Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Shadow Health Comprehensive SOAP Note Template
Patient Initials: __T.J_____ Age: 28 years_ Gender: __Female_____
SUBJECTIVE DATA:
Chief Complaint (CC): “ I want a clinical assessment for employment.”
History of Present Illness (HPI): T.J is a twenty-eight-year-old African-American female patient who visited the facility to receive an assessment for re-employment. She reported that her new employers need her to have health insurance, too. She does not have acute health concerns. The patient has been previously diagnosed with POCS and has been using medications that are well tolerated. The patient also has type 2 diabetes, which she manages through an active lifestyle, diet, and metformin.
Medications: Metformin 850 MG po BID Drospirenone and ethinyl estradiol PO QD Albuterol spay that she puffs twice (She last used this medication some three months ago). Acetaminophen 500-1000 mg PO prn for headaches. Ibuprofen for menstrual cramps (She last used this medication some six weeks ago).
Allergies: The patient is allergic to cars and dust. She also develops rashes when she takes penicillin.
Past Medical History (PMH): The patient was diagnosed with asthma when she was one year and six months old. Her last admission to the hospital for asthma last happened while in high school. She had an asthma exacerbation some three months ago. She is currently living with diabetes, which was diagnosed at 24 years old. She developed menarche at eleven years old.
Past Surgical History (PSH): The patient reports no major past surgical procedure.
Sexual/Reproductive History: she reports having sex with men, and she currently has a new boyfriend. She had her first sex at eighteen; however, she has never been pregnant.
Personal/Social History: The patient currently lives with her mother and sisters in an apartment. However, she indicates that she would like to move to her apartment when she starts her new job. She currently has no child. The patient reports liking various activities such as reading, bible studies, and attending church activities. She confessed to having used cannabis from ages fifteen to twenty-one. However, she denies tobacco use. The patient reports that she uses alcohol two to three times a month, especially when in the company of friends. She also takes Diet Coke; however, she denies taking coffee.
Health Maintenance: The patient attends doctor’s appointments as appropriate. Her last eye and dental exams were three and five months ago, respectively. Besides, her last pap smear was carried out four months ago. She was negative for PPD, which was conducted two years ago.
Immunization History: The patient’s childhood vaccine is up to date. Her immunization tetanus and HPV immunizations are current.
Significant Family History: The patient’s paternal and maternal grandparents had high cholesterol and high blood pressure. The paternal grandfather died at sixty-five years of cancer, while the maternal grandparents died of a stroke. The paternal grandmother is alive and is currently eighty-two years old.
Review of Systems:
General: She denies unintentional weight loss, fatigue, or fever.
HEENT: She denies any head injury or headache. No eye pain, itchy eyes, redness, or dry eyes. No acute visual changes. She puts on corrective lenses. Reports no changes in hearing. No ear pain or discharge. No change in the sense of smell. No sneezing, sinus pressure, or pain. Denies any issues with mouth. No difficulty in swallowing, sore throat, voice changes, or swollen nodes
Respiratory: Normal breath. Denies wheezing, chest pain, dyspnea, or cough.
Cardiovascular/Peripheral Vascular: No palpitations, tachycardia, easy bruising or edema.
Gastrointestinal: No diarrhea, pain, constipation, vomiting, or nausea
Genitourinary: no vaginal itching or discharge, no flank pain, hematuria, polyuria, nocturia, or dysuria
Musculoskeletal: No muscle swelling or weakness. No joint or muscle pain.
Neurological: Denies dizziness, tingling, light-headedness or seizures. No loss of coordination or notable loss of sensation. Denies sense of disequilibrium, no loss of sensation or coordination.
Psychiatric: Denies any mental health complications such as depression.
Skin/hair/nails: Reports that the oral contraceptives have led to improved acne. The skin has stopped darkening at the neck region, and facial and body hair has improved. She reports few moles but no other hair or nail changes.
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 appropriately dressed. She is also alert and oriented in person, place, and time. The patient has no immediate distress.
HEENT: Normocephalic head and atraumatic as well. Bilateral eyes with equal hair distribution on lashes and eyebrows, 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 is moist and pink, septum midline. Oral mucosa is 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: Normal with no complications noted.
Chest/Lungs: Symmetric chest. The lungs are clear, whilst voice occurs in all areas. Percussion produced resonance throughout. In-office spirometry: FVC 3.91, FEV1.FVC ration, 80.56%
Heart/Peripheral Vascular: 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: The abdomen is protuberant, symmetric without visible masses, scars, or lesions, and coarse hair from the pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation
Genital/Rectal:. No organomegaly. No CVA tenderness
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 has facial hair. The posterior neck has acanthosis nigricans. Nails are free of ridges or abnormalities.
Diagnostic results:
ASSESSMENT:
- Polycystic ovary syndrome: This is a condition known to be a hormonal disorder, and it impacts individuals with ovaries, especially during their reproductive years (Deswal et al.,2020). The condition can present with various symptoms. One of them is the presence of acanthosis nigricans, which the patient presented with. She was also diagnosed with this condition earlier, which makes it one of the conditions.
- Acne vulgaris: This is a condition that is known to present with various symptoms, such as pustules, papules, blackheads, and whiteheads. While it mainly affects the face, the condition can also affect other body parts (Habeshian & Cohen, 2020). The patient presented with pustules on the face, making this one of the possible conditions.
- Type 2 diabetes: Type 2 diabetes is another potential condition. It is known to mainly present with enhanced blood sugar levels. The patient was diagnosed with this condition at twenty-four and has been using various strategies to manage the condition. The clinical findings also show the presence of acanthosis nigricans, which can be an indication of insulin resistance (Sacerdote et al.,2019).
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Deswal, R., Narwal, V., Dang, A., & Pundir, C. S. (2020). The prevalence of polycystic ovary syndrome: a brief systematic review. Journal of Human Reproductive Sciences, 13(4), 261. https://doi.org/10.4103%2Fjhrs.JHRS_95_18
Habeshian, K. A., & Cohen, B. A. (2020). Current issues in the treatment of acne vulgaris. Pediatrics, 145(Supplement_2), S225-S230. https://doi.org/10.1542/peds.2019-2056L
Sacerdote, A., Dave, P., Lokshin, V., & Bahtiyar, G. (2019). Type 2 diabetes mellitus, insulin resistance, and vitamin D. Current Diabetes Reports, 19, 1-12. Doi: 10.1007/s11892-019-1201-y
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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.
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.
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 | ||||||