Adolescent Sports Evaluation Samantha Monroe shadow health

Hello. My name is xxxx, I will interview you and later conduct a physical exam.

Table of Contents

Greetings

Hello.

What is your relationship with the patient?

Oh, this is my mom.

Hey, I’m Jackie Monroe. This is my daughter, Samantha.

Why are you here today?

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. Adolescent Sports Evaluation Samantha Monroe shadow health

Any medical issue?

Uh, nope. No health issues.

Any history of surgery?

I had my tonsils removed when I was like 9, but that’s it.

Yeah, that was Samantha’s only surgery.

Any missing organ?

Does your daughter have any missing organ?

Have you had any of your organs removed?

Uh . . . no. All my organs are 100% present.

Any allergies?

No, I’ve never had any allergies before.

Are your vaccinations current?

Yeah, I’ve had all my vaccines.

I always made sure she was up to date on her vaccinations.

Are you using any medications?

No, I don’t take anything.

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. Adolescent Sports Evaluation Samantha Monroe shadow health

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.

1. Fitting in

Samantha feels like she doesn’t fit in with her peers.

“Do you want to lose weight?” (Clarified to: Why do you think you need to lose weight?)

“Just . . . to look more athletic, you know. Like I fit in with everybody.” (Clarified to: why I think I need to lose weight)

“You should not try to fit in. Everyone is unique.

Um, that makes sense.”

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.”

2. Body Image

Samantha has insecurities about her body image.

“Do you feel your weight is okay?” (Clarified to: How do you feel about your weight?)

“Um, I mean, I wish I could lose this baby fat.” (Clarified to: how I feel about my weight)

“I understand your concerns but you should not try to fit in or compare yourself to others.”

Gotcha.

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.”

3. Menstruation

Samantha has concerns that she should have had her first period already.

“Have you started your periods?”

“No, I haven’t started my period yet.”

“I understand your concerns, but it’s normal for a person of your age to not have started their periods yet.”

Cool. Good to know.

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.”

4. Skipping Meals

Samantha says that she skips lunch once or twice a week to reduce her caloric intake.

“Do you skip any meals?”

“Yeah, I skip lunch once or twice each week.”

“It is not advisable to skip any meal at your age because you are still growing.”

For sure. OK.

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.”

Objective Data Collection: 23 of 23 (100%)

Correct
Partially correct
Incorrect
Missed

Growth Chart: Height & Weight

1 of 1 point

Weight Percentile (1/4 point)
Below 5th percentile
Between 5th and 95th percentile
Above 95th percentile
Weight Growth Curve (1/4 point)
Growth curve maintained
Growth curve decline
Height Percentile (1/4 point)
Below 5th percentile
Between 5th and 95th percentile
Above 95th percentile
Height Growth Curve (1/4 point)
Growth curve maintained
Growth curve declined

Inspected Skin

1 of 1 point

Lesions (1/5 point)
No visible lesions

Documentation / Electronic Health Record

Subjective

Ms. 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. Takes multivitamin Adolescent Sports Evaluation Samantha Monroe shadow health

Treatment Plan: 21 of 21 (100.00%)

No diagnosis required
All interventions addressed

Summary

No issues found.

End of Summary

Thank you for taking the time to speak with me.

You’re welcome.

Goodbye.

Goodbye.

Samantha Monroe shadow health Subjective data

Adolescent Sports Evaluation Samantha Monroe shadow health

Transcript

	Hello. My name is xxxx, I will interview you and later conduct a physical exam.\	Greet 03/05/22 5:41 AM EST
	Hello.
	What is your relationship with the patient?	Question 03/05/22 5:42 AM EST
	Oh, this is my mom.
	Hey, I’m Jackie Monroe. This is my daughter, Samantha.
	Why are you here today?	Question 03/05/22 5:42 AM EST
	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. Adolescent Sports Evaluation Samantha Monroe shadow health
	Any medical issue?	Question 03/05/22 5:43 AM EST
	Uh, nope. No health issues.
	Any history of surgery?	Question 03/05/22 5:43 AM EST
	I had my tonsils removed when I was like 9, but that’s it.
	Yeah, that was Samantha’s only surgery.
	Any missing organ? (No matching questions found.)	Question 03/05/22 5:45 AM EST
	Does your daughter have any missing organ? (No matching questions found.)	Question 03/05/22 5:46 AM EST
	Have you had any of your organs removed?	Question 03/05/22 5:46 AM EST
	Uh . . . no. All my organs are 100% present.
	Any allergies?	Question 03/05/22 5:49 AM EST
	No, I’ve never had any allergies before.
	Are your vaccinations current?	Question 03/05/22 5:50 AM EST
	Yeah, I’ve had all my vaccines.
	I always made sure she was up to date on her vaccinations.
	Are you using any medications?	Question 03/05/22 5:50 AM EST
	No, I don’t take anything.
	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. Adolescent Sports Evaluation Samantha Monroe shadow health 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  1 Fitting in Followed Up  Description: Samantha feels like she doesn’t fit in with her peers. Do you want to lose weight? (Clarified to: Why do you think you need to lose weight?) Question 06:29 AM EST Just . . . to look more athletic, you know. Like I fit in with everybody. (Clarified to: why I think I need to lose weight) You should not try to fit in. Everyone is unique Adolescent Sports Evaluation Samantha Monroe shadow health. Educate 06:30 AM EST Um, that makes sense.  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.”  2 Body Image Followed Up  Description: Samantha has insecurities about her body image. Do you feel your weight is okay? (Clarified to: How do you feel about your weight?) Question 06:27 AM EST 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) I understand your concerns but you should not try to fit in or compare yourself to others. Educate 06:29 AM EST Gotcha.  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.”  3 Menstruation Followed Up  Description: Samantha has concerns that she should have had her first period already. Have you started your periods? Question 06:17 AM EST 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. I understand your concerns, but it’s normal for a person of your age to not have started their periods yet. Educate 06:20 AM EST Cool. Good to know.  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 Adolescent Sports Evaluation Samantha Monroe shadow health. 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.”  4 Skipping Meals Followed Up  Description: Samantha says that she skips lunch once or twice a week to reduce her caloric intake. Do you skip any meals? Question 06:32 AM EST Yeah, I skip lunch once or twice each week. It is not advisable to skip any meal at your age because you are still growing Educate 06:33 AM EST For sure. OK.  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.”
	Objective Data Collection: 23 of 23 (100%)  Correct  Partially correct  Incorrect  Missed  Growth Chart: Height & Weight 1 of 1 point Weight Percentile (1/4 point)  Below 5th percentile  Between 5th and 95th percentile  Above 95th percentile Weight Growth Curve (1/4 point)  Growth curve maintained  Growth curve decline Height Percentile (1/4 point)  Below 5th percentile  Between 5th and 95th percentile  Above 95th percentile Height Growth Curve (1/4 point)  Growth curve maintained  Growth curve declined  Inspected Skin 1 of 1 point Lesions (1/5 point)  No visible lesions
	Documentation / Electronic Health Record My Provider Notes Student Documentation Model Documentation Subjective Ms. 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. Takes multivitamin Adolescent Sports Evaluation Samantha Monroe shadow health
	Treatment Plan: 21 of 21 (100.00%) Problem Selection 8 out of 8 Primary Diagnosis Review your answers for the Problem Selection activities Adolescent Sports Evaluation Samantha Monroe shadow health. 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. 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.
	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. Found:  Indicates an item that you found. 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.
	Nope. My head’s fine.
	Have you had a concussion?	Question 03/05/22 6:03 AM EST
	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.
	Any numbness or tingling? Adolescent Sports Evaluation Samantha Monroe shadow health	Question 03/05/22 6:04 AM EST
	No numbness or tingling. That sounds weird.
	Any weakness in your limbs?	Question 03/05/22 6:09 AM EST
	Nope, no weakness.
	Do you exercise in the heat?	Question 03/05/22 6:14 AM EST
	Sure. We do gym outside sometimes. When soccer season starts, practice and games are outside.
	Any eye problems?	Question 03/05/22 6:16 AM EST
	My eyes are fine.
	Have you started your periods?	Question 03/05/22 6:17 AM EST
	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.
	She asked how old I was when I got my first period. I told her I was about 12.
	I understand your concerns, but it’s normal for a person of your age to not have started their periods yet.	Educate 03/05/22 6:20 AM EST
	Cool. Good to know.
	Tell me about your family medical history.	Question 03/05/22 6:21 AM EST
	Wait, like the entire family medical history or do you mean something more specific?
	Any genetic conditions in your family? (Clarified to Does anyone in your family have a genetic heart condition?.)	Question 03/05/22 6:22 AM EST
	I don’t know. Mom? (Clarified to if anyone in my family has a genetic heart condition.)
	No, no one in the family has any genetic heart conditions.
	Any heart problems in your family?	Question 03/05/22 6:22 AM EST
	I don’t think anyone has heart problems, but I’m not totally sure.
	You know, I can’t think of anybody in the family who’s had heart problems.
	Any history of unexpected deaths in your family? (No matching questions found.)	Question 03/05/22 6:23 AM EST
	Any family history of unexpected deaths before the age of 35? (No matching questions found.)	Question 03/05/22 6:24 AM EST
	Has any of your family members had a pacemaker before age 35? (Clarified to Has anyone in your family had a pacemaker before 35?.) Adolescent Sports Evaluation Samantha Monroe shadow health	Question 03/05/22 6:25 AM EST
	I’m not sure about the pacemaker thing. (Clarified to if anyone in my family had a pacemaker before thirty five.)
	To my knowledge, there isn’t anyone in the family who’s ever had a pacemaker.
	Do you feel your weight is okay? (Clarified to How do you feel about your weight?.)	Question 03/05/22 6:27 AM EST
	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.)
	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.
	I understand your concerns but you should not try to fit in or compare yourself to others.	Educate 03/05/22 6:29 AM EST
	Gotcha.
	Do you want to lose weight? (Clarified to Why do you think you need to lose weight?.)	Question 03/05/22 6:29 AM EST
	Just . . . to look more athletic, you know. Like I fit in with everybody. (Clarified to why I think I need to lose weight.)
	You should not try to fit in. Everyone is unique.	Educate 03/05/22 6:30 AM EST
	Um, that makes sense.
	Tell me about your diet.	Question 03/05/22 6:31 AM EST
	I do the Mediterranean diet. It’s healthy. I try not to eat bad stuff. No candy, white carbs, processed food.
	Do you skip any meals?	Question 03/05/22 6:32 AM EST
	Yeah, I skip lunch once or twice each week.
	It is not advisable to skip any meal at your age because you are still growing	Educate 03/05/22 6:33 AM EST
	For sure. OK.
	How long have you been skipping your lunch? (Clarified to How long have you been skipping lunch?.)	Question 03/05/22 6:34 AM EST
	I started skipping lunch maybe a month ago? (Clarified to how long I have been skipping lunch.)
	Inspected weight and height growth chart	Exam Action 03/05/22 6:35 AM EST
	Inspected Skin	Exam Action 03/05/22 6:48 AM EST
	Assessed appearance	Exam Action 03/05/22 6:49 AM EST
	Assessed Cervical Spine Range of Motion	Exam Action 03/05/22 6:52 AM EST
	Assessed Spine Range of Motion: Full range of motion performed without discomfort	Exam Action 03/05/22 6:53 AM EST
	Assessed wrist range of motion	Exam Action 03/05/22 7:01 AM EST
	Assessed Elbow Range of Motion	Exam Action 03/05/22 7:03 AM EST
	Assessed range of motion of shoulders – adduction and abduction: Strength equal bilaterally against full resistance	Exam Action 03/05/22 7:06 AM EST
	Assessed Trapezius Strength: Strength equal bilaterally against full resistance	Exam Action 03/05/22 7:06 AM EST
	Assessed deltoid strength and shoulder rotation	Exam Action 03/05/22 7:07 AM EST
	Assessed Hand and Finger Range of Motion and Strength: Right and left hand strength equal bilaterally against resistance	Exam Action 03/05/22 7:08 AM EST
	Assessed Symmetry of Extremities	Exam Action 03/05/22 7:09 AM EST
	Assessed leg symmetry, knee and ankle effusion	Exam Action 03/05/22 7:09 AM EST
	Assessed Calf Symmetry and Leg Strength	Exam Action 03/05/22 7:10 AM EST
	Tested Hip, Knee, and Ankle ROM	Exam Action 03/05/22 7:11 AM EST
	Tested Cardinal Fields of Vision	Exam Action 03/05/22 7:14 AM EST
	Tested peripheral vision	Exam Action 03/05/22 7:15 AM EST
	Tested visual acuity	Exam Action 03/05/22 7:15 AM EST
	Tested balance: Expected	Exam Action 03/05/22 7:16 AM EST
	Auscultated lungs	Exam Action 03/05/22 7:17 AM EST
	Auscultated abdomen	Exam Action 03/05/22 7:18 AM EST
	Auscultated heart	Exam Action 03/05/22 7:18 AM EST
	Screened Adam’s Forward Bend	Exam Action 03/05/22 7:20 AM EST
	Mrs. Monroe please step out so I can have a private conversation with your daughter.	Educate 03/05/22 7:34 AM EST
	Sure, no problem.
	I will be asking you some personal questions and I need you to know that you are in a safe and a nonjudgmental environment.	Educate 03/05/22 7:36 AM EST
	OK. That sounds alright.
	Tell me about your school life, friends and hobbies. Adolescent Sports Evaluation Samantha Monroe shadow health	Question 03/05/22 7:38 AM EST
	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.
	Am sorry about that. Everything will be fine.	Empathize 03/05/22 7:39 AM EST
	Thanks. I’m glad you understand.
	Tell me about your support system.	Question 03/05/22 7:41 AM EST
	Yeah, me and my mom are pretty close, and I have some friends who get it. We talk and stuff.
	Have you ever used tobacco?	Question 03/05/22 7:42 AM EST
	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.
	Have you used any drugs?	Question 03/05/22 7:43 AM EST
	No. I wouldn’t ever do drugs.
	Have you used alcohol?	Question 03/05/22 7:44 AM EST
	I don’t drink. No way.
	Are you interested in relationships and dating?	Question 03/05/22 7:45 AM EST
	I’m not really interested in that yet.
	Are you sexually active?	Question 03/05/22 7:45 AM EST
	No.
	I would like to know more about your feeling of nervousness or anxiety.	Question 03/05/22 7:54 AM EST
	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.
	Am sorry about that.	Empathize 03/05/22 7:55 AM EST
	Thanks.
	I noticed that you are concerned about your body image, weight, and diet.	Question 03/05/22 7:57 AM EST
	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?
	Have you ever considered doing anything more extreme to manage your weight?	Question 03/05/22 7:58 AM EST
	No, I wouldn’t do anything dangerous. I promise.
	Do you have any questions for me?	Question 03/05/22 7:59 AM EST
	No, I don’t think so.
	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.	Exam Action 03/06/22 8:19 AM EST
	I am ready to begin the conversation with Samantha.	Question 03/06/22 8:20 AM EST
	In your own words, discuss life-threatening health problems related to disordered eating with Samantha and Ms. Monroe.	Exam Action 03/06/22 8:20 AM EST
	Forcing yourself to diet or skip meals can make you very sick because strong bones teeth, and hair require adequate nutrition.	Question 03/06/22 8:23 AM EST
	Oh, um yeah. That makes sense. I don’t want any of that to happen.
	Thank you. This is pretty concerning so we’ll take this very seriously.
	In your own words, discuss limiting media intake with Samantha and Jackie.	Exam Action 03/06/22 8:24 AM EST
	You should limit media exposure and remember that your body deserves to be fed, cared or, regardless of the size.	Question 03/06/22 8:30 AM EST
	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.
	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.
	In your own words, discuss increasing knowledge of coping mechanisms with Samantha and Jackie.	Exam Action 03/06/22 8:33 AM EST
	You can try journalling, relaxation and stress management techniques, and affirmations	Question 03/06/22 8:58 AM EST
	Yeah, that make sense. It’s not like I want to feel this way, you know?
	I’m just glad we figured out that this was an issue. I had no idea.
	You have provided Samantha and her mother education on all appropriate non-pharmacological interventions. Adolescent Sports Evaluation Samantha Monroe shadow health