Week 9 – assignment 3: digital clinical experience: comprehensive

6/12/2018 Comprehensive Assessment | Completed | Shadow Health

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Comprehensive Assessment Results | Turned In
Advanced Health Assessment – Chamberlain, NR509-April-2018

Return to Assignment

Your Results Lab Pass Lab Pass

Started: Jun 10, 2018 | Patient Exam Time: 448 min

Transcript

Greet
06/10/18 3:17 PM

CDT

Question
06/10/18 3:17 PM

CDT

Question
06/10/18 3:17 PM

CDT

Question
06/10/18 3:18 PM

CDT

Overview

Transcript

Subjective Data Collection

Objective Data Collection

Documentation

Plan My Exam

Self-Reflection

Interview Questions (256)Interview Questions (256) Statements (33)Statements (33) Exam Actions (445)Exam Actions (445)

Hello my name is Sara and FNP student I will be conducting yourHello my name is Sara and FNP student I will be conducting your
interview todayinterview today

Hey.

What is your nameWhat is your name

Tina Jones.

Your date of birth?Your date of birth?

February 17th.

And how old are you?And how old are you?

I’m 28.

All Lines (734)All Lines (734)

6/12/2018 Comprehensive Assessment | Completed | Shadow Health

https://chamberlain.shadowhealth.com/assignment_attempts/3569767 2/36

Question
06/10/18 3:23 PM

CDT

Question
06/10/18 3:23 PM

CDT

Question
06/10/18 3:26 PM

CDT

Empathize
06/10/18 3:27 PM

CDT

Question
06/10/18 3:28 PM

CDT

Question
06/10/18 3:28 PM

CDT

Question
06/10/18 3:29 PM

CDT

What brought you into the clinic today?What brought you into the clinic today?

I came in because I’m required to have a recent physical exam for
the health insurance at my new job.

Do you have any current health problems?Do you have any current health problems?

I don’t have anything specific going on today. I mean, I still have
asthma and diabetes, but both of those are under control. I’m taking
good care of my health these days.

Where is your new job? (Clarified to what is your new job.)Where is your new job? (Clarified to what is your new job.)

I’m going to be an Accounting Clerk at Smith, Stevens, Stewart,
Silver & Company. I’ll be helping a more experienced accountant
with her clients, and then eventually I’ll get more responsibility, and
build my own client list. I start in two weeks–I’m really excited!

That is great that you are excitedThat is great that you are excited

Thanks.

When was your last physical?When was your last physical?

Let’s see… I had two doctor’s appointments earlier this year. About
five months ago, I came in he

Week 9

Shadow Health Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic results:

ASSESSMENT:

PLAN:
This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

© 2021 Walden University, LLC Page 2 of 3

© 20

21

Walden University

, LLC

Page

1

of

2

Week 9

Shadow Health Comprehensive SOAP Note Template

Patient Initials: _______

Age: _______

Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past

Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/

Social History:

Health

Maintenance:

Immunization History

:

Significant

Family History:

Review of Systems:

General: <

Assignment 3: 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.

Assignment Instructions

· Review this week’s Learning Resources, and review the Physical Examination Objective Data Checklist (See Attachment)

· Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment to complete this week assignment.

· Please review the attached transcripts for information to complete the assignment.

Assignment 3: 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 independe

ntly 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.

Assignment Instructions

·

Review this week’s Learning Resources, and

review the Physical Examination

Objective Data Checklist

(See

Attachment

)

·

Review the DCE (Shadow Health) Documentation Template for Comprehensive

(Head

–

to

–

Toe) Physical Assessment

to complete th

is week assignment

.

·

Please review t

he atta

ched

transcript

s

for information to complete

the

assignment

.

Assignment 3: 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 Ex

2

Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Seidel
: Mosby’s Guide to Physical Examination,
7
th

Edition

Checklists – Physical Exam

Physical Examination—Objective Data

VS

TPR, BP, Ht, Wt

G
eneral
A
ppearance

Age, race, gender, posture and gait

M
ental
S
tatus

Consciousness, cognitive ability, memory, emotional stability, thought content, speech quality

S
kin

Color, integrity, hygiene, turgor, hydration, edema, lesions, hair distribution and texture, nail texture, nail base angle

H
ead

Scalp, temporal arteries, deformities

N
eck

Trachea (position, tug), range of motion (ROM), carotid bruit, jugular venous distention (JVD), thyroid, lymph (head and neck)

E
yes

Pupils (PERRLA), eyelids, conjunctivae, sclerae, EOMs (CN III, IV, VI), light reflex, visual fields, funduscopy (CN II), acuity (CN II), nystagmus

E
ars

Deformities, lesions, discharge, otoscopy (canal, TM), hearing (Rinne, Weber, CN VIII)

N
ose

Mucosa, septum, turbinates, discharge, sinus area swelling or tenderness

M
outh
and

T
hroat

Lips/teeth/gums, tongue (CN XII), mucosa, palates, tonsils, exudate, uvula, gag reflex (CN IX, X)

C
hest/
L
ungs

Shape, movement, respirations (rate, rhythm), expansion, accessory muscles, tactile fremitus, crepitus, percussion tone, excursion, auscultation (clear, wheeze, crackles, rhonchi, rubs)

B
reasts

Contour, symmetry, nipples, areolae, discharge, lumps/masses, lymph (axillary, supraclavicular, and infraclavicular)

H
eart

PMI, lifts, thrills, rate, rhythm, S1, S2, splitting, gallops, rubs, murmurs, snaps

B
lood
V
essels

Cyanosis, clubbing, edema, peripheral pulses, skin, nails

A
bdomen

Contour, symmetry, skin, bowel sounds, bruits, hum, liver span, liver border, tenderness, masses, spleen, kidneys, aortic pulsation, reflexes, percussion tone, costovertebral angle (CVA) tenderness, fem

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