Assignment 3: 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

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

SUBJECTIVE DATA:

Chief Complaint (CC): “I have come to the unit because I am needed to have a recent physical examination report for the healthcare insurance for my newly acquired job.’

History of Present Illness (HPI): Ms. J is a 28-year-old client that came to the unit for a physical examination report, as her new employer needs it for healthcare insurance. Ms. J reports during the encounter that she has secured an employment at Smith, Stevens, Stewart, Silver & Company. The company requires her to undergo a pre-physical examination before Ms. J begins working with them. Ms. J denied any acute concern during this visit to the hospital. She reports that she visited the hospital for physical examinations four months ago when she had gone for her yearly gynecological examination at the Shadow Health General Clinic. Ms. J reported that she was diagnosed with polycystic ovarian syndrome during this visit and was prescribed to use oral contraceptives, which she has been tolerating them well. Ms. J further reported that she has type 2 diabetes mellitus, which she currently controls with metformin, diet, and exercise. She was diagnosed with diabetes five months ago and reports no side effects with metformin. The self-reported health and wellbeing of Ms. J is that she is healthy and engaging in healthy behaviors and lifestyles, as a way of promoting her health. She is excited and looking forward to starting her job with the new organization.

Medications: Ms. J is currently using and has used a number of medications. They include the following:

Metformin 850 mg PO BID (she lastly used it this morning)

Fluticasone propionate 110 mcg 2 puffs BID (she lastly used it this morning)

Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (lastly used three months ago)

Drospirenone and ethinly estradiol PO QD (lastly used this morning)

Acetaminophen 500-1000 mg PO prn (headaches)

Ibuprofen 600 mg PO TID prn (for menstrual cramps, lastly taken 6 weeks ago)

 

Allergies: Ms. J reported history of drug allergy. She is allergic to penicillin, as it causes rash. She denies any history of food or latex allergies. She however reports that she is allergic to dust and cats. She reports that her exposure to dust or cats causes her running nose, swollen eyes, itchiness, and increase in the symptoms of asthma.

 

Past Medical History (PMH): Ms. J has significant medical histories. She has history of asthma that she was diagnosed with at the age of two and half years. She reports that she managers asthma symptoms using albuterol inhaler whenever she is exposed to allergens that include dust and cats. She reports that her last experience of asthma exacerbation was three months ago. She has a history of hospital admission due to asthma when she was in high school. As noted initially, Ms. J has type 2 diabetes mellitus. She was diagnosed with it when she was 24 years old. She currently manages the diabetes using metformin, which she started taking five months ago. She reports that she experienced gastrointestinal side effects at the beginning due to metformin but has dissipated since then. She reports that she monitors her blood glucose levels on a daily basis with the average reading being in the range of 90. Ms. J also has a history of hypertension. She reports that she normalized the elevated blood pressure by engaging in regular physical activity and dietary modifications.

Past Surgical History (PSH): Ms. J denied any history of surgeries.

Sexual/Reproductive History: Ms. J reported that her menarche was when she was 11 years old. Her first sexual encounter was when she was 18 years old. She identified that she has sex with men, hence, heterosexual. She denied any history of pregnancy or pregnancy loss. She noted that her last menstrual period was two weeks ago. She has a diagnosis of polycystic ovarian syndrome that was reached in the last four months during her annual gynecological visit. Ms. J reported experiencing moderate menstrual bleeding that last five days since she started using Yaz. Ms. J also reported that she is in a new relationship with a male that she has not engaged in any sexual relationship or contact. She expressed her intention to start using condoms with her boyfriend. She reported further that she tested negative for STIs and HIV/AIDS four months ago when she came for her annual gynecological visit. There was no history of sexually transmitted infections.

 

Personal/Social History: She denied any history of marriage and children. She has been living alone since the age of 19. She however lives currently with her sister and mother and is planning to relocate to live on her own in a month’s time. Ms. J reported that she is expected to report in her new place of work in two weeks’ time. She denied any recent travel to foreign countries. She does not have pets. She denied any history of psychiatric problems such as anxiety, suicidal thoughts, attempts, or plans, and depression. She appeared alert and oriented to self, others, time, events, and place. She also appeared well groomed for the occasion, engaged easily in the conversation, cooperative with pleasant mood. She did not demonstrate any abnormal behaviors such as tics, tremors, or facial fasciculation. The speech was or normal volume, rate, fluency, and clarity.

Health Maintenance: Ms. J reported using health promotion services. Her last pap smear screening was four months ago during her annual gynecological visit. She reported that she went for eye examination three months ago. She also reported that her last dental examination was five months ago. She took a tuberculosis test two years ago, which turned negative. Information about safety practices was obtained during the assessment. She reported that she has some detectors in their home, wears seatbelt whenever driving, and do not ride a bicycle. She reported using sunscreen. She has history of handling her father’s gun that is always locked in his room. Ms. J engages in mild to moderate physical activity at least four to five times on a weekly basis. The physical activity comprises of swimming, walking or yoga. She acknowledged that engaging in physical activity has helped her manage stress and improve her sleeping difficulties.

            When asked about her hobbies, Ms. J reported that she enjoys spending her time with friends, attending Bible study sessions, reading, and volunteering in her local church. She also reported that she enjoys dancing. She reported being an active member in her church. She attributed it to the influence of her family. She identified her family to be her source of social support. She also identified that church and her family helps her in coping with stressful situations. She denied history of tobacco use. She reported history of cannabis use since when she was 15. She stopped using it at age of 21. She denied use of methamphetamines, cocaine, and heroin. She reported occasional use of alcohol when she is with friends. The frequency of alcohol use was reported to be 2-3 times in a monthly basis. When asked about her dietary habits, Ms. J reported that her breakfast often comprises of fruit smoothie with sugar-free yoghurt. Her lunch comprises of sandwich on low-fat pita or wheat bread or vegetables with brown rice. Her dinner comprises of a protein and roasted vegetables, with carrot or apple snack. Ms. J denied use of coffee but acknowledged that she drinks 1-2 sodas on a daily basis.

 

Immunization History: Her immunization history showed that she received Tetanus booster jab within the last year, with her influenza vaccination not being current. She reported that she has not received human papillomavirus vaccine. She noted that she believes that her childhood vaccinations are up to date. She received meningococcal vaccine when she was in college.

Significant Family History: Ms. J has significant family histories. They include the following:

Mother: diagnosed with hypertension and elevated level of cholesterol. She is currently aged 50 years

Father: He is deceased through a car accident one year ago at the age of 58 years. He had hypertension, type 2 diabetes, and cholesterol.

Bother: aged 25 years and is overweight

Sister: she aged 14 years old and has asthma

Maternal grandmother: she died at the age of 73 years due to stroke. She had a history of high cholesterol and hypertension.

Paternal grandmother: Still alive, aged 82 years, and living with hypertension

Paternal grandfather: died at the age of 65 years due to colon cancer and a history of type 2 diabetes mellitus

Paternal uncle: suffers from alcoholism

Ms. J denied other cancers, mental illnesses, kidney disease, thyroid disorders, sickle cell anemia, and sudden death in the family.

Review of Systems:

General: Ms. J appears well groomed for the occasion. There are no signs of weight loss. She denied fatigue, weakness or recent illness. She also denies pain. She however reports that she feels that she has lost some weight due to her adoption of healthier lifestyles.

HEENT: Ms. J denies headaches. She uses corrective lenses. She denies changes in her vision since undergoing eye examination four months ago. She denies hearing loss, tinnitus or loss of body balance. She reports history of ear infection during her childhood period. She denies changes in taste or sense of smell. She also denied difficulty in swallowing. She reports that she underwent dental examination five months ago.

Respiratory: Ms. J reports history of asthma with its exacerbations experienced three months ago. She denies shortness of breath, wheezing, dyspnea, or coughing.

Cardiovascular/Peripheral Vascular: Ms. J denies palpitations, chest pains, arrhythmia or edema. She has history of hypertension.

Gastrointestinal: Ms. J denies any abdominal tenderness, swelling, pain, or changes in bowel movements. She also denies bloating, diarrhea, and stool stained with blood.

Genitourinary: Ms. J denies any changes in frequency and urgency of urinary bladder, dysuria, or passage of blood stained urine. She also denies changes in the smell or color of urine. She also denies any history of urinary tract infections.

Musculoskeletal: Ms. J reports history of right foot injury after she slipped off a stepping stool. She experienced gait problems after the injury. She denies any current gait problems. She also denies muscle weakness, pain and limited range of motions.

Neurological: Ms. J is alert and oriented to others, place, time, events, and space. She has clear, coherent speech. Her level of judgment is intact. She denies tingling sensations, numbing or decline in the level of sensation.

Psychiatric: She denies any history of psychiatric problems such as depression, anxiety, and suicidal thoughts, plans, or intentions.

Skin/hair/nails: Ms. J reports that acne has improved as well as the excessive growth of hair in the body since she used Yaz. She denies brittle nails or hair as well as changes in moles.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Temp 37.2 C, HR 78, RR 15, BP 128.82, SPO2 99% room air, denies pain, height 170 cm, weight 84 kg, BMI 29, Random blood glucose 100 mg/dl

General: Ms. J appears appropriately dressed for the occasion. She denies fever, fatigue, and pain.

HEENT: The head is normocephalic with absence of evidence of trauma. She has bilateral eyes with equitable distribution of hair on the eyebrows and eyelashes. There is the absence of lesions, edema, or ptosis in the eyes. The conjunctiva appears pink without lesions. The sclera appears white with bilateral PERRLA. Extra-ocular muscles are intact with absence of nystagmus. There is the presence of mild changes in retinopathy on the right eye. The left fundus has sharp disc margins with no signs of hemorrhage. Snellen score is 20/20 for both eyes when the patient is using corrective lenses. There is the presence of positive light reflect. She hears whispered words bilaterally. The maxillary and frontal sinuses are not tender on palpation. The nasal mucosa appears pink with midline septum. The oral mucosa appears moist with the absence of lesions or ulcerations. There is midline rising of the uvula on phonation. The gag reflexes are intact. The dentition is normal with absence of signs of infection or dental caries. The thyroids are normal with absence of goiter or nodules. There is the absence of lymphadenopathy.

Neck: Absence of prominent veins raised jugular vein pressure, neck rigidity, and lymphadenopathy.

Chest/Lungs: The chest rises symmetrically with respirations with clear auscultation bilaterally. There is the absence of cough, wheezes, or labored breathing. There is the presence of resonance on percussion. The office spirometry results shows FVC of 3.91 L and FEV1/FVC ratio of 80.56%

Heart/Peripheral Vascular: Presence of regular heart rate with absence of adventitious heart sounds. The bilateral carotids are equal with the absence of bruit. The PMI is at the mid-clavicular line, with absence of lifts or heaves. The bilateral peripheral pulses are equal with capillary refill of less than 3 seconds. There is the absence of noticeable peripheral edema.

Abdomen: The abdomen is protuberant, symmetrical without visible scars, masses, or lesions. The client has normoactive bowel sounds in the four quadrants. There is tympanic in percussion of all the quadrants. Tenderness and guarding upon palpation are absent. Organomegally and CVA tenderness are absent.

Genital/Rectal: Not assessed, as no abnormalities or complaints were raised. 

Musculoskeletal: There are bilateral upper as well as lower extremities without evidence of masses, swelling, deformities or tenderness. The extremities have full range of motions. The client does not demonstrate any signs of pain with movement.

Neurological: The upper and lower extremities have 5/5 bilateral strength. The client has normal stereognosis, graphesthesia, and alternation of bilateral movements of the upper and lower limbs. The cerebellar function tests are normal. The muscle strength reflexes are equal bilaterally in the upper and lower extremities. There is the reduction in sensation to monofilament in the bilateral plantar surfaces.

Skin: The client has scattered facial pustules as well as facial hair on her upper lip. There is acanthosis nigricans on the posterior neck of the client.

Diagnostic results: Diagnostic investigations are not indicated because the client came for basic physical as well as health examination. The examination is needed prior to her employment in the new organization.

ASSESSMENT: Ms. J has come to the unit for a general physical examination, as a requirement by her new employer. She is currently using medications that include Flovent, Proventil, and metformin. She wore classes during the examination. She reports high tolerability for diabetes medication. She also uses other interventions such as exercise and dietary modification for diabetes management. She monitors the blood glucose level on a daily basis. She also has a history of asthma that is controlled using an inhaler. She is in a relationship and considers using condom in her sexual encounters with her boyfriend. She is on birth control to help her in the management of polycystic ovarian syndrome.

 

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

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.
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.
ï‚· 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.

ï‚· Access and login to Shadow Health using the link in the left-hand navigation of the
Blackboard classroom.
ï‚· 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:
ï‚· 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
ï‚· Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment
in Shadow Health via the Shadow Health link in Blackboard.
ï‚· 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.
ï‚· (Note: Please save your lab pass as “LastName_FirstName_AssignmentNameâ€.) You
can find instructions for downloading your lab pass
here: https://link.shadowhealth.com/download-lab-pass
ï‚· 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.
ï‚· 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.

ï‚· Chapter 7, “Mental Statusâ€
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.

ï‚· ·Chapter 23, “Neurologic Systemâ€
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 Changesâ€
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 Adultsâ€
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, “Dizzinessâ€
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, “Headacheâ€
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 Problemsâ€
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.
ï‚· 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/