to play well and stay healthy. You definitely don’t need to feel bad about eating lunch. On top of that, skipping meals can feel pretty bad. When I miss lunch, I get a headache and feel cranky. Please go easy on yourself and your body and try not to skip lunch anymore.”

Treatment Plan: 21 of 21 (100.00%)

Problem Selection
8 out of 8

Primary Diagnosis

Review your answers for the Problem Selection activities. You receive one point for each correct diagnosis, and one point for each correct evidence linked to a correct diagnosis. If there are multiple correct diagnoses, you will also receive a point for correctly selecting which diagnosis is the primary diagnosis Samantha Monroe Adolescent Sports Evaluation shadow health.

Learner Selection Model Documentation

 Diagnosis: Pre-Participation Sports Physical

Identified as primary

Evidences:

Samantha reports the reason for her visit is a sports physical

Learner Rationale:

The patient indicates that she came for a sports physical.

Score: out of 3

 Diagnosis: Pre-Participation Sports Physical

Primary: Yes

Evidences:

Samantha reports the reason for her visit is a sports physical

Model Rationale:

The primary diagnosis is the reason for the patient’s visit. Because Samantha has indicated she is in the office for her sports physical, the correct primary diagnosis is Pre-Participation Sports Physical. As a primary care provider, it is critical to properly code the reason for Samantha’s visit so it can be covered by insurance.

Additional Diagnosis

Learner Selection Model Documentation

 Diagnosis: Inappropriate Diet and Eating Habits

Evidences:

Samantha reports a desire to lose baby fat

Samantha reports dizziness

Samantha reports wanting to look more athletic

Samantha reports skipping lunch once or twice each week

Score: out of 5

 Diagnosis: Inappropriate Diet and Eating Habits

Evidences:

Samantha reports a desire to lose baby fat

Samantha reports dizziness

Samantha reports wanting to look more athletic

Samantha reports skipping lunch once or twice each week

Model Rationale:

Samantha’s desire to lose baby fat and appear more athletic, as well as her diet modifications, are clear indications that Samantha’s diagnosis pertains to Inappropriate Diet and Eating Habits. This subjective data, along with Samantha’s normal weight range and healthy BMI collected during physical examination, indicate that Samantha’s problematic behavior is not severe enough to meet the criteria of other eating-related diagnosis or disorders. Therefore, Inappropriate Diet and Eating Habits is the correct additional diagnosis at this time. American Psychiatric Association. (2017). Feeding and Eating Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.dsm10

Plan of Care
7 out of 7

Review your answers for the Plan of Care activity. You must select “Yes” or “No” for each of the seven care actions. Samantha Monroe Adolescent Sports Evaluation shadow health You will receive one point for determining the correct answer for each care action.

Learner Selection Model Documentation

Documentation / Electronic Health Record

Student Documentation Model Documentation

Subjective

Ms. Monroe is a 13 year old female presenting for a preparticipation evaluation so she can play soccer this year. Past Medical History: No current medical problems. Tonsillectomy as a child. Medications: No prescription medications.

Objective Data Collection: 23 of 23 (100%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 Growth Chart: Height & Weight
1 of 1 point
Weight Percentile (1/4 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Weight Growth Curve (1/4 point)
  •  Growth curve maintained
  •  Growth curve decline
Height Percentile (1/4 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Height Growth Curve (1/4 point)
  •  Growth curve maintained
  •  Growth curve declined
 Inspected Skin
1 of 1 point
Lesions (1/5 point)
  •  No visible lesions

Subjective Data Collection: 26 of 27 (96.3%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions Samantha Monroe Adolescent Sports Evaluation shadow health.

  • 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.

Confirmed Guardian’s Relationship


  • Finding:

    Asked about relationship with patient Samantha Monroe Adolescent Sports Evaluation shadow health