Student Documentation Model Documentation Objective Brian is a 58 year old Caucasian male appears to be well-groomed, is pleasant and answers questions clearly and appropriately. He maintains eye contact throughout the exam. He appears in no distress VSS: Bp 146/90 Skin warm to touch, dry, pink and intact. no tenting Heart: S1, s2, s3 and […]
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Document: Vitals Document: Provider Notes 1 Symptoms Followed Up 2 Medications Followed Up 3 Diet Followed Up 4 Activity Level Not Followed Up 5 Medical History Followed Up 6 Sexual Activity Followed Up 7 Family and Support Followed Up
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Focused Exam: Chest Pain Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313481/) (/site_notice_dismissals?from_flash=true&site_noticBecome a paid student tester for Shadow Health! Click here for more information (https://www.surveymonkey.com/r/TN9CMB5) (/site_notice_dismissals?from_flash=true&site_noticShadow Health will be performing planned maintenance this Friday, from 7:00am until 7:30am Eastern. During this time assignment attempts will be disabled.
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Do you have a family history of back pain? No, I don’t think so. Do you have any family medical history My mom has some issues, and I think some of my grandparents did, too. What is your mother’s medical history Mom has high cholesterol and blood pressure, I think. She seems to be doing
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Did you have this problem before No, nothing like this has ever happened to me. . . my back is usually totally fine. Question 04/15/20 4:51 PM MD Question 04/15/20 4:51 PM MD Question 04/15/20 4:51 PM MD Question 04/15/20 4:51 PM MD Question 04/15/20 4:52 PM MD Question 04/15/20 4:52 PM MD Question 04/15/20
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Are you able to walk okay I can walk, but it does hurt a little. Do you need to use a walker I can walk, but it does hurt a little. From 1 to 10 what is your pain scale (Clarified to Can you rate your current back pain level on a scale of 0
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I have a Flovent daily inhaler and a Proventil rescue inhaler. How often are you using your proventil I haven’t used my rescue inhaler in months — not since I started the daily Flovent one. That makes sense. Can I ask where is the pain located It hurts in my lower back and even, like,
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Musculoskeletal Results | Turned In Advanced Physical Assessment – March 2020, advanced_physical_assessment__td8__031720__sect1 Return to Assignment (/assignments/313477/) Transcript Started: Apr 15, 2020 | Total Time: 79 min Question 04/15/20 4:42 PM MD Question 04/15/20 4:42 PM MD Question 04/15/20 4:42 PM MD Question 04/15/20 4:43 PM MD Question 04/15/20 4:44 PM MD Question 04/15/20 4:44 PM
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Do you have any family history of neurological problems Any changes in your bladder (Clarified to Have you had a recent change in your energy level?.) No, I don’t think so. (Clarified to if my energy level has changed.) Have you had any family history of neurological problems (Clarified to Have you had neurological problems?.)
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What happens with Penicillin I don’t remember that well because the last time I had penicillin I was pretty little. . . I think I got a rash, like, hives. The doctor told me not to take it again after that. What over the counter medication are you taking Usually I’ll take Tylenol sometimes for
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