Shadow Health Comprehensive Assessment Tina Jones -Documentation (Electronic Health Record) Exam questions and verified ANSWERed

1. What is Tina Jones's primary reason for seeking care today? A. Follow-up for her diabetes B. Pain in her right upper leg C. A rash on her left arm D. A cough and sore throat ANSWER: B. Pain in her right upper leg *Explanation: Tina presents to the clinic with a chief complaint of pain in her right upper leg after falling down a flight of stairs.* 2. How did Tina Jones injure her leg? A. She was in a car accident. B. She fell down a flight of stairs. C. She fell while playing soccer. D. She tripped over a rug at home. ANSWER: B. She fell down a flight of stairs. *Explanation: The history reveals the mechanism of injury was a fall down a flight of stairs.* 3. When did the injury occur? A. 1 week ago B. 2 days ago C. 1 month ago D. Just before coming to the clinic ANSWER: A. 1 week ago *Explanation: Tina states the fall happened one week prior to her clinic visit.* 4. What is the specific location of Tina's pain? A. Her right knee B. Her right hip C. Her right upper leg D. Her right ankle ANSWER: C. Her right upper leg *Explanation: She localizes the pain to her right upper leg.* 5. Tina describes the quality of her pain as: A. A sharp, stabbing pain B. A dull, throbbing ache C. A burning sensation D. A tingling feeling ANSWER: B. A dull, throbbing ache *Explanation: During the subjective interview, Tina characterizes the pain as a dull, throbbing ache.* 6. On a scale of 0 to 10, what is the current severity of Tina's leg pain? A. 2/10 B. 5/10 C. 7/10 D. 9/10 ANSWER: C. 7/10 *Explanation: Tina rates her current pain as a 7 out of 10.* 7. What makes Tina's leg pain worse? A. Applying ice to the area B. Resting and staying off her feet C. Bearing weight on her right leg D. Taking over-the-counter pain medication ANSWER: C. Bearing weight on her right leg *Explanation: She reports that the pain increases with weight-bearing and walking.* 8. What has Tina been using for pain relief at home? A. Ibuprofen (Motrin) B. Acetaminophen (Tylenol) C. Aspirin D. Prescription opioids ANSWER: B. Acetaminophen (Tylenol) *Explanation: She states she has been taking Tylenol, which provides only minimal relief.* 9. Besides the leg pain, what other symptom is Tina experiencing at the injury site? A. Numbness B. Bruising and swelling C. A warm, red rash D. An open wound ANSWER: B. Bruising and swelling *Explanation: She reports noticeable bruising and swelling around the painful area on her right upper leg.* 10. What past medical history is most significant for Tina Jones? A. Hypertension B. Asthma C. Type 2 Diabetes Mellitus D. Hypothyroidism ANSWER: C. Type 2 Diabetes Mellitus *Explanation: Her past medical history is significant for Type 2 Diabetes, which is a key factor in her overall health and healing potential.* 11. How long has Tina been diagnosed with diabetes? A. 1 year B. 5 years C. 10 years D. Since childhood ANSWER: B. 5 years *Explanation: She reports being diagnosed with Type 2 Diabetes approximately five years ago.* 12. What medication does Tina take for her diabetes? A. Insulin injections B. Metformin (Glucophage) C. No medication, controlled by diet D. Glyburide ANSWER: B. Metformin (Glucophage) *Explanation: Her medication list includes Metformin 1000 mg twice daily.* 13. Besides diabetes, what other chronic condition does Tina have? A. High Cholesterol B. Asthma C. Coronary Artery Disease D. Arthritis ANSWER: A. High Cholesterol *Explanation: Her history also includes High Cholesterol.* 14. What medication does she take for her high cholesterol? A. Atorvastatin (Lipitor) B. Simvastatin (Zocor) C. No medication D. Cholestyramine ANSWER: A. Atorvastatin (Lipitor) *Explanation: She takes Atorvastatin 10 mg daily for cholesterol management.* 15. Does Tina have any known drug allergies? A. Yes, to Penicillin B. Yes, to Sulfa drugs C. Yes, to Iodine D. No known drug allergies (NKDA) ANSWER: D. No known drug allergies (NKDA) *Explanation: The patient denies any known drug allergies.* 16. What is Tina's current tobacco use status? A. Current smoker B. Former smoker C. Never smoker D. Occasional smoker ANSWER: B. Former smoker *Explanation: She has a history of smoking but quit five years ago.* 17. What was Tina's pack-year history as a smoker? A. 5 pack-years B. 10 pack-years C. 15 pack-years D. 20 pack-years ANSWER: B. 10 pack-years *Explanation: She smoked one pack per day for 10 years, giving her a 10-pack-year history.* 18. What is Tina's current alcohol use? A. Drinks 1-2 drinks nightly B. Drinks socially on weekends C. Does not drink at all D. Has a history of heavy drinking ANSWER: B. Drinks socially on weekends *Explanation: She reports occasional social alcohol use, typically 1-2 drinks on weekends.* 19. During the review of systems, what does Tina report regarding her skin? A. Easy bruising B. New moles C. Chronic rashes D. She denies any skin changes. ANSWER: A. Easy bruising *Explanation: She specifically mentions a tendency to bruise easily, which is relevant given the bruising at her injury site.* 20. What finding is documented in the objective assessment of Tina's right leg? A. A 4x4 cm ecchymotic area on the anterior thigh B. A deep laceration C. Crepitus upon palpation D. Cool, pale skin ANSWER: A. A 4x4 cm ecchymotic area on the anterior thigh *Explanation: The physical exam documents a visible 4x4 cm bruise (ecchymosis) on the anterior aspect of her right thigh.* 21. How is the range of motion (ROM) in Tina's right hip and knee documented? A. Full and pain-free B. Limited in all planes due to pain C. Full but with pain on extreme flexion D. Unable to assess due to patient refusal ANSWER: B. Limited in all planes due to pain *Explanation: The objective data shows that active and passive range of motion of the right hip and knee are limited due to pain.* 22. What is documented about the neurovascular status of her right lower extremity? A. Diminished pedal pulse B. Intact pulses, sensation, and motor function C. Foot drop present D. Paresthesia in the foot ANSWER: B. Intact pulses, sensation, and motor function *Explanation: Despite the injury, the distal neurovascular status is documented as intact.* 23. What is a significant finding in Tina's social history? A. She is homeless. B. She is a full-time student and works part-time. C. She is unemployed. D. She is a retired teacher. ANSWER: B. She is a full-time student and works part-time. *Explanation: Her social history reveals she is a full-time student who also works part-time, which can impact her stress levels and self-care.* 24. Who does Tina live with? A. Alone B. With her parents and siblings C. With her boyfriend D. With roommates ANSWER: B. With her parents and siblings *Explanation: She reports living at home with her parents and siblings.* 25. What is a potential psychosocial stressor for Tina? A. Recent divorce B. Financial difficulties C. Academic pressure D. Recent death of a pet ANSWER: C. Academic pressure *Explanation: She expresses feeling stressed about her academic workload.* 26. What is documented about Tina's diet? A. She follows a strict diabetic diet. B. Her diet is high in fast food and carbohydrates. C. She is a vegetarian. D. She has no specific dietary pattern. ANSWER: B. Her diet is high in fast food and carbohydrates. *Explanation: The nutritional assessment reveals a diet high in carbs and fast food, which is suboptimal for her diabetes.* 27. What is Tina's most recent Hemoglobin A1c level? A. 5.8% B. 7.2% C. 8.5% D. 10.1% ANSWER: C. 8.5% *Explanation: Her lab results show an elevated Hemoglobin A1c of 8.5%, indicating poor glycemic control.* 28. A Hemoglobin A1c of 8.5% indicates what about Tina's diabetes management? A. Excellent control B. Good control C. Suboptimal control D. Diabetic ketoacidosis ANSWER: C. Suboptimal control *Explanation: The target for most diabetics is below 7%. An A1c of 8.5% indicates hyperglycemia and suboptimal control over the past 2-3 months.* 29. What is Tina's stated goal regarding her health? A. To lose 20 pounds B. To get her blood sugar under better control C. To quit smoking D. To start an exercise program ANSWER: B. To get her blood sugar under better control *Explanation: During the interview, she expresses a desire to improve her diabetes management.* 30. During the physical exam, what is the findings regarding Tina's breath sounds? A. Clear bilaterally B. Wheezes in the lower lobes C. Crackles in the right base D. Diminished on the left side ANSWER: A. Clear bilaterally *Explanation: The objective chest assessment documents clear breath sounds in all lung fields.* 31. What is the documented heart sound assessment? A. Regular rate and rhythm, no murmurs B. S3 gallop present C. Systolic murmur heard at the apex D. Irregular rhythm ANSWER: A. Regular rate and rhythm, no murmurs