Adolescent Sports Evaluation shadow health Documentation
Samantha Monroe is a 13-year-old girl undergoing an Adolescent Sports Evaluation at Shadow Health. This documentation includes her vital signs, such as height (157.4 cm), weight (49.9 kg), and blood pressure (112/70).
Ms. Monroe is here for a preparticipation sports evaluation to play soccer. She has no current medical issues, follows a Mediterranean diet, and is not on any prescription medications. Her past medical history includes a tonsillectomy.
This adolescent health assessment helps ensure she is ready for sports participation while addressing her healthy eating habits for teens.
Vitals
- 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
Walden University NRNP 6541 Mid Term Exam: Primary Care of Adolescents and Children
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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 in adolescents as a child. Medications: No prescription medications. Takes multivitamin and apple cider vinegar.
Nutrition for athletes: Eats a Mediterranean diet and avoids sweets, processed foods, and white carbs. Skips lunch 1-2 times a week. Physical Activity Guidelines for teens: 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, heart 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 physical examination 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 for athletes: 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 Mediterranean 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: Reported a 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.
Objective
Vitals:
- Height: 62 in.
- Weight: 49.9 kg
- BP: 112/70
- T: 36.6°C
- 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.
Abdomen: No bruit in abdominal 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=36.6°C, 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 the 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, S1, S2 present, no murmurs, pulse present, equal bilaterally.
Abd: Abdomen aorta with no bruit noted.
MSK: Bilateral extremities symmetrical, FROM, equal 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.
Assessment
- Pre-participation sports physical
- Inappropriate diet and eating habits
Plan
For the pre-participation sports physical:
- Clear to participate in sports.
For inappropriate diet and eating habits:
- Provide education on healthy eating habits for teens and the effects of nutrition on her body.
- Discuss the potential life-threatening problems caused by improper nutrition.
- A healthy diet includes three meals a day and healthy snack options, especially when exercising.
- Discuss strategies for reducing shame around eating, weight, and self-perception. Coping mechanisms around self-esteem and body image to include journaling, support groups, relaxation, stress management, positive self-talk, and affirmations.
- Limit media intake and refrain from watching shows on weight loss or dieting.
- Educate on identifying problematic eating behaviors.
Anticipatory Guidance:
- Review sports safety measures, including female athlete triad awareness, injury prevention, sunscreen and sun protection, diet, and nutritional supplements.
Follow-up:
- Ms. Monroe should return to the clinic in 4 weeks for a reevaluation of her nutrition and eating habits.
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. |
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