Samantha Monroe Adolescent Sports Evaluation shadow health
Transcript
Hello. Am xxxx, I will interview you and later conduct a physical exam.
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Greet |
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Hello.
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What is your relationship with the patient?
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Question |
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Oh, this is my mom.
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Hey, I’m Jackie Monroe. This is my daughter, Samantha.
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Why are you here today?
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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?
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Uh, nope. No health issues.
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Any history of surgery?
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Question |
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I had my tonsils removed when I was like 9, but that’s it.
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Yeah, that was Samantha’s only surgery.
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Any missing organ? (No matching questions found.)
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Does your daughter have any missing organ? (No matching questions found.)
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Have you had any of your organs removed?
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Question |
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Uh . . . no. All my organs are 100% present.
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Any allergies?
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Question |
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No, I’ve never had any allergies before.
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Are your vaccinations current?
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Question |
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Yeah, I’ve had all my vaccines.
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I always made sure she was up to date on her vaccinations.
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Are you using any medications?
ORDER SHADOWHEALTH, IHUMAN, EXAM OR WRITTEN ASSIGNMENT HERE |
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No, I don’t take anything.
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Are you using any vitamins or supplements?
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Question |
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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?.)
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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?
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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?.)
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Question |
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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
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Educate |
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Thanks for the heads-up.
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Any heart problems after exercising? (Clarified to Have you had heart problems after exercise?.)
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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?
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Nope. No problems during exercise.
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Have you been diagnosed with a heart problem?
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No, I’ve never been diagnosed with any heart problems that I know of.
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No, no heart problems.
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How is your breathing during and after exercise?
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My breathing is fine during and after exercise.
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Any history of seizures?
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Pretty sure I’ve never ever had a seizure.
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That is correct. No seizures or anything like that.
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Any injuries?
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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?
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No rashes. Ew.
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Any history of head injuries?
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Nope. My head’s fine.
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Have you had a concussion?
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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?
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No numbness or tingling. That sounds weird.
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Any weakness in your limbs?
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Nope, no weakness.
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Do you exercise in the heat?
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Sure. We do gym outside sometimes. When soccer season starts, practice and games are outside.
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Any eye problems?
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My eyes are fine.
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Have you started your periods?
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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.
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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.
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Educate |
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Cool. Good to know.
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Tell me about your family medical history.
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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?.)
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I don’t know. Mom? (Clarified to if anyone in my family has a genetic heart condition.)
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No, no one in the family has any genetic heart conditions.
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Any heart problems in your family?
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I don’t think anyone has heart problems, but I’m not totally sure.
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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.)
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Any family history of unexpected deaths before the age of 35? (No matching questions found.)
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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?.)
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I’m not sure about the pacemaker thing. (Clarified to if anyone in my family had a pacemaker before thirty five.)
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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?.)
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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.)
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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.
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Educate |
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Gotcha.
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Do you want to lose weight? (Clarified to Why do you think you need to lose weight?.)
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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.
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Educate |
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Um, that makes sense.
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Tell me about your diet.
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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?
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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
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Educate |
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For sure. OK.
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How long have you been skipping your lunch? (Clarified to How long have you been skipping lunch?.)
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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
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Exam Action |
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Inspected Skin
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Exam Action |
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Assessed appearance
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Exam Action |
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Assessed Cervical Spine Range of Motion
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Assessed Spine Range of Motion: Full range of motion performed without discomfort
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Exam Action |
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Assessed wrist range of motion
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Exam Action |
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Assessed Elbow Range of Motion
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Exam Action |
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Assessed range of motion of shoulders – adduction and abduction: Strength equal bilaterally against full resistance
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Exam Action |
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Assessed Trapezius Strength: Strength equal bilaterally against full resistance
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Exam Action |
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Assessed deltoid strength and shoulder rotation
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Exam Action |
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Assessed Hand and Finger Range of Motion and Strength: Right and left hand strength equal bilaterally against resistance
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Exam Action |
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Assessed Symmetry of Extremities
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Exam Action |
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Assessed leg symmetry, knee and ankle effusion Samantha Monroe Adolescent Sports Evaluation shadow health
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Exam Action |
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Assessed Calf Symmetry and Leg Strength
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Exam Action |
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Tested Hip, Knee, and Ankle ROM
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Exam Action |
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Tested Cardinal Fields of Vision
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Exam Action |
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Tested peripheral vision
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Exam Action |
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Tested visual acuity
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Exam Action |
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Tested balance: Expected
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Exam Action |
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Auscultated lungs
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Exam Action |
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Auscultated abdomen
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Exam Action |
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Auscultated heart
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Exam Action |
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Screened Adam’s Forward Bend
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Exam Action |
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Mrs. Monroe please step out so I can have a private conversation with your daughter.
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Educate |
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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.
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Educate |
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OK. That sounds alright.
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Tell me about your school life, friends and hobbies.
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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.
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Empathize |
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Thanks. I’m glad you understand.
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Tell me about your support system.
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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?
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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?
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No. I wouldn’t ever do drugs.
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Have you used alcohol?
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I don’t drink. No way.
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Are you interested in relationships and dating?
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Question |
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I’m not really interested in that yet.
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Are you sexually active?
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No.
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I would like to know more about your feeling of nervousness or anxiety.
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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.
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Empathize |
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Thanks.
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I noticed that you are concerned about your body image, weight, and diet.
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Question |
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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?
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No, I wouldn’t do anything dangerous. I promise.
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Do you have any questions for me?
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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.
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Exam Action |
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I am ready to begin the conversation with Samantha.
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Question |
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In your own words, discuss life-threatening health problems related to disordered eating with Samantha and Ms. Monroe.
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Exam Action |
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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.
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Oh, um yeah. That makes sense. I don’t want any of that to happen.
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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.
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You should limit media exposure and remember that your body deserves to be fed, cared or, regardless of the size.
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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.
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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.
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You can try journalling, relaxation and stress management techniques, and affirmations
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Yeah, that make sense. It’s not like I want to feel this way, you know?
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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.
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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
Description: Samantha feels like she doesn’t fit in with her peers. |
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Do you want to lose weight? (Clarified to: Why do you think you need to lose weight?) |
Question |
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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 |
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Um, that makes sense. |
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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.” |
Description: Samantha has insecurities about her body image. |
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Do you feel your weight is okay? (Clarified to: How do you feel about your weight?) |
Question |
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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) |
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I understand your concerns but you should not try to fit in or compare yourself to others. |
Educate |
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Gotcha. |
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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.” |
Description: Samantha has concerns that she should have had her first period already. |
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Have you started your periods? |
Question |
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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. |
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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 |
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Cool. Good to know. |
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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.” |
Description: Samantha says that she skips lunch once or twice a week to reduce her caloric intake. |
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Do you skip any meals? |
Question |
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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 |
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For sure. OK. |
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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%)
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: 3 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: 5 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 |
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 |
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SubjectiveMs. 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
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
- Growth curve maintained
- Growth curve decline
- Below 5th percentile
- Between 5th and 95th percentile
- Above 95th percentile
- Growth curve maintained
- Growth curve declined
- 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.
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Found:
Indicates an item that you found.
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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