Assignment: Digital Clinical Experience (DCE): Health History Assessment

Assignment: Digital Clinical Experience (DCE): Health History Assessment

Assignment: Digital Clinical Experience (DCE): Health History Assessment

SUBJECTIVE DATA:

The patient is Tina Jones 28 years of age who came to the facility in regards to a scrape  on her foot that is not healing as expected that she got due to an accident. She does not  live alone but together with her sister and her mother. She is a student who is studying   bachelor in accounting. Furthermore, she is working at company known as Mid-  American Copy & Ship as a supervisor.

In terms of a relationship she does not have a  boyfriend and reports she has not been sexually active for about 2 years. Apart from those    she lives with her family further consists of a brother, a maternal grandmother and  paternal grandparents. She lost her father due to a road accident and reports that her  maternal grandfather also passed away.

Chief Complaint (CC): Pain on her foot due to a scrape that has persisted and won’t heal on its despite wound care.

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History of Present Illness (HPI):

Patient has come into the facility due to a scrape on her foot that isn’t healing normally despite appropriate interventions and is also giving her pain. She ranks the pain at 7 out of a scale of 1-10 and reports the pain is aggravated by when she attempts to stand while her pain medication tramadol provides partial relief. The wound was a result of scrapping it on a cement step the previous week.

After that she did go to the emergency room and has been taking tramadol pills as part of pain management. Her wound care consists of using bandages together with neosprin. She is not able to engage in activities of daily living as before as her ability to walk has been impaired thus limiting her in tasks she could perform.

Medications:

90 micrograms inhaler taking 2 puffs per required need for asthma treatment

50 mgs tramadol taken orally two pills three times daily

Patient was prescribed metformin but is no longer compliant with that medication

Allergies:

Patient reports she is allergic to cats that causes wheezing, sneezing and itchy eyes

Patient reports she is allergic to dust that causes wheezing, sneezing and itchy eyes.

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Patient reports she is allergic to penicillin that in her childhood caused hives.

Past Medical History (PMH):

Patient reports she has been previously diagnosed with asthma

Patient reports she has been previously diagnosed with diabetes type 2

Patient reports she is not compliant with her diabetes medication that she last took 3 years ago and her management involves not taking sweets and diet soda.

Patient reports she does not regularly monitor her glucose levels.

Patient reports her last asthma attack was in high school.

Patient reports exacerbation 3 days ago

Patient reports she uses an inhaler for her asthma per required need.

Patient reports dust, cats and running up the stairs can trigger her asthma.

Past Surgical History (PSH):

Patient has not had a surgical procedure before.

Sexual/Reproductive History:

Patient reports her last sexual activity was about 2 years ago, she is not currently in a relationship and has had 3 previous sexual partners.

Patient reports not to be under any current form of contraception.

Patient reports previous condom and oral birth control use.

Personal/Social History:

Patient reports to take alcohol though when her friends are around.

Patient reports previous marijuana use that she no longer takes.

Patient reports an increase in appetite.

Patient reports not to have stress

Patient denies to take tobacco.

Patient denies caffeine consumption.

Immunization History:

Patient reports to have had all her childhood vaccines and is up to date with current vaccines she is supposed to take.

Health Maintenance:       

Patient reports that she is no longer compliant with her diabetes medication and her management from the condition involves not taking sweets and drinking diet soda instead of regular.

Patient reports to manage her pain due to the scrape in her foot she takes tramadol pain pills and wound care that involves bandages applied with neosprin.

Patient reports asthma management that involves use of an inhaler per required need and staying away from her asthma triggers.

Significant Family History (Include history of parents, maternal/paternal Grandparents, siblings, and children):

Patient reports a family history of high cholesterol and high blood pressure from her parents, maternal as well as paternal grandparents.

Patient reports a family high history of diabetes that her father had.

Patient reports that her sister had been diagnosed with asthma

Review of Systems

General: Patient reports an occurrence of weight loss, fever and fatigue.

            HEENT: Patient reports occasional headaches, blurry vision but reports no ear     pain, nosebleeds or sore throat

Neck:  Patient reports no neck problems

            Breasts: Patients reports having regular breast exams with no problems noted.

            Respiratory: Patient reports at the time no wheezing, chest tightness or pain while breathing.

            Cardiovascular/Peripheral Vascular: Patient reports no palpitations or edema.

            Gastrointestinal: Patient reports no nausea or vomiting.

            Genitourinary: Patient reports increased urine frequency though no blood in the urine

Reproductive: Patient reports irregular periods.

            Musculoskeletal: Patient reports no swelling of joints, no back pain and no pain   in the joints

            Psychiatric: Patient denies having suicidal ideations.

            Neurological: Patient denies having seizures, tingling or feeling dizzy.

            Skin: Patient reports having acne, dry skin at times, excessive hair in the body      and moles.

            Hematologic: Patient reports not having excessive bleeding.

            Endocrine:  Patient reports not having issues in her thyroid.

Assignment 2: Digital Clinical Experience
(DCE): Health History Assessment
In Week 3, you began your DCE: Health History Assessment. For this week, you will
complete this Health History Assessment in your simulation tool, Shadow Health and
finalize for submission.

Photo Credit: Sam Edwards / Caiaimage / Getty Images

To Prepare
 Review this week's Learning Resources as well as the Taking a Health History media
program in Week 3, and consider how you might incorporate these strategies. Download
and review the Student Checklist: Health History Guide and the History Subjective Data
Checklist, provided in this week's Learning Resources, to guide you through the
necessary components of the assessment.
 Review the DCE (Shadow Health) Documentation Template for Health History found in
this week’s Learning Resources and use this template to complete your Documentation
Notes for this DCE Assignment.

 Access and login to Shadow Health using the link in the left-hand navigation of the
Blackboard classroom.
 Review the Shadow Health Student Orientation media program and the Useful Tips and
Tricks document provided in the week’s Learning Resources to guide you through
Shadow Health.
 Review the Week 4 DCE Health History Assessment Rubric, provided in the Assignment
submission area, for details on completing the Assignment.
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must
achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and
video presentation in order to fully understand the requirements of this assignment.
DCE Health History Assessment:
Complete the following in Shadow Health:
Orientation
 DCE Orientation (15 minutes)
 Conversation Concept Lab (50 minutes)
Health History
 Health History of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as
necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and
your Documentation Notes), but you must take all attempts by the Week 4 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 4
 Complete your Health Assessment DCE assignments in Shadow Health via the Shadow
Health link in Blackboard.
 Once you complete your assignment in Shadow Health, you will need to download your
lab pass and upload it to the corresponding assignment in Blackboard for your faculty
review.
 (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can
find instructions for downloading your lab pass here:
https://link.shadowhealth.com/download-lab-pass
 Once you submit your Documentation Notes to Shadow Health, make sure to copy and
paste the same Documentation Notes into your Assignment submission link below.
 Download, sign, date, and submit your Student Acknowledgement Form found in the
Learning Resources for this week.

 Note: You must pass this assignment with a minimum score of 80%  in order to pass
the class. Once submitted, there are not any opportunities to revise or repeat this
assignment.
Grading Criteria

To access your rubric:
Week 4 Assignment 2 DCE Rubric

Submit Your Assignment by Day 7 of Week 4

To submit your Lab Pass:
Week 4 Lab Pass

To submit this required part of the Assignment:
Week 4 Documentation Notes for Assignment 2

To Submit your Student Acknowledgement Form:
Submit your Week 4 Assignment 2 DCE Student Acknowledgement Form

Learning Resources

Required Readings (click to expand/reduce)

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019).
Seidel's guide to physical examination: An interprofessional approach (9th ed.).
St. Louis, MO: Elsevier Mosby.

 Chapter 9, “Skin, Hair, and Nails”
This chapter reviews the basic anatomy and physiology of skin, hair, and
nails. The chapter also describes guidelines for proper skin, hair, and nails
assessments.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA:
F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R.
Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis
Company via the Copyright Clearance Center.

This section explains the procedural knowledge needed prior to performing
various dermatological procedures.

Chapter 1, “Punch Biopsy”

Chapter 2, “Skin Biopsy”

Chapter 10, “Nail Removal”

Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”

Chapter 16, “Skin Tag (Acrochordon) Removal”

Chapter 22, “Suture Insertion”

Chapter 24, “Suture Removal”

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment
and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary
Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019
by Mosby. Reprinted by permission of Mosby via the Copyright Clearance
Center.

Chapter 28, “Rashes and Skin Lesions”
This chapter explains the steps in an initial examination of someone with
dermatological problems, including the type of information that needs to be
gathered and assessed.

Note: Download and use the Student Checklist and the Key Points when you
conduct your assessment of the skin, hair, and nails in this Week’s Lab
Assignment.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019).
Skin, hair, and nails: Student checklist. In Seidel's guide to physical examination
(9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W.,
Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by
Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019).
Skin, hair, and nails: Key points. In Seidel's guide to physical examination: An
interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W.,
Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by
Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences
via the Copyright Clearance Center.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia,
PA: F. A. Davis.
 Chapter 2, "The Comprehensive History and Physical Exam" (Previously
read in Weeks 1 and 3)

VisualDx. (n.d.). Clinical decision support. Retrieved June 11, 2019, from
http://www.skinsight.com/info/for_professionals

This interactive website allows you to explore skin conditions according to age,
gender, and area of the body.

Clothier, A. (2014). Assessing and managing skin tears in older people. Nurse
Prescribing, 12(6), 278–282.

Document: Skin Conditions (Word document)

This document contains five images of different skin conditions. You will use this
information in this week’s Discussion.

Document: Comprehensive SOAP Exemplar (Word document)

Document: Comprehensive SOAP Template (Word document)

Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well
as other support resources:

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Document: Shadow Health Support and Orientation Resources (PDF)

Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Shadow Health Nursing Documentation Tutorial (Word document)

Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to Walden
University’s Code of Conduct.

Document: DCE (Shadow Health) Documentation Template for Health History
(Word document)
Use this template to complete your Assignment 2 for this week.

Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic
examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 6, “The Skin and Nails”

In this chapter, the authors provide guidelines and procedures to aid in the
diagnosis of skin and nail disorders. The chapter supplies descriptions and
pictures of common skin and nail conditions.

Ethicon, Inc. (n.d.-a). Absorbable synthetic suture material. Retrieved from
https://web.archive.org/web/20170215015223/ http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/absorbable_suture
_chart.pdf

Ethicon, Inc. (2006). Dermabond topical skin adhesive application technique.
Retrieved from
https://web.archive.org/web/20150921174121/http://academicdepartments.musc.e
du/surgery/education/resident_info/supplement/suture_manuals/db_application_p
oster.pdf

Ethicon, Inc. (2001). Ethicon needle sales types. Retrieved from
https://web.archive.org/web/20150921171922/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/needle_template.
pdf

Ethicon, Inc. (n.d.-b). Ethicon sutures. Retrieved from
https://web.archive.org/web/20150921202525/ http://academicdepartments.musc.e
du/surgery/education/resident_info/supplement/suture_manuals/suture_chart_ethi
con.pdf

Ethicon, Inc. (2002). How to care for your wound after it's treated with
Dermabond topical skin adhesive. Retrieved from
https://web.archive.org/web/20150926002534/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/db_wound_cap
df

Ethicon, Inc. (2005). Knot tying manual. Retrieved from
https://web.archive.org/web/20160915214422/

http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/knot_tying_manu
al.pdf

Ethicon, Inc. (n.d.-c). Wound closure manual. Retrieved from
http://www.uphs.upenn.edu/surgery/Education/facilities/measey/Wound_Closure
_Manual.pdf

Required Media (click to expand/reduce)

Module 3 Introduction

Dr. Tara Harris reviews the overall expectations for Module 3. Consider how you
will manage your time as you review your media and Learning Resources for
your Discussions, Case Study Lab Assignments, DCE Assignments, and your

Midterm exam (12m).
Skin, Hair, and Nails – Week 4 (19m)
Online media for Seidel's Guide to Physical Examination
In addition to this week's media, it is highly recommended that you access and view the
online resources included with the text, Seidel's Guide to Physical Examination. Focus on
the videos and animations in Chapter 8 that relate to the assessment of the skin, hair, and
nails.
Note: To access the online resources included with the text, you need to complete
the FREE online registration that is located at
https://evolve.elsevier.com/cs/product/9780323172660?role=student .
To Register to View the Content
1. Go to https://evolve.elsevier.com/cs/product/9780323172660?role=student
2. Enter the name of the textbook, Seidel's Guide to Physical Examination (name of
text without the edition number) in the Search textbox.
3. Complete the registration process.
To View the Content for this Text
1. Go to https://evolve.elsevier.com/

2. Click on Student Site.
3. Type in your username and password.
4. Click on the Login button.
5. Click on the plus sign icon for Resources on the left side of the screen.
6. Click on the name of the textbook for this course.
7. Expand the menu on the left to locate all the chapters.
8. Navigate to the desired content (checklists, videos, animations, etc.).
Note: Clicking on the URLs in the APA citations for the Resources from the
textbook will not link directly to the desired online content. Use the online menu
to navigate to the desired content.
Suturing Tutorials
The following suturing tutorials provide instruction on the basic interrupted suture, as
well as the vertical and horizontal mattress suturing techniques

Tulane Center for Advanced Medical Simulation & Team Training. (2010, July
8). Suturing technique [Video file]. Retrieved from
https://www.youtube.com/watch?v=c-LDmCVtL0o
Note: Approximate length of this media program is 5 minutes.

Mikheil. (2014, April 22). Basic suturing: Simple, interrupted, vertical mattress,
horizontal mattress [Video file]. Retrieved from
https://www.youtube.com/watch?v=MFP90aQvEVM
Note: Approximate length of this media program is 9 minutes.

Incision and Drainage of an Abscess (a common procedure in primary care)

New England Journal of Medicine (NEJM). (2013, September 30). NEJM abscess
incision and drainage [Video file]. Retrieved from
https://www.youtube.com/watch?v=MwgNdrA18fM&list=PL9UKTUFtRDcNq4-
-Vf2NYfUANEyObfeNm&index=8
Note: Approximate length of this media program is 10 minutes.

Dermablade Use for Shave Biopsies

Dermablade®. (2012, November 9). PersonnaBlades [Video file]. Retrieved from
https://www.youtube.com/watch?v=D8u1Y18L9DQ
Note: Approximate length of this media program is 5 minutes.

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