NURS 6512 Digital Clinical Experience Head-to-Toe Physical Assessment
Past Medical History (PMH): The patient received an asthma diagnosis at the age of 2.5 years. She uses an Albuterol inhaler 2-3 times per week when exposed to dust or cats. She last utilized the inhaler three days ago due to exposure to felines. At the age of 24, she received a diagnosis of diabetes and began managing her condition with the use of metformin. However, three years ago, she discontinued taking the medication due to experiencing side effects related to flatulence. Since then, she has not been checking her blood sugar levels. The patient states that her blood glucose levels experienced a significant increase during her previous visit to the emergency room, which occurred one week before the current appointment.
Hospitalization: During her time in high school, she experienced an asthma attack. The patient did not require intubation.
Past Surgical History (PSH): denies having had surgery in the past.
NURS 6512 Digital Clinical Experience Head-to-Toe Physical Assessment
NURS 6512 Digital Clinical Experience Head-to-Toe Physical Assessment
Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.
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To Prepare
- Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
- Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment 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 Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
- Also, your Week 9 Assignment 3 should be in the Complete SOAP Note format. Refer to Chapter 2 of the Sullivan text and the Week 4 Complete Physical Exam template and use the template below for your submission.
Week 9 Shadow Health Comprehensive SOAP Note Documentation Template
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 Comprehensive Physical Assessment:
Complete the following in Shadow Health:
- Episodic/Focused Note for Comprehensive Physical Assessment 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 9 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 9
- Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment 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
- Review the Week 9 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
- Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
- Complete the Code of Conduct Acknowledgement.
- 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 9 Assignment 3 DCE Rubric
Submit Your Assignment by Day 7 of Week 9
To submit your Lab Pass:
Week 9 Lab Pass
To sumit this required part of the Assignment:
Week 9 Documentation Notes for Assignment 3
To Submit your Student Acknowledgement:
Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.
What’s Coming Up in Week 10?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will examine how to assess problems with the breasts, genitalia, rectum, and prostate while making the patient feel safe, listened to, and cared about using a non-invasive approach. Once again, you will use a SOAP note format to complete your Lab Assignment for this week.
Week 10 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Lab Assignment on time.
Next Week
Week 9: Assessment of Cognition and the Neurologic System
A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.
An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.
This week, you will explore methods for assessing the cognition and the neurologic system.
Learning Objectives
Students will:
- Evaluate abnormal neurological symptoms
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
- Assess health conditions based on a head-to-toe physical examination
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 7, “Mental Status”This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.
- ·Chapter 23, “Neurologic System”The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
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.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.
Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination.
This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Use this template to complete your Assignment 3 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 14, “The Neurologic Examination” (pp. 683–765)This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.
- Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.
Required Media (click to expand/reduce)
Neurologic System – Week 9 (16m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/
Patient Information:
Initials: J.K.L
Age: 40 years
Sex: Female
Race: African American
Source: Patient
S.
CC: “I have a headache around my forehead.”
HPI: J.K.L is a 40-year-old African American female who presents with a complaint of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It is non-radiating. The headache is constant and varies in severity ranging from 2/10 at its best to 8/10 at its worst. It is usually worse in the morning and while bending. Acetaminophen reduces the severity of the headache to 4/10 and occasionally 2/10. It is associated with fever, postnasal drip, nasal congestion, sneezing, and occasional non-productive cough. She takes Sudafed HCL 120 mg every 12 hours to obtain some relief. The symptoms have significantly impaired her concentration at work and made her feel very tired. Finally, she reports a head cold three weeks ago.
Current Medications: Pseudoephedrine 120 mg BID for nasal congestion and acetaminophen for headaches.
Allergies: She has no known food and drug allergies.
Past Medical History: During her last visit to the primary care physician 2 months ago, she was noted to be prehypertensive and was advised on lifestyle modifications. No prior hospitalization. No previous surgeries or blood transfusions.
Social History: She is married with two children both alive and well. She works as a secretary Her husband is a college teacher. She neither drinks alcohol nor smokes tobacco. She does not use marijuana or other illicit drugs. She strictly adheres to dietary advice from her nutritionist and she exercises regularly. Denies caffeine intake.
Family History: Father alive aged 60 years and with hypertension while her mother is 58 years old alive and well. Her brother and sister are 35 and 20 years old respectively, alive and well. Her paternal grandfather died at the age of 80 years due to a heart attack while her paternal grandmother is 78 years and is hypertensive. Her maternal grandfather is 77 years with a history of type 2 diabetes and high cholesterol while her maternal grandmother died at the age of 70 years due to a stroke. No family history of malignancies, mental illness, asthma, sickle cell, or diabetes.
ROS:
GENERAL: Reports fatigue and occasional fever. Denies weight loss, night sweats, and chills.
HEENT: Reports headaches, nasal congestion, post nasal drip, and sneezing. No blurring of vision, visual loss, hearing loss, tinnitus, nose bleeds, ear pain, mouth sores, or sore throat.
SKIN: no skin lesion or rashes. No abnormal pigmentation.
CARDIOVASCULAR: Negative for palpitations, chest pain, paroxysmal nocturnal dyspnea, and peripheral limb edema.
RESPIRATORY: Occasional non-productive cough. No difficulty in breathing, dyspnea, or orthopnea.
GASTROINTESTINAL: Reports loss of appetite and occasional nausea and vomiting. Denies change in bowel habits, abdominal pain, or distention.
GENITOURINARY: No frequency, dysuria, nocturia, and polyuria. No vaginal itchiness or abnormal vaginal discharge.
NEUROLOGICAL: Reports headache. Denies dizziness, lightheadedness, numbness, tingling, loss of sensation, syncope, and convulsion.
MUSCULOSKELETAL: No muscle pain, joint pains, muscle weakness, or muscle swelling.
HEMATOLOGIC: No anemia, easy bruising, or bleeding.
LYMPHATICS: Normal lymph nodes
PSYCHIATRIC: Denies anxiety, depression, suicidal ideations, or hallucinations.
ENDOCRINOLOGIC: Denies heat or cold intolerance, polyphagia, and polydipsia.
ALLERGIES: Reports no allergies.
O.
Physical exam:
VITAL SIGNS: BP 125/78 mmHg, HR 88 b/min, Temp 99. 8 F, RR 20 b/min, saturation 95% on room air, Height 168 cm, weight 76 Kg. Pain level 5/10
GENERAL: A middle-aged African-American female, well kempt, not in any form of respiratory distress but slight discomfort. Maintains eye contact, coherent speech, and a stable mood. Well-hydrated and nourished. No palmar or conjunctival pallor, jaundice, central or peripheral cyanosis, cervical or inguinal lymphadenopathy, and peripheral limb edema.
HEENT: Normocephalic and atraumatic head. Non-tender scalp. Bilateral eyes with pink conjunctiva and white sclera. Pupils equally and bilaterally reacting to light, no ptosis or lid edema. Normal extraocular movements. Bilateral ears present, no impaction or skin lesions, tympanic membrane pearly grey bilaterally, and positive white reflex. Both nares are present and are discharging mucus, midline nasal septum, and pink and soft nasal mucosa. Tender maxillary and frontal sinus. Moist and pink oral mucosa, no oral lesions or ulceration. Normal dentition and teeth alignment.
NECK: Soft neck. The trachea is central. Full range of motion, non-tender, no cervical lymphadenopathy, and no thyroid enlargement.
CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse in the 5th intercostal space in the midclavicular line. S1 and S2 head, no murmurs, thrills, gallops, rubs, or heaves.
RESPIRATORY: Symmetrical chest that moves with respiration. No scars or skin lesions. Equal chest expansion and equal tactile fremitus bilaterally. Equal air entry, vesicular breath sounds, no wheezes, and crackles, and equal vocal fremitus in all lung zones.
NEUROLOGICAL: GCS 15/15, oriented to time, place, and person, intact short-term and long-term memory, good concentration, and a clear coherent speech. Cranial nerves 1 to 12 intact. Normotonic across all joints, normal bulk, and power 5/5 across all muscle groups in upper and lower extremities, deep tendon reflexes 2+ and equal bilaterally in upper and lower limbs. Intact monofilament sensation across all dermatomes, good bowel, and bladder function. No spinal tenderness, normal gait, coordination, graphesthesia, and stereognosis. Normal finger nose, heel to the shin, and rapid alternating movements tests.
Diagnostic results:
J.K.L appears to have an inflammatory/infectious condition. Consequently, complete blood count and inflammatory markers particularly CRP and ESR are paramount. Similarly, bacterial or fungal cultures obtained endoscopically or by direct sinus aspiration are required to identify the possible pathogen. Additionally, a skin prick test is essential to exclude allergic rhinitis. Imaging modalities principally Sinus CT and MRI are recommended to evaluate for rhinosinusitis and intraorbital or intracranial involvement.
A.
Differential Diagnoses
Acute Sinusitis- refers to the inflammation of sinuses lasting less than 4 weeks (DeBoer & Kwon, 2022). The condition is more common in females and particularly during early fall to early spring (DeBoer & Kwon, 2022). It is most commonly caused by viral infection following a common cold although bacteria and fungi are not uncommon etiologies. J.K.L presents with clinical features that are typical of acute sinusitis including fatigue, fever, headache, facial pain, and pressure worse on bending (DeBoer & Kwon, 2022). Maxillary sinuses and frontal sinuses appear to be the affected sinuses in her as evidenced by pain around the forehead and tenderness of the maxillary and frontal sinuses (DeBoer & Kwon, 2022).
Rhinitis- Refers to the inflammation of the nasal mucosa. J.K.L presents with clinical manifestations suggestive of rhinitis including sneezing, nasal congestion, postnasal drip, and rhinorrhea (Liva et al., 2021). Similarly, she reports a “head cold” three weeks ago. Rhinitis is mostly caused by an upper respiratory infection or type 1 hypersensitivity reaction (Liva et al., 2021). However, an upper respiratory tract infection is likely the cause in her case.
Cluster headache- Cluster headache is a type of primary headache that is usually unilateral retro-orbital and characterized by sharp and stabbing pain (Goadsby et al., 2018). Cluster headache may present with symptoms of lacrimation, nasal congestion, rhinorrhea, ptosis, or miosis (Goadsby et al., 2018). However, it is unlikely the diagnosis in her as cluster headache usually lasts for a brief period. Similarly, cluster headaches mostly awake the patient at night.
Migraine headache- Migraine headache is another type of primary headache that may be preceded with or without aura. It is usually pulsating and moderate to severe (Pescador Ruschel & O, 2022). It is common in young women. However, it is unlikely the diagnosis as migraines last 4 to 72 hours if untreated and are typically associated with nausea, vomiting, photophobia, and phonophobia (Pescador Ruschel & O, 2022).
Rebound headache– Commonly referred to as medication overuse headache. Rebound headache predominantly occurs in individuals with primary headaches who overuse analgesia (Micieli & Robblee, 2018). Rebound headaches are more common in females and individuals less than 50 years. Drugs precipitating this headache include barbiturates, acetaminophen, opioids, ergotamine, and triptans (Micieli & Robblee, 2018). However, this is an unlikely diagnosis in J.K.L as a diagnosis of primary headache hasn’t been established.
References
DeBoer, D. L., & Kwon, E. (2022). Acute Sinusitis. https://pubmed.ncbi.nlm.nih.gov/31613481/
Goadsby, P., Wei, D.-T., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), 3. https://doi.org/10.4103/aian.aian_349_17
Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183
Micieli, A., & Robblee, J. (2018). Medication-overuse headache. Journal de l’Association Medicale Canadienne [Canadian Medical Association Journal], 190(10), E296–E296. https://doi.org/10.1503/cmaj.171101
Pescador Ruschel, M., & O, D. J. (2022). Migraine Headache. https://pubmed.ncbi.nlm.nih.gov/32809622/
SUBJECTIVE DATA:
Chief Complaint (CC): I have come for my pre-employment assessment.
History of Present Illness (HPI): The patient is a 28-year-old African American unmarried female that came to the clinic for pre-employment assessment. She is cooperative and offers information. She maintains normal eye contact and has normal speech. The client reports that she recently got a job that requires her to have a health insurance. She denies any acute concern. She reports that she had her gynecological exam four months ago where she was diagnosed with POCS and prescribed medications that she tolerates well. She is also diabetic and manages it with metformin and active lifestyle. She tolerates the medication well.
Medications: The patient currently uses Metformin 850 MG po BID Drospitenone and ethinyl estradiol PO QD. She also has Albuterol spay that she puffs twice and last use was three months ago. She occasionally uses Acetaminophen 500-1000 mg PO prn for headaches and Ibuprofen for menstrual cramps and last taken 6 weeks ago.
Allergies: The client reports allergic reaction to penicillin, which causes rashes. She also reports allergic reaction to dust and cats. She denies food and latex allergies.
Past Medical History (PMH): The client reports that she was diagnosed with asthma when 1 1/2 years old. Her last asthma exacerbation occurred three months ago. Last asthma hospitalization was when in high school. She report that she has never been intubated. The client reported that she has type 2 diabetes that was diagnosed at the age of 24. She has been taking metformin for five months without much side effects. Her average blood sugar is 90 and she monitors it daily in the morning. She also exercises and diets to manage the condition as well as hypertension. She has never undergone any surgery.
Past Surgical History (PSH): She has no history of surgery
Sexual/Reproductive History: She developed menarche at the age of 11. She has sex with men. She has never been pregnant whilst her had first sex at the age of 18. She has a new boyfriend.
Personal/Social History: She graduated with accounting degree and has been hired as an accounting clerk at Smith, Stevens, Steward, Silver & Company. The patient does not have children. She is not married. She lives with her mother alongside sister in a single apartment but planning to move to her own once she starts work. She enjoys reading, attending Bible studies, dancing and attending church functions. She considers her social support to include the church, friends and her family. She does not use tobacco. She used cannabis from ages 15-21. She does not abuse any other drugs. She uses alcohol in the company of friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, lunch to supper. She does not take coffee. She takes diet coke. She has not travelled outside recently and does not keep pets. She does mild exercise at least four times per week. She denies being stressed or anxiety.
Health Maintenance: The patient attends to the doctor’s appointment as scheduled. She had a pap smear 4 months ago. She also had an eye exam 3 months ago. The dental exam was last conducted 150 days ago. She is negative for PPD that was done two years ago. Her immunization status is current bar tetanus and HPV vaccines. She swims at YMCA. She reports that she has smoke detectors in the home. She wears safety belts in the car. She does not ride the bike. She uses sunscreen in the sun. She has locked her father’s gun in their bedroom.
Immunization History: Her immunization status is current bar tetanus and HPV vaccines. Childhood vaccines are up to date ad as well as meningococcal vaccine.
Significant Family History: There is history of hypertension in all the grandparents from both sides and both parents. Both parents and maternal grandparents have high cholesterol. Stroke killed maternal grandparents. Paternal grandmother is alive and 82 years of age whilst grandfather died of cancer at 65. The latter also had a history of type 2 diabetes alongside the patient’s father who died in an accident. Has an overweight brother and an asthmatic sister. Alcoholism in paternal uncle. There are no other diseases in the family.
Review of Systems:
General: The client is dressed appropriately for the occasion. She maintains normal eye contact during the assessment. Her speech is of normal rate and tone. She denies, chills, night sweats, headache, fatigue, or weight changes
HEENT: The client denies headache or head injuries. She denies general hearing problems, changes in hearing, ear pain or discharge. She also denies eye pain, itchy eyes, eye redness, or dry eyes. She denies changes in smell, sneezing, runny nose, nose bleeds or sinus pain. Dental visit was five months ago. She denies general mouth problems, changes in sense of taste, dry mouth, mouth pain, gum problems, tongue or jaw problems, and dental problems. She denies difficulty in swallowing, sore throat, voice changes, neck pain, or lymphadenopathy.
Respiratory: She denies any current breathing problems. She chest tightness, wheezing, chest pain, or cough.
Cardiovascular/Peripheral Vascular: She denies palpitations, irregular heartbeat, easy bruising, edema, or circulation problems.
Gastrointestinal: She denies nausea, vomiting, stomach pain, constipation, diarrhea, or flatulence.
Genitourinary: She denies dysuria, nocturia, polyuria, blood stained urine, flank pain, abnormal vaginal discharge, breast lump or breast pain.
Musculoskeletal: She denies muscle pain, joint pain, muscle weakness, or swelling.
Neurological: She denies dizziness, vision disturbance, numbness or tingling, loss of coordination or sensation, seizures or balance problems.
Psychiatric: Has enhanced coping mechanism to stress. Does not suffer depression, anxiety, or suicidal thoughts. She is alert to all faculties. She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear. Skin/hair/nails: she uses sun-glasses when playing outdoors. She denies slow-healing wounds, with improving acne and some male-pattern hair growth. She denies sores, dandruff, nail fungus, dry skin or rashes.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Height: 170m cm Weight: 84 bmi: 29.00 Blood glucose: 90 RR: 15 HR: 78 BP: 128/82 Pulse Ox: 99% Temperature: 99.0 F
General: She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear.
HEENT: Normocephalic head, and atraumatic as well. Bilateral eyes with equal hair distribution on lashes and eye brows, lids without lesions. No ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. OEMS intact bilaterally, no nystagmus. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMS intact and pearly gray bilaterally, positive light reflex. Whispered words bilaterally heard. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions. Uvula rises midline on phonation. Gag reflex is intact, Dentation minus evidence of carries or infection. Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.
Neck: Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.
Chest/Lungs: Chest is symmetric. The lung sounds are clear whilst voice occurs in all areas. Percussion produced resonance throughout. In office spirometry: FVC 3.91, FEV1/FVC ratio 80.56%.
Heart/Peripheral Vascular: Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts or thrills. Bilateral peripheral pulses equal bilaterally, capillary refills less than 3 seconds. No peripheral edema.
Abdomen: Abdomen is protuberant, symmetric without visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.
Genital/Rectal:
Musculoskeletal: Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.
Neurological: Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterally. Cerebella function tests produced normal results. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.
Skin: Pustules on the face are scattered whilst the upper lip ha facial hair. The posterior neck has acanthosis nigricans. Nails are free of ridges or abnormalities.
Diagnostic results: none. The client has come for preemployment physical examination.
ASSESSMENT: The patient is a 28-year-old African American unmarried female that came to the clinic for pre-employment assessment. She is cooperative and offers information. She maintains normal eye contact and has normal speech. The client reports that she recently got a job that requires her to have a health insurance. She denies any acute concern. She reports that she had her gynecological exam four months ago where she was diagnosed with POCS and prescribed medications that she tolerates well. She is also diabetic and manages it with metformin and active lifestyle. She tolerates the medication well. The patient currently uses Metformin 850 MG po BID Drospitenone and ethinyl estradiol PO QD. She also has Albuterol spay that she puffs twice and last use was three months ago. She occasionally uses Acetaminophen 500-1000 mg PO prn for headaches and Ibuprofen for menstrual cramps and last taken 6 weeks ago. Physical examination findings are unremarkable. She denies any mental health problems such as anxiety or depression. No diagnostic investigations were ordered during this client’s visit.
Week 9
Shadow Health Comprehensive SOAP Note Template
Patient Initials: __T.J_____ Age: ___28____ Gender: ___Female____
SUBJECTIVE DATA: ‘I have come for my pre-employment assessment’
Chief Complaint (CC): Tina Jones is a 28-year-old African American that came to the unit for her pre-employment physical examination.
History of Present Illness (HPI): Tina Jones has come today for her pre-employment physical assessment. According to her, she has been employed at Smith, Stevens, Stewart, Silver & Company, and is required to undertake the assessment before reporting at her new workplace. Jones no acute health problems currently. She reports that her last visit to a healthcare provider was four months ago for annual gynecological exam. Her last general physical examination as five months ago where she was prescribed daily inhaler and metformin twice a day. She currently uses daily inhaler (Proventil rescue inhaler, twice daily) and diabetes medication (Metformin 850 mg twice daily). She is also taking birth control pills prescribed for polycystic ovarian syndrome diagnosed during her last gynecological visit. Her diabetes is controlled with metformin, exercise and diet.
Medications: Jones noted that she is currently on the following medications
- Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
- Metformin, 850 mg PO BID (last use: this morning)
- Drospirenone and ethinyl estradiol PO QD (last use: this morning)
- Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago)
- Acetaminophen 500-1000 mg PO prn (headaches)
- Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)
Allergies: Jones denies no new allergies as well as seasonal allergies. She reports that she is allergic to penicillin, dust and cats. The associated allergic symptoms include rhinorrhea, exacerbated asthma symptoms, and swollen eyes. She does not have food or latex allergy.
Past Medical History (PMH): Jones reports that her last health visit was 4 months ago when she underwent her annual gynecological exam. She was diagnosed with polycystic ovarian syndrome, which she has been treating with oral contraceptives. She has a history of asthma and diabetes. She was diagnosed with diabetes when she was 24 years. She controls diabetes with metformin, dietary modifications, and exercise. Her blood glucose levels are currently controlled. She performs daily self-monitoring of blood glucose, with her blood glucose levels being around 90. She has adequate supplies for blood glucose monitoring. She was diagnosed with asthma at the age of two and half years and has been using albuterol inhaler to manage and prevent it. She denies recent asthma exacerbations or current asthma symptoms. Last asthma exacerbation was three months ago. She has a history of hospitalization due to asthma when she was in high school. She also has a history of hypertension, which resolved following her dietary modifications and engaging in physical activity. She has a history of optometrist visit (3 months ago) where she was prescribed eyeglasses to improve vision.
Past Surgical History (PSH): She reported that she has no history of surgery.
Sexual/Reproductive History: Her menarche was when she was 11 years. Her first sexual encounter was when she was 18 years. Identifies herself as heterosexual. Her menarche pattern is every four weeks, which last five days, with medium flow. Her last menstrual period was 2 weeks ago. She was diagnosed with polycystic ovarian syndrome four months ago and has been on treatment. Her menstrual period lasts about five days. She reports that she is currently in a new month-old relationship. She intends to use condoms with any sexual activity. Tested negative for HIV/AIDS and STIs four months ago. She has never been married nor pregnant.
Personal/Social History: Jones currently lives with her sister and mother and intends to live alone in a month’s time close to her workplace. She is a graduate with accounting degree. She secured a job with Smith, Stevens, Steward, Silver & Company to start in 2 weeks’ time as an accounting clerk. She has strong support system comprising her friends, family, and church. She spends her time with friends, reading, attending bible study, volunteering in her church and dancing. No history of tobacco use. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin.
Health Maintenance: Jones utilizes health screening services. Her last gynecological exam was four months ago where she was diagnosed with polycystic ovarian syndrome. Her dental examination was done last five months ago. She reports that their home has smoke detectors. She drinks 2-3 alcohol drinks per month and 2 or 3 single drinks (rum and diet coke) when out with friends. Her typical diet comprises of fruit smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt. Lunch comprises of dinner leftovers or tuna or chicken sandwich on wheat bread. Her typical dinner is vegetables with a protein and brown rice or quinoa. Her snack is carrot sticks or an apple. She limits intake of caffeine due to sleep and heart problems. She does not drink coffee. She drinks about 2 diet cokes per day. She engages in mild to moderate exercises by walking four or five times a week, lasting 30-40 minutes. She also swims weakly at YMCA. She reports improved ability to cope with stress after passing graduating and passing CPA exam. She sleeps 8-9 hours a night.
Immunization History: Jones reports that she believes that all her immunizations are current.
Significant Family History: The following are Jones’ significant family histories
- Her father died of car accident. He had a history of high cholesterol, type 2 diabetes, and hypertension
- Her brother, Michael is overweight
- Her sister, Britney is asthmatic
- Her deceased maternal grandmother had hypertension, stroke, and high cholesterol
- Her deceased maternal grandfather had hypertension, high cholesterol, and stroke
- Her paternal grandmother has hypertension
- Her deceased paternal grandfather had colon cancer and type 2 diabetes
- Her paternal uncle is alcoholic
- There is no history of kidney disease, thyroid problems or any other cancers in the family
Review of Systems:
General: Jones denies chills, fatigue, recent illness, or night sweats She reports recent weight loss of about 10 pounds due to diet and increased exercise
HEENT: Jones denies headache, head injuries, changes in hearing, ear pain or discharge. She denies eye pain, discharge, itchiness, redness, or dry eyes. She uses corrective lenses. She denies changes in smell, sneezing, nosebleeds, sinus pain, sinus pressure, or rhinorrhea. Her dental visit was five months ago. She denies changes in senses of taste, dry mouth, mouth pain, sores, tongue, or gum problems. She denies dysphagia, sore throat, chronic throat problems, neck pain, lymphadenopathy, or swollen glands.
Respiratory: Denies current breathing problems, wheezing, chest tightness, pain when breathing, or cough.
Cardiovascular/Peripheral Vascular: She denies palpitations, irregular heartbeat, easy bruising, edema, or circulation problems.
Gastrointestinal: She denies nausea, vomiting, stomach pain, constipation, diarrhea, or flatulence.
Genitourinary: She denies dysuria, nocturia, polyuria, frequency, blood in urine, flank pain, vaginal itchiness, or abnormal discharge. She denies breast lumps or pain
Musculoskeletal: She denies muscle or joint pain, muscle weakness, or swelling.
Neurological: She denies dizziness, vision disturbance, numbness, tingling, loss of coordination, seizures, or balance problems.
Psychiatric: She denies history of mental problems
Skin/hair/nails: Reports using sunscreen when exercising outdoors, no recent slow healing wounds, improving acne, and some male-hair like pattern. Denies no changes in moles, dandruffs, sores, nail fungus, or dry skin.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Respiration- 15
Temp- 37.2 C
Heartrate – 78
SpO2- 99%
- Height: 170 cm
- Weight: 84 kg
- BMI: 29.0
- Blood Glucose: 100
- RR: 15
- HR: 78
- BP:128 / 82
- Pulse Ox: 99%
- Temperature: 99.0 F
General: Jones is alert oriented, seated upright on examination table, and is in no distress. She is well-nourished, developed, and dressed appropriately with good hygiene.
HEENT: Head is normocephalic, atraumatic. Eyes bilateral with equal hair distribution on lashes and eyebrows. No lesions on lids, no edema or ptosis. Pink conjunctiva, white sclera, PERRLA bilaterally, intact extraocular eye movements, and no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection.
Neck: Thyroid smooth without nodules, no goiter. No lymphadenopathy.
Chest/Lungs: Lung sounds clear and voice is present in all areas. Spanish symmetrically. Chest anterior and posterior normal upon inspection. fremitus equal bilaterally. Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.
Heart/Peripheral Vascular: Pirated 2 + with no thrill or bruit bilaterally. PMI non-discplaced. S1 and S2 only regular rhythm. No bruit in aorta or any other arteries. Capillary refill is less than 3 seconds in fingers and toes no edema is present. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.
Abdomen: bowel sounds are normal in all quadrants. moves bowels regularly. Abdomen is soft with no Masses. liver is one centimeter below the right costal margin. Quadrants are tympanic and spleen is Not dull in sound. Kidney is not palpable no masses are present
Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.
Genital/Rectal: –
Musculoskeletal: Range of motion in all areas of full or muscle strength or 5 out of 5 no CVA tenderness. DTR 2+. Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.
Neurological: for the feet especially left foot area. Patient is able to sense position of body fingers and toes. Graphesthesia normal sense. Patient is oriented to time person and place. Heel to Shin normal. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.
Skin: Acne is present on the face. Skin is normal. Norwegians or abnormalities in the nails. Old scar is present on the left shin.
Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities.
Diagnostic results: None
ASSESSMENT: Jones is a 28-year-old female that has come today for her pre-employment assessment. She appears well dressed and responsive. She is diabetic and asthmatic, which are controlled. She uses corrective lenses. She has normal sleeping cycle. She engages in active physical activity and has dietary modifications for diabetes control. She monitors her blood glucose levels on a daily basis. She also monitors her peak flow to track asthma and uses albuterol inhaler to manage its symptoms. She denies any current acute health problems.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
Rubric Detail
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Content
Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
| Excellent | Good | Fair | Poor | ||
| Student DCE score(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.) Note: DCE Score – Do not round up on the DCE score. | Points Range: 56 (56%) – 60 (60%)DCE score>93 | Points Range: 51 (51%) – 55 (55%)DCE Score 86-92 | Points Range: 46 (46%) – 50 (50%)DCE Score 80-85 | Points Range: 0 (0%) – 45 (45%)DCE Score <79 No DCE completed. | |
| Documentation in Provider Notes AreaSubjective documentation of the comprehensive exam in Provider Notes is detailed, organized, and includes documentation of identifying data, general survey, reason for visit/chief complaint, history of present illness, medications, allergies, medical history, health maintenance, family history, social history, mental health history, and review of systems. The review of systems is clearly defined by each body system (skin, eyes, cardiac, etc.) and all conditions or illnesses asked of the patient are documented along with the patient response. | Points Range: 16 (16%) – 20 (20%)Documentation is detailed and organized with all pertinent information noted in professional language. Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). | Points Range: 11 (11%) – 15 (15%)Documentation with sufficient details, some organization and some pertinent information noted in professional language. Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). | Points Range: 6 (6%) – 10 (10%)Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language. Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). | Points Range: 0 (0%) – 5 (5%)Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). or No documentation provided. | |
| Objective Documentation in Provider Notes – this is to be completed in Shadow HealthPhysical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”. Diagnostic result- Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). | Points Range: 16 (16%) – 20 (20%)Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language. Each system assessed is clearly documented with measurable details of the exam. | Points Range: 11 (11%) – 15 (15%)Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language. Each system assessed is somewhat clearly documented with measurable details of the exam. | Points Range: 6 (6%) – 10 (10%)Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language. Each system assessed is minimally or is not clearly documented with measurable details of the exam. | Points Range: 0 (0%) – 5 (5%)Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language. None of the systems are assessed, no documentation of details of the exam. or No documentation provided. | |
| Total Points: 100 | |||||
Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
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