ASSIGNMENT: Week 9 Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
ASSIGNMENT: Week 9 Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Patient Initials: T.J Age: 28 years old Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): “I am here to fulfill the requirement of obtaining a recent physical examination to secure health insurance coverage at my new place of employment.”
Struggling to meet your deadline ?
Get assistance on
ASSIGNMENT: Week 9 Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
done on time by medical experts. Don’t wait – ORDER NOW!
History of Present Illness (HPI): T.J., a 28-year-old African American female, visited the clinic to undergo a comprehensive physical examination as mandated by her employer for health insurance purposes. She was recently hired by Smith, Stevens, Stewart, Silver & Company. She currently has no medical conditions and underwent her most recent medical check-up four months ago as part of her routine annual gynecological examination. The patient received a diagnosis of PCOS and was prescribed oral contraceptives, which have demonstrated effectiveness thus far. The patient also has a history of well-controlled type 2 diabetes mellitus, which has been managed using metformin in addition to exercise and dietary interventions. Nevertheless, she appears to be in good health and does not currently have any other medical conditions.
ORDER A PLAGIARISM FREE PAPER HERE
Thanks for stopping by this assessment. We can assist you in completing it and other subsequent ones. Our expert writers will comprehensively review instructions, synthesize external evidence sources, and customize an A-grade paper. Kindly scroll down to review the sample.
Medications:
- Metformin 850 mg twice per day for type 2 diabetes
- Flovent inhaler 110 mcg, two puffs twice per day
- Proventil rescue inhaler, 90 mcg (base) per actuator, two puffs as needed.
- Oral contraception with Drospirenone and Ethinyl estradiol every morning.
- Advil 600 mg as needed is used to alleviate menstrual cramping.
Allergies:
- No known food or latex sensitivities.
- Drug hypersensitivity – Penicillin
- Validates dust and feline allergy
- Allergic reaction: runny nose, swollen eyes with itching, and worsening asthma symptoms.
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.
Sexual/Reproductive History: The onset of menarche occurred at 11 years of age. She identifies as heterosexual and had their first sexual experience at the age of 18. She denies any claims of having experienced pregnancy. The patient has experienced irregular and prolonged menstrual cycles lasting 9-10 days, occurring every 4 to 8 weeks over the past year. The most recent menstrual period occurred approximately 3 weeks before the current visit. The patient reports previous use of oral contraceptive pills but currently does not have a partner. She consistently engages in sexual activity without utilizing condoms. She claims to have never undergone an HIV/AIDS test and has no record of experiencing symptoms related to sexually transmitted infections or diseases. She stated that her most recent pap smear test occurred approximately four years ago.
Personal/Social History: The patient is unmarried and has no children. Since the age of 19, she has resided independently. However, following her father’s recent passing, she relocated to their single-family residence to receive assistance from her sister and mother. She has secured a new job and intends to commence it in two weeks. In her leisure time, she socializes with friends and participates in Bible study sessions. In addition, she engages in dancing and actively participates in volunteer work within her church community. She actively participates in church activities and considers her family to be a robust source of social support. The primary source of stress for her family is the loss of her father, which has necessitated her to juggle the demands of school, work, and financial responsibilities. She expresses gratitude towards both the church and her family for their support during periods of stress. She refutes any usage of tobacco, cocaine, heroin, or methamphetamine. She acknowledges the sporadic utilization of Canis between the ages of 15 and 21. She consumes alcohol socially, typically 2 to 3 times per month, limiting herself to no more than 3 drinks on each occasion. She confirms consuming approximately four caffeinated beverages daily. She has not traveled abroad and does not own any pets. She ended a lengthy committed relationship which lasted for nearly years around two years ago, and she presently denies having an intimate connection. Nevertheless, she aspires to marry and have children in the future.
Health Maintenance: Her most recent eye examination occurred three months ago. The most recent Pap smear was conducted four months ago. The most recent dental examination took place 5 months ago. A PPD test with a negative result was performed two years ago. Lack of physical activity. Nutrition: She can recall her dietary intake over the previous 24-hour period. She asserts that they did not consume breakfast on the previous day of their current visit. Safety measures have been implemented in her residence, including the installation of smoke detectors. She affirms the practice of utilizing a seatbelt while inside a motor vehicle and refutes engaging in bicycling activities. She does not utilize sunscreen. The firearms belonging to her father are currently stored in their parent’s room, securely locked.
Immunization History: The previous year, she had gotten her most current tetanus booster shot. The influenza vaccination is out of date. She was not vaccinated against human papillomavirus. She feels her childhood vaccination is current since she had the meningococcal vaccine during her college years.
Significant Family History: The patient’s 50-year-old mother has high blood pressure and high cholesterol. Her father, who had a history of diabetes mellitus and hypercholesterolemia, died at the age of 58 due to a motor vehicle accident. Her 25-year-old brother is obese. Her 14-year-old sister has asthma. At the age of 73, the maternal grandmother of the patient had a stroke and died. She had a history of excessive blood pressure and high cholesterol. The 78-year-old maternal grandfather has a history of hypertension and hypercholesterolemia as well as having had a stroke. The 82-year-old paternal grandmother of the client has been diagnosed with hypertension. The patient’s paternal grandfather died of colon cancer at the age of 65. On her father’s side, she has an alcoholic uncle.
Review of Systems:
General: Denies weariness, fever, and shivering. She has lost ten pounds in recent weeks owing to food adjustments and activity.
HEENT: Head: Denies headache and head injury symptoms. Neck: no evidence of lymph node enlargement or edema. Eyes: denial of itching, excessive tear production, discomfort, and discharge. The previous eye exam occurred two years ago. Ears/Nose/Mouth/Throat: Denies issues with hearing, discomfort, and drainage. Denies nasal congestion, nasal discharge, epistaxis, and nasal mucosal irritation. Denies bleeding gums, toothache, ulcers, painful throat, and difficulty swallowing. Due to a slight toothache, she last saw a dentist around six months ago.
Respiratory: denies having respiratory issues at the moment. reports having an asthma episode accompanied by periodic chest tightness, coughing, and shortness of breath.
Cardiovascular/Peripheral Vascular: denies having ever had cyanosis or bruising murmurs. denies experiencing any chest pain or palpitations. Respiratory: There is no hacking, gasping for air, wheezing, or sneezing. rejects pleuritic pain.
Gastrointestinal: denies tenderness, vomiting, diarrhea, discomfort in the stomach, constipation, jaundice, bloating, or irritable bowel syndrome
Genitourinary: Denies any alterations to her menstrual cycle. No discharge, itching, redness, or irritation in the vaginal region.
Musculoskeletal: denies having any joint, muscular, or back pain.
Neurological: denies experiencing headaches, vertigo, nausea, vomiting, ataxia, or syncopal paresthesia.
Psychiatric: denies having ever had anxiety, sadness, or mood problems.
Skin/hair/nails: reports of reduced acne. She has made progress in lightening the skin on her neck. improved body and facial hair. reports of a few skin moles.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Height: 170 cm, Weight: 84 kg, BMI: 29, Heart Rate: 78, Blood Pressure: 128/82, Respiration Rate: 15, Temperature: 99.0 degrees Fahrenheit, and SpO2: 99 percent
General: The patient looks to be in good health with no indications of concern. Aware and centered in time, place, and person. Very friendly and helpful throughout the interview.
HEENT: Eyes: Anicteric sclera, no lid lag, moist conjunctiva, and mild retinopathy in the right eye. bilaterally PERRLA. Ears, Nose, Mouth & Throat: mucosal membranes of the oropharynx are moist and clear. There are no mucosal ulcerations visible. complete dentition with no indication of gum bleeding. No abnormalities were found, only hard and soft palates.
Neck: without jugular vein distention, soft. Nothing stiff. neither swollen lymph nodes nor lumps.
Chest/Lungs: Auscultation reveals bilateral clarity. a prolonged period of expiration. No rales, rhonchi, or wheezing.
Heart/Peripheral Vascular: Existence of S1 and S2. 2/6 systolic murmur. the regular rhythm of the heartbeat. No rales or gallops were seen.
Abdomen: Bowel sounds were apparent, and the patient had no CVA discomfort and was fat and mushy.
Genital/Rectal: a female who seems typical. No unusually strong or offensive discharge. displays a sacral or right buttock region that is somewhat erythematous and slightly broken.
Musculoskeletal: both upper and lower extremities have a full range of motion. No joint pain or stiffness.
Neurological: Lack of specific neurological impairments. full mental and verbal faculties. minimally intact II through XII cranial nerves. reduced monofilament feeling on both plantar surfaces.
Skin, Hair & Nails: facial hair on the upper lip and a face covered in many pustules. Ankylosis nigricans of the back of the neck. No further anomalies in the hair or nails.
Diagnostic results: The requested laboratory tests include a basic metabolic panel, a thyroid function test, a kidney function test, and a full blood count. Additional tests may include cholesterol testing, pap smears, and screenings for cervix and breast cancer. Imaging modalities, such as computed tomography (CT) and X-rays, are utilized to evaluate the prognosis of polycystic ovary syndrome (PCOS) (Sullivan, 2019).
ASSESSMENT:
- The patient’s physical findings indicate a high BMI, indicating overweight status (Lebiedowska et al., 2020).
- The monofilament test indicates reduced sensation in the patient’s feet, indicating peripheral neuropathy as a result of diabetes (Liu et al., 2019).
- Mild retinopathy, indicating early stages of diabetes, was observed in the right eye (McAnany et al., 2019).
- Acanthosis nigricans, a skin condition, is commonly linked to systemic diseases such as diabetes and obesity, which are caused by insulin resistance (Das et al., 2020).
- The presence of upper lip facial hair may be linked to her prior PCOS diagnosis (Shah & Lieman, 2022).
The patient’s care plan will be determined based on an additional assessment of her conditions, including overweight, diabetes, PCOS, and asthma.
References
Das, A., Datta, D., Kassir, M., Wollina, U., Galadari, H., Lotti, T., Jafferany, M., Grabbe, S., & Goldust, M. (2020). Acanthosis nigricans: A review. Journal of Cosmetic Dermatology, 19(8), 1857–1865. https://doi.org/10.1111/jocd.13544
Lebiedowska, A., Hartman-Petrycka, M., & Błońska-Fajfrowska, B. (2020). How reliable is BMI? Bioimpedance analysis of body composition in underweight, normal weight, overweight, and obese women. Irish Journal of Medical Science (1971 -). https://doi.org/10.1007/s11845-020-02403-3
Liu, X., Xu, Y., An, M., & Zeng, Q. (2019). The risk factors for diabetic peripheral neuropathy: A meta-analysis. PLOS ONE, 14(2), e0212574. https://doi.org/10.1371/journal.pone.0212574
McAnany, J. J., Park, J. C., Liu, K., Liu, M., Chen, Y., Chau, F. Y., & Lim, J. I. (2019). Contrast sensitivity is associated with outer‐retina thickness in early‐stage diabetic retinopathy. Acta Ophthalmologica, 98(2). https://doi.org/10.1111/aos.14241
Shah, T., & Lieman, H. J. (2022). Managing the PCOS-Related Symptoms of Hirsutism, Acne, and Female Pattern Hair Loss. Polycystic Ovary Syndrome, 205–231. https://doi.org/10.1007/978-3-030-92589-5_11
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). F.A. Davis Company.
ORDER A PLAGIARISM-FREE PAPER HERE
Digital Clinical Experience: 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 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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
Learning Resources
Required Readings
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.
Chapter 4, “Affective Changes”
Download 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 evaluation 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”
Download 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”
Download 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”
Download 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”
Download 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)
O’Caoimh, R., & Molloy, D. W. (2019). Comparing the diagnostic accuracy of two cognitive screening instruments in different dementia subtypes and clinical depression.
Links to an external site. Diagnostics, 9(3), 93. https://doi.org/10.3390/diagnostics9030093
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Shadow Health. (2021). Welcome to your introduction to Shadow Health.
Links to an external site. https://link.shadowhealth.com/Student-Orientation-Video
Shadow Health. (n.d.). Shadow Health help desk.
Links to an external site.Retrieved from https://support.shadowhealth.com/hc/en-us
Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students.
Download Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)
Download 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.
Required Media
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/
Links to an external site.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.
Chapter 14, “The Neurologic Examination”
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”
In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.
Kim, H., Lee, S., Ku, B. D., Ham, S. G., & Park, W. (2019). Associated factors for cognitive impairment in the rural highly elderly.
Links to an external site. Brain and Behavior, 9(5), e01203. https://doi.org/10.1002/brb3.1203
Lee, K., Puga, F., Pickering, C. E., Masoud, S. S., & White, C. L. (2019). Transitioning into the caregiver role following a diagnosis of Alzheimer’s disease or related dementia: A scoping review.
Links to an external site. International Journal of Nursing Studies, 96, 119–131. https://doi.org/10.1016/j.ijnurstu.2019.02.007
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
Download 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 information
Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment in Shadow Health via the Shadow Health link in Canvas.
Once you complete your assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Canvas 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
Links to an external site.
Review the Week 9 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
Links to an external site.Complete your documentation using the documentation template in your resources and submit it into your Assignment submission link.
To submit your completed assignment, save your Assignment as WK9Assgn3+last name+first initial.
Then, click on Start Assignment near the top of the page.
Next, click on Upload File and select both files and then Submit Assignment for review.
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.
ORDER A PLAGIARISM-FREE PAPER HERE
Rubric
NURS_6512_Week_9_DCE_Assignment_3_Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning Outcome 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. |
|
60 pts | ||||
| This criterion is linked to a Learning Outcome Subjective Documentation in Provider Note Template: Subjective narrative documentation in Provider Note Template is detailed and organized and includes: Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome Objective Documentation in Provider Notes – this is to be completed using the documentation template that is provided. 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”. You only need to examine the systems that are pertinent to the CC, HPI, and History. 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). |
|
20 pts | ||||
| Total Points: 100 | ||||||
Struggling to meet your deadline ?
Get assistance on
ASSIGNMENT: Week 9 Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
done on time by medical experts. Don’t wait – ORDER NOW!