Adolescent Sports Evaluation shadow health Documentation
Vital Signs for Current Visit
Height: 157.4 centimeters
Weight: 49.9 kilograms
Body Mass Index (BMI): 20
Temperature (Below 38 degrees Celsius): 36.6 degrees Celsius
Heart Rate (Normal Range 60-100): 78 beats per minute
Respiratory Rate (Normal Range 12-20): 16 breaths per minute
Blood Pressure: 112/70
Recording in the Electronic Health Record
My Doctor’s Notes
Student’s Records Model Documentation
Personal Information
A young lady named Ms. Monroe, aged 13, is here for her check-up before joining soccer this season. Medical History: She has no current health issues. She had her tonsils removed when she was younger. Medication: She doesn’t take any prescribed medicine but takes a multivitamin and apple cider vinegar. Eating Habits: She follows a Mediterranean diet and avoids sugary treats, processed foods, and carbohydrates. Sometimes she skips lunch once or twice a week. Physical Activity: She plays soccer on weekends. Family History: No one in her family has had heart problems. Review of Body Systems HEENT (Head, Eyes, Ears, Nose, Throat): She has no issues with her eyes, vision, or hearing. Cardiovascular: She doesn’t experience chest pain or heart issues during exercise. Respiratory: No breathing difficulties during physical activity. Musculoskeletal: No history of joint or muscle injuries. Genitourinary: She hasn’t started menstruating yet.
Assessment of the Patient
Ms. Monroe, a 13-year-old girl, is here for her sports check-up to join soccer this season. She had her regular check-up six months ago. Medical History: No current health concerns. She had her tonsils removed when she was a child. She doesn’t have any missing organs. Medications: She’s not on any prescribed medications. She takes a daily multivitamin and a tablespoon of apple cider vinegar with water. She has no known allergies to medications. Eating Habits: She follows a Mediterranean diet and avoids sugary treats, carbohydrates, and processed foods. She skips lunch once or twice a week for the past month. Physical Activity: She plays recreational soccer on weekends and wants to join her school team. Family History: No family members have genetic heart conditions or have had early cardiac deaths. Social Habits: She follows a Mediterranean diet, avoids carbohydrates and processed foods, and skips lunch occasionally. She wants to lose weight to look like her friends and feel more athletic. Review of Body Systems HEENT: She has no eye problems, vision difficulties, or hearing issues. Cardiovascular: She has no chest pain during exercise, no history of heart problems, and no prior cardiac tests. Respiratory: No shortness of breath during exercise. Musculoskeletal: She had a sprained ankle at age 10 but has no current muscle or joint injuries. Neurological: No fainting during exercise. She experiences occasional dizziness after skipping lunch. No head injuries or numbness reported. Skin: No rashes. Genitourinary: No menstruation yet.
Objective Findings
Vital Signs: Height=62 inches, Weight=49.9 kg, BMI=20, Blood Pressure=112/70, Temperature=36.6C, Heart Rate=78/min, Respiration Rate=16 breaths/min General: A pleasant 13-year-old girl in good condition. HEENT: Symmetrical head. Eyes respond normally to light, and eye movements are intact. Neck has full range of motion. Respiratory: Even chest movements with clear lung sounds. Cardiovascular: Regular heart rate and rhythm with normal heart sounds. Abdomen: No unusual sounds in the abdomen. Musculoskeletal: Both sides of the body are symmetrical with full range of motion. Skin: Warm and smooth with no rashes or lesions. Neurological: Alert and oriented, good balance, and steady gait.
Assessment
Pre-participation sports physical examination Inappropriate diet and eating habits
Plan
Pre-participation sports physical examination: 1. Cleared to participate in sports Inappropriate diet and eating habits: 1. Educate on healthy nutrition and its impact on the body. 2. Discuss potential serious issues from poor nutrition. 3. Encourage a balanced diet with three meals a day and healthy snacks, especially during exercise. 4. Address issues of shame related to eating and body weight. Offer coping strategies such as journaling, support groups, and stress management. 5. Limit exposure to media promoting weight loss or dieting. 6. Identify and address problematic eating behaviors. Anticipatory Guidance Safety: Review safety measures for sports, including risks like the female athlete triad, injury prevention, sun protection, and proper diet and supplements. Follow-up Return for reevaluation of nutrition and eating habits in 4 weeks.
Adolescent Sports Evaluation shadow health Documentation
Vitals
| Vitals | Current Visit |
|---|---|
| Height | 157.4 cm |
| Weight | 49.9 kg |
| BMI | 20 |
| Temp (<38° C) | 36.6° C |
| HR (60-100) | 78 |
| RR (12-20) | 16 |
| BP | 112/70 |
Documentation / Electronic Health Record
My Provider Notes
| Student Documentation | Model Documentation |
|---|---|
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. Takes multivitamin and apple cider vinegar. Nutrition: Eats a Mediterranean diet and avoids sweets, processed foods, and white carbs. Skips lunch 1-2 times a week. Physical Activity: Plays soccer on weekends. Family Medical History: No family history of genetic heart problems. Review of Systems HEENT: Denies eye, vision, and hearing problems. Cardiovascular: Denies chest pain during exercise, hear problems. Respiratory: Denies breathing problems during exercise. Musculoskeletal: Denies joint or muscle injuries. Genitourinary: Denies starting menses.
|
Ms. Monroe is a 13 year old female who presents today for her sports preparticipation evaluation so she can play soccer this year. She had her annual well visit 6 months ago. Past Medical History: No current medical concerns. Had a tonsillectomy as a child. Denies any missing organs. Medications: Currently not taking any prescription medications, Daily Multivitamin and drinks Apple Cider Vinegar, 1 tablespoon a day with water. No known medication allergies Nutrition: Eats a Mediterranean diet and avoids sweets, “white carbs” and processed foods. Skips lunch 1-2 times a week for the last month. Physical Activity: Plays recreational soccer on the weekends, but really wants to play for her school team. Family Medical History: Denies history of any family members with genetic heart conditions, denies any family members with early cardiac death. Social History: Reports following a Mediterrranean diet, avoiding “white carbs”, and processed foods. Skips lunch 1-2 times a week. Feels like she needs to lose her baby fat so she can look like her friends. Feels like she does not fit in and wants to look athletic. Review of Systems HEENT: Denies eye problems, vision difficulties, and hearing problems. Cardiovascular: Denies any chest pain during exercise, denies history of cardiac issues, denies any prior cardiac tests. Respiratory: Denies shortness of breath during exercise. Musculoskeletal: Report sprained ankle at age 10. Denies any current muscle or joint injuries. Neurological: Denies syncope with exercise, positive for intermittent dizziness 1-2 times after skipping lunch. Denies head injury or concussions, denies numbness, tingling or weakness. Integumentary: Denies rashes. Genitourinary: Denies starting menses. |
ObjectiveVitals: H 62 in., W 49.9 kg, BP 112/70, T 36.6C, HR 78 RR 16 General: Pleasant 13-year old in no acute distress. HEENT: Symmetrical head. Eyes PERLA, EOM intact. Neck with full ROM Respiratory: Symmetrical chest rise and fall, lungs clear to auscultation. CV: S1, S2 present, RRR, no murmurs or gallops. Abd: No bruit in abdomen aorta. MSK: Symmetrical bilateral extremities. Full ROM. Skin: Warm, no rash or lesions. Neuro: Alert and oriented x3, intact balance, steady gait. |
Vital signs: Length=62 in., Weight=49.9 kg, BMI= 20, Blood pressure=112/70, Temp=36.6C, Heart rate= 78/min, Resp=16 breaths/min General: Well-appearing 13-year-old in no acute distress. Upright posture without tension or rigidity, clothing clean and appropriate for season HEENT Head: Symmetrical Eyes: PERRLA, EOM intact, peripheral vision equal to examiner, vision 20/20 bilaterally Neck: Neck with full ROM Resp: Symmetrical chest rise and fall, smooth even respirations, bilateral lungs clear to auscultation CV: Regular rate and rhythm, S1S2 present, no murmurs, pulse present, equal bilaterally Abd: Abdomen aorta with no bruit noted MSK: Bilateral extremities symmetrical, FROM equally strength 5+ all extremities, Adam’s forward bend-equal iliac crest height, expected curvature of spine, scapula equal height, cervical spine full range of motion, lumbar spine-full range of motion, trapezius strength +5 bilaterally Neuro: Alert and oriented x3, balance intact, sensation intact Skin: Warm, smooth, congruent with genetic background. Elastic turgor. No lesions noted Hearing/Vision: Vision 20/20 uncorrected. Hearing intact |
AssessmentPre-participation sports physical Inappropriate diet and eating habits |
Pre-Participation Sports Physical Inappropriate diet and eating habits |
PlanPre-participation sports physical 1. Clear to participate in sports Inappropriate diet and eating habits Educate on healthy nutrition Discuss strategies for reducing shame around eating, weight. Educate on detecting problematic eating behaviors. RTC in 4 weeks for reevaluation. |
Preparticipation physical 1. Clear to participate in sports Inappropriate diet and eating habits 1. Will provide education on healthy nutrition and the effects of nutrition on her body. 2. Discuss the potential life threatening problems caused by improper nutrition. 3. Healthy diet includes 3 meals a day and healthy snack options especially when exercising. 4. Discuss strategies for reducing shame around eating, weight and self-perception. Coping mechanisms around self-esteem and body image to include journaling, support group, relaxation, stress management, positive self talk and affirmations. 5. Limit media intake and refrain from watching shows on weight loss or dieting. 6. Educate on identifying problematic eating behaviors. Anticipatory Guidance Safety: Review sports safety measures including female athlete triad, injury prevention, sunscreen and sun protection, diet and nutritional supplements Follow-up Return to the clinic in 4 weeks to reevaluate nutrition and eating habits. |
