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Week 9

Shadow Health Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic results:

ASSESSMENT:

PLAN:
This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

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10/29/2017 Comprehensive Assessment | Completed | Shadow Health

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Comprehensive Assessment Results | Turned In
Advanced Health Assessment – September ’17 , NREO81 NRE-662 01A

Return to Assignment

Your Results Lab Pass

Documentation

Vitals

Student Documentation Model Documentation

128/82 mm Hg (97.3 MAP)
HP 78
99% SpO2
98.9 degrees F
FVC 3.91 L
FEV1 3.15 L
FEV1/FVC – 0.81

• Height: 170 cm
• Weight: 84 kg
• BMI: 29.0
• Blood Glucose: 100
• RR: 15
• HR: 78
• BP:128 / 82
• Pulse Ox: 99%
• Temperature: 99.0 F

Health History

Student Documentation Model Documentation

Identifying Data & Reliability

Able to state name and date of birth that matches
EHR records. Oriented x3.

(For the record, I did stop before starting asking
questions. There should be a lapse in time. I was
documenting)

Ms. Jones is a pleasant, 28-year-old African
American single woman who presents for a pre-
employment physical. She is the primary source of
the history. Ms. Jones offers information freely and
without contradiction. Speech is clear and coherent.
She maintains eye contact throughout the interview.

General Survey

Ms. Jones is a 28 year old obese, African American
woman who is clearly able to keep up with her ADLs.
Her hair is braided, her clothes are clean, she seems
to be able to keep up with hygiene. She does not
seem to be in any acute distress.

Ms. Jones is alert and oriented, seated upright on
the examination table, and is in no apparent distress.
She is well-nourished, well-developed, and dressed
appropriately with good hygiene.

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Documentation

Plan My Exam

Self-Reflection

Documentation / Electronic Health Record

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Student Documentation Model Documentation

Reason for Visit

Ms. Jones is here for a head-to-toe exam for
insurance purposes for her new job.

“I came in because I’m required to have a recent
physical exam for the health insurance at my new
job.”

History of Present Illness

No present illness, does not admit to symptoms and
states she is “doing well, thanks!”

Ms. Jones reports that she recently obtained
employment at Smith, Stevens, Stewart, Silver &
Company. She needs to obtain a pre-employment
physical prior to initiating employment. Today she
denies any acute concerns. Her last healthcare visit
was 4 months ago, when she received her annual
gynecological exam at Shadow Health General
Clinic. Ms. Jones states that the gynecologist
diagnosed her with polycystic ovarian syndrome and
prescribed oral contraceptives at that visit, which she
is tolerating well. She has type 2 diabetes, which she
is controlling with diet, exercise, and metformin,
which she just started 5 months ago. She has no
medication side effects at this time. She states that
she feels healthy, is taking better care of herself than
in the past, and is looking forward to beginning the
new job.

Medications

Metformin 850 mg BID last taken today
Proventil 2 puffs PRN 90 mcg/spray
Flovent 2 puffs 88 mcg/spray BID

• Fluticasone propionate, 110 mcg 2 puffs BID (last
use: this morning)
• Metformin, 850 mg PO BID (last use: this morning)
• Drospirenone and ethinyl estradiol PO QD (last
use: this morning)
• Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last
use: three months ago)
• Acetaminophen 500-1000 mg PO prn (headaches)
• Ibuprofen 600 mg PO TID prn (menstrual cramps:
last taken 6 weeks ago)

Allergies

Cats – breathing issues, sneezing, itchy eyes. Treat
with leaving, showering, and rescue inhaler.
Penicilin, not severe, per pt – hives/rash. Treat by not
taking again.

• Penicillin: rash
• Denies food and latex allergies
• Allergic to cats and dust. When she is exposed to
allergens she states that she has runny nose, itchy
and swollen eyes, and increased asthma symptoms.

Medical History

T2DM at age 24. Treat with diet, exercise, and
metformin
Asthma at 2 1/2. Treat with inhalers and watching for
triggers.

Asthma diagnosed at age 2 1/2. She uses her
albuterol inhaler when she is around cats. Her last
asthma exacerbation was three months ago, which
she resolved with her inhaler. She was last
hospitalized for asthma in high school. Never
intubated. Type 2 diabetes, diagnosed at age 24.
She began metformin 5 months ago and initially had
some gastrointestinal side effects which have since
dissipated. She monitors her blood sugar once daily
in the morning with average readings being around
90. She has a history of hypertension which
normalized when she initiated diet and exercise. No
surgeries. OB/GYN: Menarche, age 11. First sexual
encounter at age 18, sex with men, identifies as
heterosexual. Never pregnant. Last menstrual period
2 weeks ago. Diagnosed with PCOS four months
ago. For the past four months (after initiating Yaz)
cycles regular (every 4 weeks) with moderate
bleeding lasting 5 days. Has new male relationship,
sexual contact not initiated. She plans to use
condoms with sexual activity. Tested negative for
HIV/AIDS and STIs four months ago.

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Student Documentation Model Documentation

Health Maintenance

Doctors visits, diet, exercise, taking medication as
directed.

Last Pap smear 4 months ago. Last eye exam three
months ago. Last dental exam five months ago. PPD
(negative) ~2 years ago. Immunizations: Tetanus
booster was received within the past year, influenza
is not current, and human papillomavirus has not
been received. She reports that she believes she is
up to date on childhood vaccines and received the
meningococcal vaccine for college. Safety: Has
smoke detectors in the home, wears seatbelt in car,
and does not ride a bike. Uses sunscreen. Guns,
having belonged to her dad, are in the home, locked
in parent’s room.

Family History

Mom – high cholesterol and bp
Dad – high bp and cholesterol, diabetes
Sister – asthma
Brother – obese
Maternal grandfather- died of MI
Maternal grandma – died of stroke
Pat. Grandma – high cholesterol and BP
Pat. Grandpa – colon cancer, high BP, diabetes

• Mother: age 50, hypertension, elevated cholesterol
• Father: deceased in car accident one year ago at
age 58, hypertension, high cholesterol, and type 2
diabetes
• Brother (Michael, 25): overweight
• Sister (Britney, 14): asthma
• Maternal grandmother: died at age 73 of a stroke,
history of hypertension, high cholesterol
• Maternal grandfather: died at age 78 of a stroke,
history of hypertension, high cholesterol
• Paternal grandmother: still living, age 82,
hypertension
• Paternal grandfather: died at age 65 of colon
cancer, history of type 2 diabetes
• Paternal uncle: alcoholism
• Negative for mental illness, other cancers, sudden
death, kidney disease, sickle cell anemia, thyroid
problems

Social History

Social drinker, no drugs, no tobacco.

Never married, no children. Lived independently
since age 19, currently lives with mother and sister
in a single family home, but will move into own
apartment in one month. Will begin her new position
in two weeks at Smith, Stevens, Stewart, Silver, &
Company. She enjoys spending time with friends,
reading, attending Bible study, volunteering in her
church, and dancing. Tina is active in her church and
describes a strong family and social support system.
She states that family and church help her cope with
stress. No tobacco. Cannabis use from age 15 to
age 21. Reports no use of cocaine,
methamphetamines, and heroin. Uses alcohol when
“out with friends, 2-3 times per month,” reports
drinking no more than 3 drinks per episode. Typical
breakfast is frozen fruit smoothie with unsweetened
yogurt, lunch is vegetables with brown rice or
sandwich on wheat bread or low-fat pita, dinner is
roasted vegetables and a protein, snack is carrot
sticks or an apple. Denies coffee intake, but does
consume 1-2 diet sodas per day. No recent foreign
travel. No pets. Participates in mild to moderate
exercise four to five times per week consisting of
walking, yoga, or swimming.

Mental Health History

No history.

Reports decreased stress and improved coping
abilities have improved previous sleep difficulties.
Denies current feelings of depression, anxiety, or
thoughts of suicide. Alert and oriented to person,
place, and time. Well-groomed, easily engages in
conversation and is cooperative. Mood is pleasant.
No tics or facial fasciculation. Speech is fluent,
words are clear.

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Student Documentation Model Documentation

Review of Systems – General

HEENT: scalp normal, hair normal, ears normal
(bilaterally pearly grey, cone of light aprox. 5 mm),
nares reddish pink with no drainage, whisper test
normal, eyelids normal, right eye woolen bodies,
sharp disc, left eye sharp disc. 20/20 bilaterally with
corrective lenses. PERRLA bilaterally. Mouth WDL,
moist, no swelling, tonsils normal (2), gag reflex
present. Lymph nodes not palpable in all areas, no
goiter, no sinus pain.
Resp: Fremitus equal bilatterally. Lung sounds and
voice sounds present and normal in all areas, clear.
Expansion symmetrical. Chest anterior and posterior
normal upon inspection, resonant upon percussion.
CV: Carotids 2+ with no thrill bilaterally, no bruits.
PMI nondiscplaced, no heaves or lifts. S1 and S2
only, regular. No bruit in the AAA, arteries in
abdomen and pelvis have no bruities, Pulses 2+ in
all areas. Capilary refil <3 seconds in fingers and toes. No edema. GI: Bowel sounds normal in all quadrants. No masses or abnormalities upon inspection, palpation, ausculation, or percussion. Abdomen is soft with no masses. Liver is 1 cm below right costal margin, spleen not palpable, kidneys not palpable with no masses. Quadrants percussion tympanic, spleen not dull sounding. Musc: ROM in all areas normal, all muscle strengths 5/5. No CVA tenderness. DTR 2+ all over. Neuro: Finger/Nose test normal. Rapid alternating hand movements normal. Sensation normal everywhere except limited in feet, especially left foot. Able to sense position of body/fingers/toes. Graphesthesia: normal sense. Stereognosis: normal sense. Heel/sin normal. Hair, Skin, and Nails: No ridges or abnormalities in nails. Extra hair below belly button and on face. Acne present on face, acanthosis nigricans on neck. Skin normal, old scar on left shin. Hair on scalp normal.

No recent or frequent illness, fatigue, fevers, chills,
or night sweats. States recent 10 pound weight loss
due to diet change and exercise increase.

HEENT

Student Documentation Model Documentation

Subjective

“I’m doing really well”
”

Reports no current headache and no history of head
injury or acute visual changes. Reports no eye pain,
itchy eyes, redness, or dry eyes. Wears corrective
lenses. Last visit to optometrist 3 months ago.
Reports no general ear problems, no change in
hearing, ear pain, or discharge. Reports no change
in sense of smell, sneezing, epistaxis, sinus pain or
pressure, or rhinorrhea. Reports no general mouth
problems, changes in taste, dry mouth, pain, sores,
issues with gum, tongue, or jaw. No current dental
concerns, last dental visit was 5 months ago.
Reports no difficulty swallowing, sore throat, voice
changes, or swollen nodes.

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Student Documentation Model Documentation

Objective

Scalp normal, hair normal, ears normal (bilateral
pearly grey, cone of light aprox. 5 mm). Nares
reddish pink with no drainage. Whisper test normal,
eyelids normal, right eye 20/20 (corrective lenses)
with woolen bodies and sharp disc, left eye 20/20
(corrective lenses) with sharp disc. PERRLA
bilaterally. Mouth WDL, moist, tonsils 2, gag reflex
present, lymph nodes not palpable, no goiter, no
sinus pain. EOM normal.

PCOS
Diabetic Neuropathy
Obesity

Head is normocephalic, atraumatic. Bilateral eyes
with equal hair distribution on lashes and eyebrows,
lids without lesions, no ptosis or edema. Conjunctiva
pink, no lesions, white sclera. PERRLA bilaterally.
EOMs intact bilaterally, no nystagmus. Mild
retinopathic changes on right. Left fundus with sharp
disc margins, no hemorrhages. Snellen: 20/20 right
eye, 20/20 left eye with corrective lenses. TMs intact
and pearly gray bilaterally, positive light reflex.
Whispered words heard bilaterally. Frontal and
maxillary sinuses nontender to palpation. Nasal
mucosa moist and pink, septum midline. Oral
mucosa moist without ulcerations or lesions, uvula
rises midline on phonation. Gag reflex intact.
Dentition without evidence of caries or infection.
Tonsils 2+ bilaterally. Thyroid smooth without
nodules, no goiter. No lymphadenopathy.

Respiratory

Student Documentation Model Documentation
Subjective

“I’m doing really well”
“I don’t have anything specific going on today”
My asthma is “under control”
Rarely needs rescue inhaler

Reports no shortness of breath, wheezing, chest
pain, dyspnea, or cough.

Objective

Femitus equal bilteraly. Lung sounds clear and voice
sounds present in all areas. Expansion symmetrical.
Chest, anterior and posterior normal upon
inspection, resonant upon percussion.

PCOS
Diabetic neuropathy
Obesity

Chest is symmetric with respiration, clear to
auscultation bilaterally without cough or wheeze.
Resonant to percussion throughout. In office
spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Cardiovascular

Student Documentation Model Documentation
Subjective

“I’m doing really well”
“I don’t have anything specific going on today”

Reports no palpitations, tachycardia, easy bruising,
or edema.

Objective

Caroitds 2+ whit no thrill or bruit, bilaterally. PMI
nondiscplaced, no heaves or lifts. S1 and S2 only,
regular rhythm. No bruits in the aorta or any other
arteries in the abdomen and pelvis. Pulses 2+ in all
areas. Capillary refill <3 seconds in fingers and toes. No edema. PCOS Diabetic neuropathy Obesity

Heart rate is regular, S1, S2, without murmurs,
gallops, or rubs. Bilateral carotids equal bilaterally
without bruit. PMI at the midclavicular line, 5th
intercostal space, no heaves, lifts, or thrills. Bilateral
peripheral pulses equal bilaterally, capillary refill less
than 3 seconds. No peripheral edema.

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Abdominal

Student Documentation Model Documentation
Subjective
“I’m doing really well”
“I don’t have anything specific going on today”

Gastrointestinal: Reports no nausea, vomiting, pain,
constipation, diarrhea, or excessive flatulence. No
food intolerances. Genitourinary: Reports no dysuria,
nocturia, polyuria, hematuria, flank pain, vaginal
discharge or itching.

Objective

Bowel sounds normal in all quadrants. No masses or
abnormalities upon inspection, palpation,
auscultation, or percussion. Abdomen is soft with no
masses. Liver is 1 cm below right costal margin,
spleen not palpable, kidneys not palpable and no
masses present. Quadrants are tympanic and spleen
not dull sounding.

PCOS
Diabetic Neuropathy
Obesity

Abdomen protuberant, symmetric, no visible
masses, scars, or lesions, coarse hair from pubis to
umbilicus. Bowel sounds are normoactive in all four
quadrants. Tympanic throughout to percussion. No
tenderness or guarding to palpation. No
organomegaly. No CVA tenderness.

Musculoskeletal

Student Documentation Model Documentation
Subjective

“I’m doing realy well”
“I don’t have anything specific going on today”

Reports no muscle pain, joint pain, muscle
weakness, or swelling.

Objective

ROM in all areas full, all muscle strengths are 5/5, no
CVA tenderness, DTR 2+ all over.

PCOS
Diabetic Neuropathy
Obesity

Strength 5/5 bilateral upper and lower extremities,
without swelling, masses, or deformity and with full
range of motion. No pain with movement.

Neurological

Student Documentation Model Documentation
Subjective
“I’m doing really well”
“I don’t have anything specific going on today”

Reports no dizziness, light-headedness, tingling,
loss of coordination or sensation, seizures, or sense
of disequilibrium.

Objective

Finger/nose test normal, rapid alternationg hand
movements normal. Sensation normal except for
feet, especially left foor. Able to sense position of
body/fingers/toes. Graphesthesia: normal sense.
Sterognosis: normal sense. Heel/shin normal.
Orientation normal.

PCOS
Diabetic neuropathy
Obesity

Normal graphesthesia, stereognosis, and rapid
alternating movements bilaterally. Tests of cerebellar
function normal. DTRs 2+ and equal bilaterally in
upper and lower extremities. Decreased sensation to
monofilament in bilateral plantar surfaces.

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Skin, Hair & Nails

Student Documentation Model Documentation
Subjective
“I’m doing really well”
“I don’t have anything specific going on today”

Reports improved acne due to oral contraceptives.
Skin on neck has stopped darkening and facial and
body hair has improved. She reports a few moles but
no other hair or nail changes.

Objective

No ridges or abnormalities in nails. Extra hair below
belly button and on face. Acne present on face,
acanthosis nigricans on neck. Skin normal, old scar
on left shin. Hair on scal normal, skin on scalp
normal.

PCOS
Diabetic Neuropathy
Obesity

Scattered pustules on face and facial hair on upper
lip, acanthosis nigricans on posterior neck. Nails free
of ridges or abnormalities.

Comments

If your instructor provides individual feedback on this assignment, it will appear here.

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3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health

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Comprehensive Assessment (120 min minimum) Results | Turned In
Advanced Physical Assessment Across the Lifespan (FNP) – USU – February 2021, msn572

Return to Assignment (/assignments/470720/)

Subjective Data Collection: 45 of 50 (90.0%)

Current Health Status

Your Results Lab Pass (/assignment_attempts/9539340/lab_pass.pd

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Documentation

Plan My Exam

Indicates an item that you
found.
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 t
patient’s case.

Confirmed reason for visit Reports needing a pre-employment physical
Reports no current acute health problems

Asked about last visit to a healthcare provider Last visit to a healthcare provider was 4 months
ago
Reason for last visit was annual gynecological

exam
Last general physical examination was 5 months

ago when she was prescribed metformin and daily
inhaler

Asked about current prescription medications Reports taking diabetes medication
Reports using a daily inhaler
Reports taking prescription birth control pills

Followed up about diabetes medication Medication is metformin
Started taking metformin 5

months ago

Reports that eating probiotic yogurt helps with

side effects and they have abated over time

Followed up on metformin frequency and dose Reports taking metformin twice daily
Metformin dose is 850 mg

Asked about asthma medication Reports using Flovent inhaler twice daily
Has a Proventil rescue inhaler
Last use of Proventil inhaler was three months

ago
Has used Proventil inhaler twice in the last year

Hover To Reveal…

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

Support

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Followed up about birth control prescription Started taking birth control 4 months ago
Reason for birth control was to manage PCOS

symptoms
Birth control type is Yaz (drospirenone and ethinyl

estradiol)
Takes birth control pill daily
Takes birth control pill at the same time every day
Reports no skipped days

Asked about current non-prescription
medications

Reports rare Advil use for cramps
Reports no OTC herbal products
Reports no OTC vitamins
Reports no OTC supplements

Asked about allergies Confirms allergies
Reports no new allergies

Followed up on seasonal allergies Reports no recent seasonal allergy symptoms
Reports no current medication for allergies

Asked about diabetes Reports managing diabetes with diet and exercise
in addition to medication

Asked about blood glucose monitoring Reports checking blood sugar once a day
Checks sugar in the morning
Blood sugar number is usually around 90
Reports having adequate supplies

Asked about asthma symptoms Reports no current asthma symptoms
Reports no recent asthma exacerbations
Reports last asthma exacerbation was three

months ago

Asked about headache symptoms Reports no recent headache

Asked about vision Reports optometrist visit
Optometrist visit 3 months ago
Reports prescription eyeglasses
Reports that glasses improve overall vision
Reports reduction in blurry vision

Asked about palpitations Reports no current palpitations
Reports no recent palpitations

Asked about hypertension treatment Reports that blood pressure responded to diet
and exercise

changes

Asked about GERD Reports no recent GERD symptoms
Reports no current GERD symptoms
Reports no current medication for GERD

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Psychosocial History

Social Determinants of Health

Reports no recent back pain

Asked date of last menstrual period Last menstrual period was 2 weeks ago

Asked about menstrual patterns Reports a period every 4 weeks
Reports that period lasts 5 days
Reports some cramping
Reports a medium flow

Asked about weight changes Reports recent weight loss
Reports weight loss of about 10 pounds
Reports that weight loss was result of change in

diet and increased exercise

Asked about diet Typical breakfast is fruit smoothie with probiotic
yogurt or egg on wheat toast with probiotic yogurt
Typical lunch is dinner leftovers or tuna or chicken

sandwich on wheat bread
Typical dinner is vegetables with a protein and

brown rice or quinoa
Typical snack is carrot sticks or an apple

Asked about caffeine intake Reports limiting caffeine since heart and sleep
problems
Reports no coffee drinking
Reports only caffeine is diet Coke
Reports drinking 2 diet Cokes per day

Asked about alcohol intake Drinks 2-3 nights per month
Has 2 or 3 drinks when out with friends
Orders single drinks
Usually orders rum and diet Coke

Asked about exercise Reports mild to moderate exercise
Reports walking four or five times a week
Reports that a typical walk is thirty or forty

minutes
Reports weekly swimming at YMCA
Reports no asthma exacerbation during exercise

Asked about relationship status and current
sexual activity

Reports no new sexual partners
Reports new month-old relationship
Plans to use condoms if sexually active in the

future

Asked about education Reports graduated with accounting degree

Asked about work Reports being hired at Smith, Stevens, Stewart,
Silver & Company
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Mental Health

Review of Systems

Reports will start work in 2 weeks

Asked about living situation Reports currently living at home with mom and
sister
Reports moving into her own apartment near work

in 1 month

Asked about support system Reports strong friendships
Reports strong familial relationships
Reports church remains a strong support system

Asked about stress Reports feeling less stress after graduation and
passing CPA exam
Reports improved ability to cope with stress

Asked about indicators of depression Reports no depression
Reports feeling positive about upcoming life

changes

Asked about anxiety Reports anxiety improved with relief of stressors
and passing of time
Reports coping well with upcoming life changes

Asked about sleep Reports no current difficulties falling asleep
Reports sleeping 8 or 9 hours a night

Asked general indicators of health Reports no recent or frequent illness
Reports no fatigue
Reports no fever
Reports no chills
Reports no night sweats

Asked about review of systems for head Reports no current or recent head problems
Reports no head injury

Asked about review of systems for ears Reports no general ear problems
Reports no change in hearing
Reports no ear pain
Reports no ear discharge

Asked about review of systems for eyes Reports no eye pain
Reports no itchy eyes
Reports no eye redness
Reports no dry eyes

Asked about review of systems for nose Reports no general nose problems
Reports no change in sense of smell
Reports no sneezing
Reports no nosebleedsThis study source was downloaded by 100000770473191 from CourseHero.com on 01-26-2022 21:45:20 GMT -06:00

https://www.coursehero.com/file/87550556/ShadowHealth-Final-Head-to-Toepdf/

https://www.coursehero.com/file/87550556/ShadowHealth-Final-Head-to-Toepdf/

3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health

https://classroom.usuniversity.edu/d2l/le/content/61343/viewContent/3173533/View 5/6

Reports no sinus pain
Reports no sinus pressure
Reports no runny nose

Asked about review of systems for mouth and
jaw

Reports no current dental problems
Reports last dental visit was 5 months ago
Reports no general mouth problems
Reports no change in sense of taste
Reports no dry mouth
Reports no mouth pain
Reports no mouth sores
Reports no gum problems
Reports no tongue problems
Reports no jaw problems

Asked about review of systems for neck and
throat

Reports no difficulty swallowing
Reports no sore throat
Reports no history of throat problems
Reports no voice changes
Reports no general neck problems
Reports no history of lymph node problems
Reports no swollen glands

Asked about review of systems for respiratory Reports no current breathing problems
Reports no wheezing
Reports no chest tightness
Reports no pain while breathing
Reports no coughing

Asked about review of systems for
cardiovascular

Reports no palpitations
Reports no irregular heartbeat
Reports no easy bruising
Reports no edema
Reports no circulation problems

Asked review of systems for gastrointestinal Reports no nausea
Reports no vomiting
Reports no stomach pain
Reports no constipation
Reports no diarrhea
Reports no flatulence

Asked review of systems for genitourinary Reports no dysuria
Reports reduction in nocturia
Reports no polyuria
Reports no blood in urine
Reports no flank pain
Reports no vaginal itching or irritation
Reports normal vaginal discharge

Asked review of systems for breasts Reports no general breast problems
Reports no breast lumps
Reports no breast pain

Asked review of systems for musculoskeletal Reports no muscle pain
Reports no joint pain

This study source was downloaded by 100000770473191 from CourseHero.com on 01-26-2022 21:45:20 GMT -06:00
https://www.coursehero.com/file/87550556/ShadowHealth-Final-Head-to-Toepdf/

https://www.coursehero.com/file/87550556/ShadowHealth-Final-Head-to-Toepdf/

3/31/2021 Comprehensive Assessment (120 min minimum) | Completed | Shadow Health

https://classroom.usuniversity.edu/d2l/le/content/61343/viewContent/3173533/View 6/6

Reports no muscle weakness
Reports no muscle swelling

Asked review of systems for neurological Reports no dizziness or lightheadedness
Reports no vision disturbance
Reports no numbness or tingling
Reports no loss of coordination
Reports no loss of sensation
Reports no seizures
Reports no problems with balance

Asked review of systems for skin, hair and nails Reports no rashes
Reports using sunscreen while exercising

outdoors
Reports no recent slow-healing wounds
Reports improving acne
Reports some male-pattern hair growth
Reports no changes in moles
Reports no sores
Reports no dandruff
Reports no nail fungus
Reports no dry skin

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