Shadow Health || Tina Jones || Respiratory ||CARDIOVASCULAR||HEE NT || Gastrointestinal|, Exams of Medicine

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Shadow Health || Tina Jones || Respiratory ||CARDIOVASCULAR||HEE NT || Gastrointestinal|| Musculoskeletal|| Neurological Assessment SHADOW HEALTH | TINA JONES | RESPIRATORY ASSESSMENT Review of Systems: Correct Answer Asked about cough history Correct Answer - Reports only coughing when she has a cold - Denies coughing up blood Asked about sputum Correct Answer - Denies sputum Risk Factors: Correct Answer Asked about respiratory illness history besides asthma Correct Answer - Denies history of bronchitis - Denies history of pneumonia - Denies history of emphysema Followed up on asthma diagnosis Correct Answer - Report specific age of diagnosis is 2.5 years old Asked about seeing an asthma specialist Correct Answer - Reports not seeing asthma doctor in two years Asked about past hospitalizations Correct Answer - Reports past hospitalizations for asthma - Reports five past hospitalizations for asthma - Reports most recent hospitalization at age 16 - Reports hospital treatment was usually steroids and a nebulizer Asked about general allergies Correct Answer - Reports allergy to cats Asked about number of puffs when using asthma inhaler Correct Answer - Reports recommended is dose 1-3 puffs as needed - Reports typically taking 2 puffs - Reports sometimes needing 3 puffs to control symptoms Asked exacerbation symptoms Correct Answer - Reports chest tightness during exacerbation - Reports wheezing during exacerbation - Reports shortness of breath during exacerbation - Denies coughing during exacerbation - Denies chest pain during exacerbation - Denies painful breathing Asked current breathing Correct Answer - Denies current breathing problems Shadow Health- HEENT -Tina Jones Is your throat sore? Correct Answer Reports sore throat Is your throat itchy? Correct Answer Reports itchy throat Are your eyes itchy? Correct Answer Reports itchy eyes Do you have a runny nose? Correct Answer Reports runny nose How long has your throat been sore? Correct Answer began 1 week ago When did your nose start running? Correct Answer began 1 week ago When did your eyes start itching? Correct Answer began 1 week ago is the throat pain constant Correct Answer constant throat pain when does your throat pain feel the worst Correct Answer worse in morning does it hurt when you swallo Correct Answer soreness with swallowing rate throat pain on 1-10 scale Correct Answer mild to moderate throat discomfort how often does your nose run Correct Answer constant runny nose does your nose itch Correct Answer denies do you have sinus pain Correct Answer denies do you have sinus pressure Correct Answer no are you sneezing Correct Answer no what color is your mucus Correct Answer clear is the mucus thick Correct Answer thin mucus does your mucus have pus in it Correct Answer denies do your eyes constantly itch Correct Answer constant itching are your eyes red Correct Answer reports eye redness have you had changes in your breathing Correct Answer not affected do you have a cough Correct Answer denies do you have chest tightness Correct Answer denies have you been wheezing Correct Answer denies has your asthma worsened Correct Answer denies do you know what is causing your symptoms Correct Answer allergy like symptoms do you think you have a cold Correct Answer no cold symptoms do you think you're having an allergic reaction Correct Answer similar symptoms to sister's hay fever are you allergic to cats Correct Answer confirms are you allergic to dust Correct Answer confirms do you have seasonal allergies Correct Answer denies have you been sick recently Correct Answer denies do you have chills Correct Answer denies do you have fever Correct Answer denies have you felt fatigued Correct Answer low energy level have you felt nauseous Correct Answer denies nausea or vomiting do you ever get headaches Correct Answer occasional headaches do you have a headache currently Correct Answer denies have you ever had a head injury Correct Answer denies do you get lightheadedness Correct Answer denies how often do you have headaches Correct Answer once a week how long do your headaches last Correct Answer few hours how would you describe your headaches Correct Answer tight and throbbing where do you feel your headaches Correct Answer behind her forehead how would you rate your headache on a scale of 1-10 Correct Answer 3 or 4 how do you treat your headaches Correct Answer Tylenol what causes your headaches Correct Answer reading and studying do you have blurry vision Correct Answer occasionally has your vision worsened Correct Answer confirms do you have eye pain Correct Answer denies do you have dry eyes Correct Answer denies do you wear contacts Correct Answer denies can you describe your blurry vision Correct Answer fuzzy letters when do you get blurry vision Correct Answer when reading for long periods how long have you been reading when your vision gets blurry Correct Answer after 2+ hours of reading do you get headaches when you have blurry vision Correct Answer coincide have you had ear problems Correct Answer denies have you had hearing changes Correct Answer denies do you have ear pain Correct Answer denies do you have ear discharge Correct Answer denies do you have a change in your sense of smell Correct Answer denies have you had any nasal or sinus surgeries Correct Answer denies have you had any nosebleeds Correct Answer denies have you had problems with your mouth Correct Answer denies Has your sense of taste changed? Correct Answer denies have you had dry mouth recently Correct Answer denies have you had any oral surgeries Correct Answer denies do you have mouth pain Correct Answer denies do you have mouth sores Correct Answer denies do you have gum problems Correct Answer denies do you have tongue problems Correct Answer denies do you have jaw problems Correct Answer denies do you have any current dental problems Correct Answer denies what dental problems have you had Correct Answer cavities as a kid do you get strep throat often Correct Answer denies sinuses Correct Answer no tenderness temporal arteries Correct Answer no thrill, 2+ no bruit carotid arteries Correct Answer no thrill, 2+ no bruit jaw Correct Answer no abnormal findings lymph nodes Correct Answer no palpable nodes thyroid gland Correct Answer not palpable no tenderness breath sounds Correct Answer present in all areas all areas clear no adventitious sounds pupillary reaction Correct Answer PERRL EOMs, peripheral vision Correct Answer no abnormal findings right fundal exam Correct Answer cotton wool bodies sharp disc margin left fundal exam Correct Answer no abnormalities sharp disc margin visual acuity Correct Answer right: 20/40 left: 20/20 weber, rinne, whisper, gag Correct Answer normal normal normal intact subjective Correct Answer HPI: 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 specific aggravating symptoms, but states that her throat pain seems to be worse in the morning. She rates her throat pain as 4/10 and her throat itchiness as 5/10. 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 specific 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". Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. • Head: Denies history of trauma or headaches. • 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 e objective Correct Answer General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses. • Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene. Uvula midline. Tonsils 1+ and without evidence of inflammation. Posterior pharynx is slightly erythematous with mild cobblestoning. •Neck: No cervical, infraclavicular lymphadenopathy. Thyroid is smooth without nodules or goiter. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation without wheezes, crackles, or cough. assessment Correct Answer Allergic Rhinitis plan Correct Answer Encourage Ms. Jones to continue to monitor symptoms and log her episodes of allergic symptoms with associated factors and bring log to next visit. • Initiate trial of loratadine (Claritin) 10 mg by mouth daily. • Encourage to - Denies having a pacemaker Asked about chest pain Correct Answer - Denies chest pain - Denies angina Asked about chest tightness Correct Answer - Reports chest tightness during asthma exacerbations - Denies current chest tightness Asked about breathing problems Correct Answer - Reports wheezing - Reports shortness of breath - Denies waking at night, unable to breathe - Denies sleep apnea - Denies difficulty breathing when lying down - Denies current breathing problems Followed up on breathing problem triggers Correct Answer Reports breathing problems occur during asthma exacerbations Asked about leg cramping Correct Answer Denies leg cramping Asked about mobility Correct Answer Reports being immobile for past three days Asked about Venous Thrombosis Correct Answer - Denies tender or painful areas other than foot wound - Denies redness other than foot wound - Denies unusual warmth -Denies history of venous thrombosis Asked about cholesterol Correct Answer Denies cholesterol problems Asked about dietary habits Correct Answer - Reports drinking Diet Coke - Reports trying to avoid sugar - Reports not worrying about diet Asked about perceived weight Correct Answer - Reports being overweight for whole life - Reports being satisfied with weight Asked about recent weight change Correct Answer - Reports recent weight loss - Reports losing about 10 lbs Asked about alcohol intake Correct Answer - Reports last alcoholic drink was 3 weeks ago - Reports no more than 2 or 3 alcoholic drinks in one sitting - Reports no more than 1 or 2 nights a week drinking alcohol Asked about illicit drugs Correct Answer - Reports history of smoking recreational marijuana - Denies current use of recreational marijuana Asked about tobacco use Correct Answer - Denies tobacco use - Denies vaping Asked about secondhand smoke Correct Answer Denies exposure to secondhand smoke Asked family history of high blood pressure Correct Answer - Reports mother has high blood pressure - Reports father had high blood pressure - Reports maternal grandfather had high blood pressure - Reports paternal grandmother has high blood pressure - Reports maternal grandmother had high blood pressure - Reports paternal grandmother has high blood pressure Asked family history of high cholesterol Correct Answer - Reports mother has high cholesterol - Reports father had high cholesterol - Reports maternal grandfather had high cholesterol - Reports paternal grandfather had high cholesterol - Reports maternal grandmother had high cholesterol Asked family history of stroke Correct Answer Reports maternal grandmother died of stroke Asked about family history of heart attack Correct Answer Reports maternal grandfather died of heart attack Asked about family history of obesity Correct Answer Reports some family members are overweight is the pain worse when you lay down Correct Answer confirms is the pain worse when you bend over Correct Answer confirms does pain improve between meals Correct Answer improves does pain improve when upright Correct Answer improves how has your appetite been Correct Answer decreased appetite why have you been eating less Correct Answer doesn't want to eat out of anticipation of pain have you been eating smaller meals Correct Answer eats smaller meals do you still eat spicy foods Correct Answer avoids spicy foods have you been burping Correct Answer reports burping when do you burp the most Correct Answer burps after eating have you lost weight recently Correct Answer denies what medications do you take for stomach pain Correct Answer antacid use what kind of antacid do you take Correct Answer tums how often do you take antacids Correct Answer every few days how many antacids do you take at a time Correct Answer 2 to 4 tablets at a time do the antacids help Correct Answer antacids offer partial relief how often do you take ibuprofen Correct Answer denies frequent use do you have allergies Correct Answer cats and penicillin have you ever had stomach ulcers Correct Answer denies do you have GI issues Correct Answer denies have you ever been diagnosed with GERD Correct Answer denies have you had GI surgery Correct Answer denies have you had appendicitis Correct Answer denies have you had your gallbladder removed Correct Answer denies have you ever had stomach cancer Correct Answer denies have you ever had liver disease Correct Answer denies have you ever had kidney disease Correct Answer denies have you ever had bladder disease Correct Answer denies how often do you have a bowel movement Correct Answer every 2 days do you have pain with bowel movements Correct Answer denies pain do you have bloody or dark stools Correct Answer denies tarry stools do you notice mucus in stools Correct Answer denies mucus are your bowel movements consistent Correct Answer consistent bowel movements have you been urinating more Correct Answer increased urination what color is your urine Correct Answer clear yellow have you had to wake up to pee Correct Answer reports nocturia is it painful to urinate Correct Answer denies pain what does your urine look like Correct Answer normal, denies pink or bloody urine do you have trouble holding your urine in Correct Answer denies incontinence when was your last period Correct Answer 3 weeks ago are you currently sexually active Correct Answer denies what was your most recent meal and what did you eat Correct Answer breakfast 24 hour diet recall Correct Answer cereal pizza baked potato how many meals do you eat in a day Correct Answer 3 meals a day abdomen Correct Answer symmetric striae, excessive hair growth protuberent breath sounds Correct Answer present in all areas all areas clear no adventitious sounds heart sounds Correct Answer s1 and s2 audible no extra sounds bowel sounds Correct Answer normoactive all quadrants normal abdominal aorta Correct Answer no bruit renal arteries Correct Answer no bruit iliac arteries Correct Answer no bruit femoral arteries Correct Answer no bruit percussed abdomen Correct Answer all areas generally tympanic CVA tenderness Correct Answer did not react percussed spleen Correct Answer dullness percussed liver span Correct Answer between 6 and 12 cm light palpated abdomen Correct Answer no tenderness no observations no quadrants tender deep palpated abdomen Correct Answer no palpable mass palpated liver Correct Answer palpable palpated spleen Correct Answer not palpable palpated kidneys Correct Answer not palpable subjective Correct Answer HPI: 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 specifically 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. Social History: She denies any specific changes in her diet recently, but notes that she has increased her water intake. Breakfast is usually a muffin or pumpkin bread, lunch is a sandwich with chips, dinner is a homemade meal of a meat and vegetable, snacks are French fries or pretzels. She denies coffee intake, but does drink diet cola on a regular basis. She denies use of tobacco and illicit drugs. She drinks alcohol occasionally, last was 2 weeks ago, and was 1 drink. She does not exercise. Review of Systems: 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 a objective Correct Answer General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Abdominal: Abdomen is soft and protuberant without scars or skin lesions; skin is warm and dry, without tenting. Bowel sounds present and normoactive in all quadrants. No tenderness to light or deep palpation. Tympanic throughout. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. No CVA tenderness. • Cardiovascular: Regular rate and rhythm, S1 and S2 present, no murmurs, rubs, gallops, clicks, precordial movements. No bruits with auscultation over abdominal aorta. No femoral, iliac, or renal bruits. • Respiratory: Chest is symmetrical with respirations. Lung sounds clear to auscultation anteriorly and posteriorly without wheezes, crackles, or cough. assessment Correct Answer GERD without evidence of esophogitis plan Correct Answer 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, coffee, alcohol, and spicy foods. • Ms. Jones may elevate the head of her bed or sleep on a wedge-shaped bolster for comfort or symptom reduction. • 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 famotidine 10 mg by mouth twice daily for two weeks. If reduction in symptoms, Ms. Jones may continue therapy. If symptoms persist, follow up for subsequent recommendations Asked about joint stiffness Correct Answer Asked about back pain Correct Answer History of back pain Current back pain Asked about muscle injury Correct Answer History of muscle injury Current muscle injury Asked about joint injury Correct Answer Past joint injury Current joint injury Asked about history of fracture Correct Answer Asked about history of sprains Correct Answer Asked about bone problems Correct Answer History of bone problems Current bone problems Asked about neck Correct Answer History of neck problems Current neck problems Asked about range of motion of body parts Correct Answer Asked about muscle problems Correct Answer Any muscle weakness Any muscle cramping Asked about Fall history Correct Answer When was last fall Prone to falls? Family history of osteoporosis Correct Answer Family history of joint problems Correct Answer Family history of arthritis Shadow Health- Tina Jones - Neurological Asked about numbness Correct Answer denies history of numbness denies current numbness Asked about tingling Correct Answer Denies tingling Asked about vision Correct Answer Reports vision problem Followed up on vision problems Correct Answer Reports vision problems for past few months Reports periods of blurry vision Reports vision problems occur only when reading Denies double vision Asked about headaches Correct Answer Reports occasional headaches Reports last headache was a few days ago Denies current headache Asked about headache patterns Correct Answer Reports headaches have been occurring for six months Reports headaches occur a few times per month Reports headaches last a few hours Asked about headache triggers Correct Answer Reports headaches occur only when studying Asked about headache character Correct Answer Reports headaches are not severe Reports headaches feel the same on both sides of the head Reports headaches are tight