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Musculoskeletal Results | Turned In
Health Assessment - NRSE 4520 - February 2025
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Overview
Subjective Data Collection: 23 of 23 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal... Indicates an item that
Objective Data Collection you found.
Hover over the Patient Data items Indicates an item that
Documentation below to reveal important
is available to be found.
information, including Pro Tips and
Video Tutorial Example Questions.
Category Scored Items Patient Data
Not Scored
Experts selected these topics as essential A combination of open and closed questions
components of a strong, thorough interview with yield better patient data. The following deta
this patient. are facts of the patient's case.
Relevant Medical History
Asked about joint problems Denies joint pain
Denies joint swelling
Asked about mobility Denies history of walking problems
Reports recent foot wound hindered
mobility
Reports ability to walk on foot has recentl
improved
Asked pain rating when walking Reports pain as a 7 or 8/10 when walking
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,3/27/25, 3:38 AM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Asked about ability to stand Denies trouble standing before foot problems
Reports recent foot wound hindered standing
Reports improved ability to stand on injured foot
Asked pain rating when standing Reports pain as a 7 or 8/10 w
Asked about muscle soreness Denies history of muscle sore
Denies current muscle sorene
Asked about joints in proximity of injury Denies current ankle problem
Asked about occupational impact on injury Denies work being dangerous
Denies work involving repetiti
Reports foot wound prevente
Asked about activities of daily living Denies difficulty transferring f
Denies difficulty bathing
Review of Systems
Asked about joint stiffness Denies joint stiffness
Asked about back pain Denies history of back pain
Denies current back pain
Asked about muscle injury Denies history of muscle injur
Denies current muscle injury
Asked about joint injury Denies past joint injury
Denies current joint injury
Asked history of fracture Denies history of fractures
Asked history of sprains Denies history of sprains
Asked about bone problems Denies history of bone proble
Denies current bone problem
Asked about neck Denies history of neck proble
Denies current neck problems
Asked about range of motion of body parts Reports normal range of moti
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https://www.coursehero.com/file/248072405/musculoskeletal-SubjectiveTina-Jonespdf/
, 3/27/25, 3:38 AM | Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Asked about muscle problems Denies muscle weakness
Denies muscle cramping
Risk Factors
Asked fall history Reports fall
Reports fall was one week ag
Reports belief that she is not
Denies other recent falls
Reports no dizziness or weak
Relevant Family History
Asked family history of osteoporosis Denies family history of osteo
Asked family history of joint problems Denies family history of joint p
Denies family history of arthri
Asked family history of bone cancer Denies family history of bone
Comments
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, Transcript
Started: Feb 25, 2025 | Total Time: 142 min
All Lines (170)Interview Questions (104)Statements (19)Exam Actions (47)
Question
02/25/25
Hello!
11:25 PM
EST
Hi. I'm Preceptor Diana. I will explain the details of this
assignment and your objectives, just as a preceptor would
in real life. Pay close attention to this information as it will
help guide your exam. At the end of this prebrief, you
will answer a short question about the upcoming
assignment. During the simulation, you may return to
these instructions at any time by scrolling to the top of
your transcript.
Question
02/25/25
What is the situation?
11:26 PM
EST
It's 8 a.m. on Tina Jones' first morning as a patient here at
Shadow General Hospital. When Ms. Jones was admitted at
midnight last night for a foot wound, she mentioned a
history of headaches and allergies. Your role in this
simulation is that of a healthcare provider who
will perform an examination of Ms. Jones' HEENT
systems: Head, Eyes, Ears, Nose, and Throat. Examination
of all of these systems is often necessary to examine any
one of them, given their close proximity and physiological
relationships.
Question
02/25/25
What are my objectives in this assessment?
11:26 PM
EST
In your interview with Ms. Jones, you will ask about the
health of her HEENT systems so that you can identify any
issues and document findings accurately. If you discover
any disease states, ask about symptoms and the patient's
experiences of them. Your questioning should cover a