Shadow Health Follow-Up Sick Visit –
Musculoskeletal Assessment | Clinical Simulation
Practice Case Study (Completed
Patient: Tina Jones (Established Patient)
Date of Visit: [Current date – 7 days post-injury]
Visit Type: Follow Up Sick Visit
Setting: Primary Care Clinic
SECTION 1: SUBJECTIVE DATA (History of Present Illness)
Open-Ended Questions (What the student should ask):
"How has your ankle been feeling since your last visit?"
"On a scale of 0 to 10, what is your pain level now compared to last week?"
"Can you describe the pain – is it sharp, aching, or burning?"
"Are you able to walk without your crutches now?"
"Have you noticed any new swelling, bruising, or redness?"
"Have you had any numbness, tingling, or burning in your foot?"
"Have you had any pain or swelling in your calf?"
"Have you been using the RICE treatment we discussed?"
"Have you taken any medications for the pain?"
"Have you returned to school, work, or exercise?"
"Have you had any previous ankle injuries?"
"Do you have any other concerns today?"
Expected Patient Responses (Shadow Health Simulation):
, Question
Expected Response
Pain level now? "About a 3 out of 10, mostly at the end of the day."
Pain character? "More of an ache now, not as sharp as last week."
Walking? "I can walk without crutches, but I have a little limp."
Swelling? "It's still a little puffy, but much less. The bruise is turning yellow."
Numbness? "No numbness."
Calf pain? "No, my calf feels fine."
RICE use? "I've been icing it at night and wrapping it during the day."
Medications? "Tylenol a couple times, maybe 3-4 pills total this week."
Return to activity? "I'm back in class. Lots of stairs – that's hard. Haven't tried the gym."
Previous injuries? "I sprained this ankle in high school, but it healed fine."
SECTION 2: OBJECTIVE DATA (Physical Exam Findings)
Vital Signs:
Parameter
Value
Blood Pressure 118/72
Heart Rate 78 bpm
Respiratory Rate 16 breaths/min
Temperature 98.2°F (36.8°C)
O2 Saturation 99% RA
Focused Musculoskeletal Exam:
Musculoskeletal Assessment | Clinical Simulation
Practice Case Study (Completed
Patient: Tina Jones (Established Patient)
Date of Visit: [Current date – 7 days post-injury]
Visit Type: Follow Up Sick Visit
Setting: Primary Care Clinic
SECTION 1: SUBJECTIVE DATA (History of Present Illness)
Open-Ended Questions (What the student should ask):
"How has your ankle been feeling since your last visit?"
"On a scale of 0 to 10, what is your pain level now compared to last week?"
"Can you describe the pain – is it sharp, aching, or burning?"
"Are you able to walk without your crutches now?"
"Have you noticed any new swelling, bruising, or redness?"
"Have you had any numbness, tingling, or burning in your foot?"
"Have you had any pain or swelling in your calf?"
"Have you been using the RICE treatment we discussed?"
"Have you taken any medications for the pain?"
"Have you returned to school, work, or exercise?"
"Have you had any previous ankle injuries?"
"Do you have any other concerns today?"
Expected Patient Responses (Shadow Health Simulation):
, Question
Expected Response
Pain level now? "About a 3 out of 10, mostly at the end of the day."
Pain character? "More of an ache now, not as sharp as last week."
Walking? "I can walk without crutches, but I have a little limp."
Swelling? "It's still a little puffy, but much less. The bruise is turning yellow."
Numbness? "No numbness."
Calf pain? "No, my calf feels fine."
RICE use? "I've been icing it at night and wrapping it during the day."
Medications? "Tylenol a couple times, maybe 3-4 pills total this week."
Return to activity? "I'm back in class. Lots of stairs – that's hard. Haven't tried the gym."
Previous injuries? "I sprained this ankle in high school, but it healed fine."
SECTION 2: OBJECTIVE DATA (Physical Exam Findings)
Vital Signs:
Parameter
Value
Blood Pressure 118/72
Heart Rate 78 bpm
Respiratory Rate 16 breaths/min
Temperature 98.2°F (36.8°C)
O2 Saturation 99% RA
Focused Musculoskeletal Exam:
