Digital Clinical Experience: Comprehensive Head-to-Toe Physical Assessment NURS 6512N-32

Assignment 3: Digital Clinical Experience: Comprehensive Head-to-Toe Physical Assessment NURS 6512N-32

Digital Clinical Experience: Comprehensive Head-to-Toe Physical Assessment

History of Present Illness (HPI): Ms. Tina Jones is currently employed with Smith, Stevens, Stewart, Silver, and Company. Ms. Jones must have a pre-employment physical before she may begin working. During the interview, she maintains that she has no pressing concerns. Ms. Jones got her yearly gynecological exam at the Shadow Health General Clinic four months ago. She was later diagnosed with POCS, and her gynecologist advised her to use oral contraceptives.

She claims to be putting up with the contraception. The patient also admits to having type 2 diabetes, which she manages through exercise, a good diet, and the prescription metformin, which she was prescribed around five months ago. She denies having experienced any bad drug interactions. The patient claims to be healthy because she takes better care of her body than she did previously and because she is excited about her new job.

Medication: The patient is on Flucotisone propionate 110 mcg twice day, with the last puff administered in the morning. In addition, the patient takes Metformin 859 mg PO twice a day, the last dose in the AM. In addition, the patient takes drospirenone and ethinyl estradiol orally (PO) four times each day, with the last dose taken in the morning. Ms. Jones also uses albuterol spray for her asthma; her most recent use was three months ago. Tina also takes Ibuprofen 600 three times every day to ease period symptoms. Her prescription hadn’t been taken in six weeks.

She is allergic to penicillin, which produces rashes. However, she denies food and latex sensitivities. She admits to having dust and pet allergies. When exposed to her allergens, the patient experiences a runny nose, puffy, itchy eyes, and an exacerbation of her asthma symptoms.

According to Tina’s medical history, her asthma was identified when she was 21/2 years old (PMH). When she is around allergies, such as cats, she utilizes the albuterol inhaler. When her asthma flared up again three months later, she used the same inhaler. Her asthma most recently required hospitalization when she was a senior in high school. She asserts that she was never intubated. She was diagnosed with type 2 diabetes when she was 24 years old.

She began taking metformin five months ago to address her asthma. She initially experienced gastrointestinal adverse effects, but they have since subsided. The patient ensures that daily morning blood sugar readings are taken, with an average value of 90. Her hypertension was managed with diet and exercise. She had never undergone surgery before.

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.

Week 9: Shadow Health Comprehensive SOAP Note Template

SUBJECTIVE DATA:

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Chief Complaint (CC): “I came here because I am required to have a recent physical exam for the health insurance at my new job”

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 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 (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
 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?

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 1

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.

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”
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
assist 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 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)

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/