Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32
Comprehensive (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 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32 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.
Week 9: Shadow Health Comprehensive SOAP Note Template
Patient Initials: ___T. J____ Age: _____28__ Gender: __F_____
SUBJECTIVE DATA:
Chief Complaint (CC): “I came here because I am required to have a recent physical exam for the health insurance at my new job”
History of Present Illness (HPI): Ms. Tina Jones states that she is presently going to be employed at Smith, Stevens, Stewart, Silver and Company. As a prerequisite for her employment, Ms. Jones needs to have a pre-employment physical. During the interview, she states that she does not have any acute concerns. Ms. Jones last visited a facility, the Shadow Health General Clinic, four months ago for a yearly gynecological assessment. Consequently, she was diagnosed with POCS at which point the gynecologist prescribed contraceptives for her that were to be taken orally. She states that she is tolerating the contraceptives. The patient also admits to having type 2 diabetes that she manages using exercise, diet and the drug metformin that was prescribed to her some five months ago. She denies having any adverse events with any of the drugs. The patient admits to feeling healthy since she is careful with her body compared to the past and she is excited for the new job.
Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment (NURS 6512N-32) is the third assignment.
Physical Assessment from Head to Toe (Comprehensive)
In this course, you were encouraged to practice conducting numerous physical Assessments on various parts of the body, ranging from the head to the toes, over the duration of the course. Digital Clinical Experience for each of the Assignment 3 Digital Clinical Experience However, these examinations were carried out in a separate manner from one another, according to NURS 6512N-32: Comprehensive (Head-to-Toe) Physical Assessment. This DCE Assignment requires you to connect the knowledge and abilities you obtained from each individual assessment in order to execute a comprehensive head-to-toe physical examination in your Digital Clinical Experience during your Digital Clinical Experience.
Week 9: Shadow Health SOAP Note Template (Comprehensive SOAP Note)
Initials of the patient: ___T. J___ _____28_ years of age Gender: __F____ __F____ __F____
OBJECTIVE INFORMATION:
“I came here because I was obligated to undergo a recent physical exam for the health insurance coverage at my new employment,” says the Chief Complaint (CC).
History of Present Illness (HPI): Ms. Tina Jones claims that she is currently employed at Smith, Stevens, Stewart, Silver, and Company and that she has no plans to leave the company. Ms. Jones is required to undergo a pre-employment physical examination as a condition of her employment. During the interview, she adds that she is not concerned about anything in particular. She received her yearly gynecological assessment at a facility, the Shadow Health General Clinic, four months prior to her most recent visit there. Because of this, she was diagnosed with POCS, and her gynecologist recommended oral contraceptives to her for the duration of her pregnancy. In her own words, the contraceptives are being tolerated by her. Aside from that, the patient acknowledges that she has type 2 diabetes, which she maintains with exercise, nutrition, and the medication metformin, which was provided to her around five months ago. She asserts that she has not had any negative side effects from any of the medications. The patient admits to feeling healthy since she is more conscious of her body’s needs now than she was in the past, and she is looking forward to her new career.
Medication: The patient is taking Flucotisone propionate 110 mcg twice daily, with the last dose being taken in the morning. She takes 2 puffs per day, twice everyday. The patient is also taking Metformin 859 mg PO twice daily, with the most recent administration being in the morning. Furthermore, the patient is prescribed Drospirenone and ethinyl estradiol PO four times per day, with the last dose being administered in the early morning. Ms. Jones also uses the Albuterol spray for her asthma, and she hasn’t used it in three months, according to her medical records. Tina also takes Ibuprofen 600 mg three times a day to alleviate the pain of her menstrual cramps. She had not taken the drug in six weeks when she last did so.
Allergies: She is allergic to penicillin, which causes her to break out in hives. She, on the other hand, denies any latex or food allergies. She acknowledges that she is allergic to cats and dust. When the patient is exposed to her allergens, she experiences symptoms such as runny nose, puffy itchy eyes, and worsening of her asthma symptoms.
Tina’s asthma was discovered when she was 2 1/2 years old, according to her past medical history (PMH). She utilizes the Albuterol inhaler when she is in the presence of allergies such as cats. When she had her previous asthma attack, which occurred three months ago, she used the same inhaler to get rid of it. Her asthma had caused her to be admitted to the hospital for the last time when she was in high school. She asserts that she has never been intubated. It wasn’t until she was 24 years old that she was diagnosed with type 2 diabetes. Her metformin treatment for asthma began 5 months ago, with some gastrointestinal side effects at first, which have since subsided completely. The patient makes a point of taking her blood sugar readings every morning in the morning, with an average result of 90. She used diet and exercise to manage her previous history of hypertension. She does not have a prior history of surgical procedures.
Past Surgical History (PSH): The patient denies having any previous surgical history.
Readings that are required (Click to enlarge/reduce the image)
A review of the literature by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., and Stewart, R. W. (2019). The Seidel’s Guide to Physical Examination: An Interprofessional Approach is a resource for healthcare professionals (9th ed.). Elsevier Mosby, St. Louis, Missouri.
Chapter 7, “Mental Status,” is a section of the book that describes the state of one’s mind.
This chapter is concerned with the Assessment of an individual’s entire cognitive condition, which is known as the mental status Assessment. The chapter offers a list of mental disorders as well as descriptions of their symptoms.
Chapter 23, “The Neurological System,” is devoted to the study of the nervous system.
The authors of this chapter provide an overview of the anatomy and physiology of the central nervous system. The writers also provide an overview of neurological tests and likely findings in their book.
In J. E. Dains and L. C. Baumann’s article, P. Scheibel describes how they came to be (2019). In primary care, advanced health assessment and clinical diagnosis are performed (6th ed.). Elsevier Mosby, St. Louis, Missouri.
Reference: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., and Scheibel, P. Source: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition. Mosby has copyright protection till the year 2019. Mosby has granted permission for this reprint to be made available through the Copyright Clearance Center.
Chapter 4, “Affective Changes,” is the fourth chapter of the book.
When a patient experiences affective changes, this chapter will explain how to identify the possible cause. When evaluating this type of change, the authors offer a proposed approach, as well as specific instruments that can be used in conjunction with the Assessment.
Chapter 9, “Confusion in Older Adults,” discusses the phenomenon of confusion in older adults.
This chapter examines the reasons of confusion in older persons, with a particular emphasis on Alzheimer’s disease. It is suggested that you ask the following questions when taking a focused history, and you should also know what to look for during a physical examination.
Chapter 13, “Dizziness,” describes the sensation of being dizzy.
Many different underlying disorders can manifest itself as dizziness. This chapter describes the questions to ask a patient during a focused history taking session, as well as the various tests to perform during a physical examination.
Chapter 19, titled “Headache,” is about a headache.
The identification of the factors that contribute to headaches is the primary emphasis of this chapter.
The first step is to make sure that the headache is not a life-threatening condition before taking any further action. The authors make recommendations for conducting a complete history and doing a thorough examination.
Medications: The patient is on Flucotisone propionate 110 mcg that she takes 2 puffs twice daily with the last use occurring in the morning. The patient is also on Metformin 859 mg PO twice daily and its last use was equally in the morning. Moreover, the patient takes Drospirenone and ethinyl estradiol PO four times daily with the last use happening in the morning. Ms. Jones also uses the Albuterol spray for her asthma and the last use was three months ago. Tina also uses Ibuprofen 600 thrice per day in order to manage her menstrual cramps. The last time she used the medication was six weeks ago.
Allergies: She is allergic to penicillin which elicits rashes. She however denies latex and food allergies. She admits being allergic to cats and dust. Upon exposure to her allergens, the patient reacts by having runny nose, swollen itchy eyes, as well as exacerbation of her asthma symptoms.
Past Medical History (PMH): Tina’s asthma was revealed when she was 21/2 years old. When around allergens such as cats, she uses the Albuterol inhaler. She used the same inhaler to resolve her last asthma exacerbation that occurred three months ago. Her asthma last resulted in hospitalization when she was in high school. She denies ever being intubated. Her type 2 diabetes was diagnosed when she was 24 years old. Her metformin management of the asthma begun 5 months ago with GI side effects initially, which have since been resolved. The patient ensures to take her blood sugar readings daily in the morning with the average readings standing at 90. She used diet and exercise to manage her hypertension history. She does not have a history of surgeries.
Past Surgical History (PSH): Denies any surgical history
Sexual/Reproductive History: She had menarche at the age of 11. She had her maiden sex at the age of 18. She identifies as heterosexual and only has sex with men. She denies ever being pregnant with her last monthly periods occurring a fortnight ago. She was also diagnosed with PCOS during her last physical exam, which occurred 4 months ago. After starting on the prescription drug Yaz, her cycles have become regular accompanied with bleeding that is moderate and which lasts five days. She has started a new relationship with a man but they have not had sex yet. She has plans to protect herself when she starts having sex. She does not have any sexually transmitted infections or HIV/AIDS with the last test occurring four months ago.
Photo Credit: Getty Images/Hero Images
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 the 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. DCE Comprehensive Physical Assessment: Complete the following in Shadow Health:
Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180minutes) 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
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.
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 participate in this Assignment:
Week 9 Documentation Notes for Assignment 3
To Submit your Student Acknowledgement Form:
Submit your Week 9 Assignment 3 DCE Student Acknowledgement Form
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
To go to the next week:
Week 10
ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32
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 Assessment 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.
Chapter 4, “Affective Changes”
This chapter outlines how to identify the potential cause of affective
changes in a patient. The authors provide a suggested approach to the
Assessment of this type of change, and they include specific tools that can
be used as part of the diagnosis.
Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults, with an
emphasis on dementia. The authors include suggested questions for
taking a focused history as well as what to look for in a physical
examination.
Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions. This chapter
outlines the questions to ask a patient in taking a focused history and
different tests to use in a physical examination.
Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of headaches.
The first step is to ensure that the headache is not a life-threatening
condition. The authors give suggestions for taking a thorough history and
performing a physical exam.
Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep problems.
They also provide possible questions to use in taking the patient’s history,
things to look for when performing a physical exam, and possible
laboratory and diagnostic studies that might be useful in making the
diagnosis.
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.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. (2011). Physical examination objective data checklist. In
Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier
Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A.,
Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance
Center.
Note: Download and review the Student Checklists and Key Points to use
during your practice neurological examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Neurologic system: Student checklist. 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.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Neurologic system: 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.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Mental status: Student checklist. 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.
Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis
of adults with unexplained acute alteration of mental status. American
Journal of Electroneurodiagnostic Technology, 51(2), 92–104.
This article reviews the use of electrocenographs (EEG) to
Help in differential diagnoses. The authors provide differential
diagnostic scenarios in which the EEG was useful.
Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in
persons with chronic diseases in primary care: Challenges and
recommendations for practice. American Journal of Alzheimer’s Disease &
Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127
Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013).
Brief report: Use of the Mini-Cog as a screening tool for cognitive
impairment in diabetes in primary care. Diabetes Research and Clinical
Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001
Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., &
Arnold, S. E. (2013). Comparative accuracies of two common screening
instruments for classification of Alzheimer’s disease, mild cognitive
impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537.
doi:10.1016/j.jalz.2012.10.001. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/
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
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: 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
Comprehensive (Head-to-Toe) Physical Assessment (Word document)
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 Assessments” (pp.
766–786)
