Samantha Monroe Adolescent Sports Evaluation shadow health

Hello. I’m going to interview you and later conduct a physical exam.

Table of Contents

Hello.

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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.

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.

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.

Are you using any medications?

No, I don’t take anything.

Are you using any vitamins or supplements?

I take a multivitamin. Plus, I drink apple cider vinegar, which is kinda like a supplement.

Do you pass out during exercise?

No way. I’ve never passed out while I was exercising.

Any dizziness?

Oh, no. I feel totally fine right now.

Have you ever been dizzy?

I’ve only been dizzy like once or twice. And that was because I skipped lunch and then had to go to gym class.

Am sorry about that.

Thanks for the heads-up.

Any heart problems after exercising?

No heart problems after exercise.

Have you had heart problems during exercise?

Nope. No problems during exercise.

Have you been diagnosed with a heart problem?

No, I’ve never been diagnosed with any heart problems that I know of.

How is your breathing during and after exercise?

My breathing is fine during and after exercise.

Any history of seizures?

Pretty sure I’ve never ever had a seizure.

Any injuries?

Um, well I did sprain my ankle when I was like 10. That’s really it, though. I’m always good to play.

Any rashes?

No rashes. Ew.

Any history of head injuries?

Nope. My head’s fine.

Have you had a concussion?

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?

No numbness or tingling. That sounds weird.

Any weakness in your limbs?

Nope, no weakness.

Do you exercise in the heat?

Sure. We do gym outside sometimes. When soccer season starts, practice and games are outside.

Any eye problems?

My eyes are fine.

Have you started your periods?

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.

Cool. Good to know.

Tell me about your family medical history.

Wait, like the entire family medical history or do you mean something more specific?

Any genetic conditions in your family?

I don’t know. Mom?

No, no one in the family has any genetic heart conditions.

Any heart problems in your family?

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?

Any family history of unexpected deaths before the age of 35?

Has any of your family members had a pacemaker before age 35?

I’m not sure about the pacemaker thing.

To my knowledge, there isn’t anyone in the family who’s ever had a pacemaker.

Do you feel your weight is okay?

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.

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

Um, that makes sense.

Do you want to lose weight?

Just . . . to look more athletic, you know. Like I fit in with everybody.

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

Um, that makes sense.

Tell me about your diet.

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?

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.

Regulation for Nursing Practice Staff Development Meeting PowerPoint presentation

For sure. OK.

How long have you been skipping your lunch?

Inspected weight and height growth chart

Inspected height and weight growth chart.

You look like you are losing weight.

Wait, what? Like losing weight as in . . . in a bad way? I mean, I’m on the Mediterranean diet. I thought I was supposed to be healthier.

Your weight is below normal, so I think it’s not healthy.

Is it really that bad?

Yes, it is. Your weight is below normal, and it can affect your health.

I didn’t realize it was that bad. I just wanted to eat healthy and look good, you know?

It’s important to focus on being healthy, not just on appearance.

I get it. I’ll try to eat more regularly and maybe talk to someone about it.

That’s a good idea.

Do you smoke?

No, I’ve never smoked. Smoking is so gross.

Any exposure to secondhand smoke?

I think my uncle smokes, but I don’t spend much time around him.

Your weight is below normal, so it’s important to eat regular meals and consult with a healthcare professional about it. Smoking is definitely not a healthy choice.

I’ll definitely talk to someone about my weight, and I’ll stay away from smoking.

Great, that’s a positive step towards better health.

Thanks for the advice.

Do you use alcohol or recreational drugs?

No, I don’t use any of that stuff. It’s not my thing.

That’s a wise choice.

I just don’t see the point in it.

That’s a very responsible attitude.

I try to be responsible.

That’s good to hear.

Do you have any questions for me?

Nope, I’m good.

Alright, you can change into a gown and we’ll continue with the physical examination.

Alright, thanks.

END OF TRANSCRIPT

Started: Mar 05, 2022 | Total Time: 306 min

	Hello. Am 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. Samantha Monroe Adolescent Sports Evaluation 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? ORDER SHADOWHEALTH, IHUMAN, EXAM OR WRITTEN ASSIGNMENT HERE	Question 03/05/22 5:50 AM EST
	No, I don’t take anything.
	Are you using any vitamins or supplements?	Question 03/05/22 5:51 AM EST
	I take a multivitamin. Plus, I drink apple cider vinegar, which is kinda like a supplement.
	Do you pass out during exercise? (Clarified to Have you passed out during exercise?.)	Question 03/05/22 5:52 AM EST
	No way. I’ve never passed out while I was exercising. (Clarified to if I have passed out during exercise.)
	Any dizziness?	Question 03/05/22 5:53 AM EST
	Oh, no. I feel totally fine right now.
	Have you ever been dizzy? (Clarified to Have you felt dizzy in the past?.)	Question 03/05/22 5:53 AM EST
	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.)
	Am sorry about that	Educate 03/05/22 5:54 AM EST
	Thanks for the heads-up.
	Any heart problems after exercising? (Clarified to Have you had heart problems after exercise?.)	Question 03/05/22 5:56 AM EST
	No heart problems after exercise. (Clarified to if I have had heart problems after exercise.) Samantha Monroe Adolescent Sports Evaluation shadow health
	Have you had heart problems during exercise?	Question 03/05/22 5:57 AM EST
	Nope. No problems during exercise.
	Have you been diagnosed with a heart problem?	Question 03/05/22 5:58 AM EST
	No, I’ve never been diagnosed with any heart problems that I know of.
	No, no heart problems.
	How is your breathing during and after exercise?	Question 03/05/22 5:59 AM EST
	My breathing is fine during and after exercise.
	Any history of seizures?	Question 03/05/22 6:00 AM EST
	Pretty sure I’ve never ever had a seizure.
	That is correct. No seizures or anything like that.
	Any injuries?	Question 03/05/22 6:01 AM EST
	Um, well I did sprain my ankle when I was like 10. That’s really it, though. I’m always good to play.
	Any rashes?	Question 03/05/22 6:01 AM EST
	No rashes. Ew.
	Any history of head injuries?	Question 03/05/22 6:02 AM EST
	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?	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?.)	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 Samantha Monroe Adolescent Sports Evaluation shadow health.
	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 Samantha Monroe Adolescent Sports Evaluation shadow health	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.	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.

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

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.	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. 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.”

Problem Selection

8 out of 8

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

Plan of Care

7 out of 7

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

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.

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.

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

Samantha Monroe Adolescent Sports Evaluation shadow health