ation
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revision
NR 509 Shadow Health Physical Assessment: Week 1 Shadow Health
History Assignment.
Document: Provider Notes
Student Response Model Documentation
Ms. Jones is a pleasant, 28-year-old obese
African American single woman who
Identifying Tina Jones age: 28 African American presents to establish care and with a recent
Data & female patient herself, seems reliable right foot injury. She is the primary source
Reliability supervisor at Mid-American Copy & of the history. Ms. Jones offers
Ship information freely and without
contradiction. Speech is clear and
coherent. She maintains eye contact
throughout the interview.
Tina is a 28 year old African Ms. Jones is alert and oriented, seated
General upright on the examination table, and is in
American female that appears healthy
no apparent distress. She is well-
Survey and stated age. Alert, oriented, and
nourished, well-developed, and dressed
cooperative. No signs of distress.
appropriately with good hygiene.
“I got this scrape on my foot a while ago,
Chief "I got this scrape on my foot a while and I thought it would heal up on its own,
Complaint ago...and the pain is killing me!" but now it's looking pretty nasty. And the
pain is killing me!”
History Of First noticed scrape on right foot two Ms. Jones reports that a week ago she
Present days ago. Tripped and fell down tripped while walking on concrete stairs
Illness steps, scraped foot on the edge of the outside, twisting her right ankle and
step. Sharp, throbbing pain rated a 7 scraping the ball of her foot. She sought
on 0-10 scale. White drainage. Unable care in a local emergency department
to bear weight on right foot and has where she had x-rays that were negative;
missed two days of work. No chills or she was treated with tramadol for pain. She
fever noted. Reports temperature of has been cleansing the site twice a day.
102 last night. She has been applying antibiotic ointment
and a bandage. She reports that ankle
swelling and pain have resolved but that
the bottom of the foot is increasingly
painful. The pain is described as
“throbbing” and “sharp” with weight
bearing. She states her ankle “ached” but is
resolved. Pain is rated 7 out of 10 after a
recent dose of tramadol. Pain is rated 9
/2027 Exam
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Health
Q&AexamExam
Physical
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Assessment
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Exam
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Academic
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2026/2027
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026 2027
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2026/2027
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examExam
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Academic
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2026/2027
exam
and answers
revision
Student Response Model Documentation
with weight bearing. She reports that over
the past two days the ball of the foot has
become swollen and increasingly red;
yesterday she noted discharge oozing from
the wound. She denies any odor from the
wound. Her shoes feel tight. She has been
wearing slip-ons. She reports fever of 102
last night. She denies recent illness.
Reports a 10-pound, unintentional weight
loss over the month and increased appetite.
Denies change in diet or level of activity.
Acetaminophen 500-1000 mg PO prn
Tramadol 50 mg tablet, 2 tablets by
(headaches) • Ibuprofen 600 mg PO TID
mouth three times a day as needed for
prn (menstrual cramps) • Tramadol 50 mg
pain Proventil 90 mcg/spray MDI, 2
Medications PO BID prn (foot pain) • Albuterol 90
puffs by mouth as needed for asthma
mcg/spray MDI 2 puffs Q4H prn
No vitamins or herbal supplements
(Wheezing: “when around cats,” last use
Advil as needed for menstrual cramps
three days ago)
Allergic to penicillin, develops rash, Penicillin: rash • Denies food and latex
hives. Allergic to cats, develops itchy allergies • Allergic to cats and dust. When
Allergies eyes, shortness of breath. No food she is exposed to allergens she states that
allergies. No seasonal allergies. No she has runny nose, itchy and swollen
latex allergy. eyes, and increased asthma symptoms.
Medical Chickenpox in second or third grade. Asthma diagnosed at age 2 1/2. She uses
History No measles, mumps, pertussis. Strep her albuterol inhaler when she is around
once a year as a child but not since cats and dust. She uses her inhaler 2 to 3
high school. No rheumatic fever, times per week. She was exposed to cats
scarlet fever, or polio. Diagnosed with three days ago and had to use her inhaler
asthma at age 2. Diagnosed with once with positive relief of symptoms. She
diabetes a few years ago. Hospitalized was last hospitalized for asthma “in high
several times as a child for asthma school”. Never intubated. Type 2 diabetes,
attacks, last time was age 16. Gravida diagnosed at age 24. She previously took
0/Para 0/Abortion 0. Recent weight metformin, but she stopped three years
loss of 10 pounds. No excessive ago, stating that the pills made her gassy
bruising. No fever or sweats. No and “it was overwhelming, taking pills and
broken bones. No burns. No eczema checking my sugar.” She doesn't monitor
or psoriasis. Darkening of skin on her blood sugar. Last blood glucose was
neck reported. Excessive dryness on elevated last week in the emergency room.
/2027 Exam
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026 2027
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2026/2027
exam
and answers
revision
Student Response Model Documentation
arms and legs. Excessive thirst.
Wakes up 2-3 times a night to urinate.
No hair loss or change in nails.
Doesn't get much sun, reports use of
sunscreen when outdoors. No
headaches, head injury, dizziness, or
tinnitus. No seizures. No surgeries.
Reports blurry vision. Wears no
corrective lenses. Develops headache No surgeries. OB/GYN: Menarche, age 11.
after reading too long. No eye pain. First sexual encounter at age 18, sex with
No earaches, cleans ears with Q Tips. men, identifies as heterosexual. Never
Recommended use of washcloth to pregnant. Last menstrual period 3 weeks
clean ears. No nose discharge, no ago. For the past year cycles irregular
sinus (every 4-8 weeks) with heavy bleeding
pain orpain, no runny
bleeding nose.
gums. No No mouth
dysphagia.
lasting 9-10 days. No current partner. Used
Brushes teeth twice a day. No neck
oral contraceptives in the past. When
pain. No nipple discharge. No chest
sexually active, reports she did not use
pain. No wheezing. No cough.
condoms. Never tested for HIV/AIDS. No
Shortness of breath only during
history of STIs or STI symptoms. Last
asthma attack. Must use inhaler when
tested for STIs four years ago.
climbs steps to third floor for class Hematologic: Denies bleeding, bruising,
quickly. No trouble breathing at night.
blood transfusions and history of blood
No numbness or tingling in hands or
clots. Skin: Reports acne since puberty and
feet. No swelling in legs. Swelling on
bumps on the back of her arms when her
bottom of right foot around scrape.
Appetite good with three meals a day. skin is dry. Complains of darkened skin on
her neck and increase facial and body hair.
No heartburn, pain, nausea, or
She reports a few moles but no other hair
vomiting. Bowel movement 1/day or
or nail changes.
every other day, soft, brown. No
constipation, diarrhea or blood with
bowel movement. No hemorrhoids.
No uses of laxatives or antacids.
Frequency in urinations. No dysuria
or straining. Urine color light yellow,
clear. Menarche at 11. Cycle usually
last 7-10 days. Menstrual pain. No
vaginal itching or discharge.
Health Childhood immunizations up to date. Last Pap smear 4 years ago. Last eye exam
Maintenance Last dental visit was a few years ago. in childhood. Last dental exam “a few
Last eye doctor visit was as a kid. years ago.” PPD (negative) ~2 years ago.
Last pap smear was 4 years ago, No exercise. 24-hour Diet Recall: States
normal. Last physical was 2 years that she skipped breakfast yesterday, and
/2027 Exam
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Physical
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Assessment
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Academic
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2026/2027
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026 2027
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Academic
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2026/2027
exam
and answers
revision
Student Response Model Documentation
would typically have a baked good for
breakfast, a sandwich for lunch, and a
meatloaf or chicken for dinner. Her snacks
consist of pretzels or French fries.
Immunizations: Tetanus booster was
ago. Does not perform breast self- received within the past year, influenza is
not current, and human papillomavirus has
not been received. She reports that she
exams. Last chest x-ray at 16. Last TB
believes she is up to date on childhood
skin test 2 years ago. No ECG.
vaccines and received the meningococcal
vaccine in college. Safety: Has smoke
detectors in the home, wears seatbelt in
car, and does not ride a bike. Does not use
sunscreen. Guns, having belonged to her
dad, are in the home, locked in parent’s
room.
• Mother: age 50, hypertension, elevated
cholesterol • Father: deceased in car
accident one year ago at age 58,
hypertension, high cholesterol, and type 2
diabetes • Brother (Michael, 25):
overweight • Sister (Britney, 14): asthma •
Tina has one brother and one sister. Maternal grandmother: died at age 73 of a
Father had diabetes and hypertension, stroke, history of hypertension, high
Family but died last year in a car accident. cholesterol • Maternal grandfather: died at
History Mother has hypertension. Grandfather age 78 of a stroke, history of hypertension,
had diabetes. Grandmother has high cholesterol • Paternal grandmother:
hypertension. still living, age 82, hypertension • Paternal
grandfather: died at age 65 of colon
cancer, history of type 2 diabetes • Paternal
uncle: alcoholism • Negative for mental
illness, other cancers, sudden death, kidney
disease, sickle cell anemia, thyroid
problems
Social Feels safe at home and work. No Never married, no children. Lived
History history of tobacco use. No one in independently since age 20, currently lives
household smokes. History of with mother and sister in a single family
smoking pot, last time was age 21. home to support family after death of
Drinks alcohol 1-2 times a week, few father one year ago. Employed 32 hours
drinks each time. Baptist religion. per week as a supervisor at Mid-American
/2027 Exam
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2026
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509
2027
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Health
Q&AexamExam
Physical
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Assessment
Q&Aquestions
Exam
TBS.pdf
preparation
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questions
Academic
with answers
exam revision
Academic
2026/2027
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026 2027
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Academic
2026/2027
with answers
examExam
revision
Academic
questions
2026/2027
exam
and answers
revision
NR 509 Shadow Health Physical Assessment: Week 1 Shadow Health
History Assignment.
Document: Provider Notes
Student Response Model Documentation
Ms. Jones is a pleasant, 28-year-old obese
African American single woman who
Identifying Tina Jones age: 28 African American presents to establish care and with a recent
Data & female patient herself, seems reliable right foot injury. She is the primary source
Reliability supervisor at Mid-American Copy & of the history. Ms. Jones offers
Ship information freely and without
contradiction. Speech is clear and
coherent. She maintains eye contact
throughout the interview.
Tina is a 28 year old African Ms. Jones is alert and oriented, seated
General upright on the examination table, and is in
American female that appears healthy
no apparent distress. She is well-
Survey and stated age. Alert, oriented, and
nourished, well-developed, and dressed
cooperative. No signs of distress.
appropriately with good hygiene.
“I got this scrape on my foot a while ago,
Chief "I got this scrape on my foot a while and I thought it would heal up on its own,
Complaint ago...and the pain is killing me!" but now it's looking pretty nasty. And the
pain is killing me!”
History Of First noticed scrape on right foot two Ms. Jones reports that a week ago she
Present days ago. Tripped and fell down tripped while walking on concrete stairs
Illness steps, scraped foot on the edge of the outside, twisting her right ankle and
step. Sharp, throbbing pain rated a 7 scraping the ball of her foot. She sought
on 0-10 scale. White drainage. Unable care in a local emergency department
to bear weight on right foot and has where she had x-rays that were negative;
missed two days of work. No chills or she was treated with tramadol for pain. She
fever noted. Reports temperature of has been cleansing the site twice a day.
102 last night. She has been applying antibiotic ointment
and a bandage. She reports that ankle
swelling and pain have resolved but that
the bottom of the foot is increasingly
painful. The pain is described as
“throbbing” and “sharp” with weight
bearing. She states her ankle “ached” but is
resolved. Pain is rated 7 out of 10 after a
recent dose of tramadol. Pain is rated 9
/2027 Exam
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2026/2027andExam
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questions
2026 2027
and answers
Complete
2026
NR
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509
2027
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Shadow
Complete
Health
Q&AexamExam
Physical
solutions
preparation
Assessment
Q&Aquestions
Exam
TBS.pdf
preparation
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questions
Academic
with answers
exam revision
Academic
2026/2027
exam revisioQ
,ation
026 2027
q Exam
Q&A
Complete
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2026/2027
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2026 Exam
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and answers
Complete
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Examsolutions
Academic
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Academic
2026/2027
with answers
examExam
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Academic
questions
2026/2027
exam
and answers
revision
Student Response Model Documentation
with weight bearing. She reports that over
the past two days the ball of the foot has
become swollen and increasingly red;
yesterday she noted discharge oozing from
the wound. She denies any odor from the
wound. Her shoes feel tight. She has been
wearing slip-ons. She reports fever of 102
last night. She denies recent illness.
Reports a 10-pound, unintentional weight
loss over the month and increased appetite.
Denies change in diet or level of activity.
Acetaminophen 500-1000 mg PO prn
Tramadol 50 mg tablet, 2 tablets by
(headaches) • Ibuprofen 600 mg PO TID
mouth three times a day as needed for
prn (menstrual cramps) • Tramadol 50 mg
pain Proventil 90 mcg/spray MDI, 2
Medications PO BID prn (foot pain) • Albuterol 90
puffs by mouth as needed for asthma
mcg/spray MDI 2 puffs Q4H prn
No vitamins or herbal supplements
(Wheezing: “when around cats,” last use
Advil as needed for menstrual cramps
three days ago)
Allergic to penicillin, develops rash, Penicillin: rash • Denies food and latex
hives. Allergic to cats, develops itchy allergies • Allergic to cats and dust. When
Allergies eyes, shortness of breath. No food she is exposed to allergens she states that
allergies. No seasonal allergies. No she has runny nose, itchy and swollen
latex allergy. eyes, and increased asthma symptoms.
Medical Chickenpox in second or third grade. Asthma diagnosed at age 2 1/2. She uses
History No measles, mumps, pertussis. Strep her albuterol inhaler when she is around
once a year as a child but not since cats and dust. She uses her inhaler 2 to 3
high school. No rheumatic fever, times per week. She was exposed to cats
scarlet fever, or polio. Diagnosed with three days ago and had to use her inhaler
asthma at age 2. Diagnosed with once with positive relief of symptoms. She
diabetes a few years ago. Hospitalized was last hospitalized for asthma “in high
several times as a child for asthma school”. Never intubated. Type 2 diabetes,
attacks, last time was age 16. Gravida diagnosed at age 24. She previously took
0/Para 0/Abortion 0. Recent weight metformin, but she stopped three years
loss of 10 pounds. No excessive ago, stating that the pills made her gassy
bruising. No fever or sweats. No and “it was overwhelming, taking pills and
broken bones. No burns. No eczema checking my sugar.” She doesn't monitor
or psoriasis. Darkening of skin on her blood sugar. Last blood glucose was
neck reported. Excessive dryness on elevated last week in the emergency room.
/2027 Exam
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Complete
2026
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Health
Q&AexamExam
Physical
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Assessment
Q&Aquestions
Exam
TBS.pdf
preparation
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Academic
with answers
exam revision
Academic
2026/2027
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026 2027
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Academic
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2026/2027
exam
and answers
revision
Student Response Model Documentation
arms and legs. Excessive thirst.
Wakes up 2-3 times a night to urinate.
No hair loss or change in nails.
Doesn't get much sun, reports use of
sunscreen when outdoors. No
headaches, head injury, dizziness, or
tinnitus. No seizures. No surgeries.
Reports blurry vision. Wears no
corrective lenses. Develops headache No surgeries. OB/GYN: Menarche, age 11.
after reading too long. No eye pain. First sexual encounter at age 18, sex with
No earaches, cleans ears with Q Tips. men, identifies as heterosexual. Never
Recommended use of washcloth to pregnant. Last menstrual period 3 weeks
clean ears. No nose discharge, no ago. For the past year cycles irregular
sinus (every 4-8 weeks) with heavy bleeding
pain orpain, no runny
bleeding nose.
gums. No No mouth
dysphagia.
lasting 9-10 days. No current partner. Used
Brushes teeth twice a day. No neck
oral contraceptives in the past. When
pain. No nipple discharge. No chest
sexually active, reports she did not use
pain. No wheezing. No cough.
condoms. Never tested for HIV/AIDS. No
Shortness of breath only during
history of STIs or STI symptoms. Last
asthma attack. Must use inhaler when
tested for STIs four years ago.
climbs steps to third floor for class Hematologic: Denies bleeding, bruising,
quickly. No trouble breathing at night.
blood transfusions and history of blood
No numbness or tingling in hands or
clots. Skin: Reports acne since puberty and
feet. No swelling in legs. Swelling on
bumps on the back of her arms when her
bottom of right foot around scrape.
Appetite good with three meals a day. skin is dry. Complains of darkened skin on
her neck and increase facial and body hair.
No heartburn, pain, nausea, or
She reports a few moles but no other hair
vomiting. Bowel movement 1/day or
or nail changes.
every other day, soft, brown. No
constipation, diarrhea or blood with
bowel movement. No hemorrhoids.
No uses of laxatives or antacids.
Frequency in urinations. No dysuria
or straining. Urine color light yellow,
clear. Menarche at 11. Cycle usually
last 7-10 days. Menstrual pain. No
vaginal itching or discharge.
Health Childhood immunizations up to date. Last Pap smear 4 years ago. Last eye exam
Maintenance Last dental visit was a few years ago. in childhood. Last dental exam “a few
Last eye doctor visit was as a kid. years ago.” PPD (negative) ~2 years ago.
Last pap smear was 4 years ago, No exercise. 24-hour Diet Recall: States
normal. Last physical was 2 years that she skipped breakfast yesterday, and
/2027 Exam
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answers
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and answers
Complete
2026
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509
2027
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Health
Q&AexamExam
Physical
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preparation
Assessment
Q&Aquestions
Exam
TBS.pdf
preparation
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questions
Academic
with answers
exam revision
Academic
2026/2027
exam revisioQ
,ation
026 2027
q Exam
Q&A
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Academic
2026/2027
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Academic
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2026/2027
exam
and answers
revision
Student Response Model Documentation
would typically have a baked good for
breakfast, a sandwich for lunch, and a
meatloaf or chicken for dinner. Her snacks
consist of pretzels or French fries.
Immunizations: Tetanus booster was
ago. Does not perform breast self- received within the past year, influenza is
not current, and human papillomavirus has
not been received. She reports that she
exams. Last chest x-ray at 16. Last TB
believes she is up to date on childhood
skin test 2 years ago. No ECG.
vaccines and received the meningococcal
vaccine in college. Safety: Has smoke
detectors in the home, wears seatbelt in
car, and does not ride a bike. Does not use
sunscreen. Guns, having belonged to her
dad, are in the home, locked in parent’s
room.
• Mother: age 50, hypertension, elevated
cholesterol • Father: deceased in car
accident one year ago at age 58,
hypertension, high cholesterol, and type 2
diabetes • Brother (Michael, 25):
overweight • Sister (Britney, 14): asthma •
Tina has one brother and one sister. Maternal grandmother: died at age 73 of a
Father had diabetes and hypertension, stroke, history of hypertension, high
Family but died last year in a car accident. cholesterol • Maternal grandfather: died at
History Mother has hypertension. Grandfather age 78 of a stroke, history of hypertension,
had diabetes. Grandmother has high cholesterol • Paternal grandmother:
hypertension. still living, age 82, hypertension • Paternal
grandfather: died at age 65 of colon
cancer, history of type 2 diabetes • Paternal
uncle: alcoholism • Negative for mental
illness, other cancers, sudden death, kidney
disease, sickle cell anemia, thyroid
problems
Social Feels safe at home and work. No Never married, no children. Lived
History history of tobacco use. No one in independently since age 20, currently lives
household smokes. History of with mother and sister in a single family
smoking pot, last time was age 21. home to support family after death of
Drinks alcohol 1-2 times a week, few father one year ago. Employed 32 hours
drinks each time. Baptist religion. per week as a supervisor at Mid-American
/2027 Exam
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2026/2027andExam
answers
questions
2026 2027
and answers
Complete
2026
NR
exam
509
2027
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Shadow
Complete
Health
Q&AexamExam
Physical
solutions
preparation
Assessment
Q&Aquestions
Exam
TBS.pdf
preparation
with answers
questions
Academic
with answers
exam revision
Academic
2026/2027
exam revisioQ
