Comprehensive (Head-to-Toe) Physical Assessment
Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
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
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.
Comprehensive (Head-to-Toe) Physical Assessment
Module 7 Assignment – Head to Toe Write-Up
Patient name and initials: Tina Jones (TJ) Age: 28 Race: African American
Identifying data: TJ is alert and well-groomed, conscious, and can engage in the interview. She recalls her age and also provides other information about herself, such as her medical, social, and family history.
Chief complaint (CC). She needs a head to toe examination, which is a requirement at the new place where she recently got an employment opportunity”
History of presenting illness (HPI): TJ is a 28-year-old African American female that presents to the healthcare facility for a head-to-toe examination. She reports that these findings are required for insurance purposes at the new job that she found with Smith, Stevens, steward, silver, and company. Part of the benefits that she gets includes medical insurance, and therefore, the company requires her updated medical profile, which will be used for insurance purposes. She is in good health and reports that she is feeling fine with no new medical issues. According to the patient, she has a gynecological review where she was diagnosed with the polycystic ovarian syndrome.
Allergies: She reports that she is allergic to cats and explains that exposure to cats causes symptoms such as sneezing and breathing difficulties. She however relieves the symptoms by taking an inhaler. For drug allergies, she reports an allergy to penicillin, which makes her develop rashes and hives. There is no relief for these symptoms and she can only prevent them or wait until they go away. She denies any food allergies and also says she is not allergic to latex.
Medical history: TJ reports has been having asthma, which was diagnosed when she was 2.5 years old. She has been outing in place strategies to manage the condition and this includes avoiding triggers and also using her medication and inhalers.
She was also diagnosed with diabetes mellitus at the age of 4 ad she has been taking different drugs until recently when metformin was prescribed for her.
TJ has also been diagnosed with PCOS after a history of dysmenorrhea, which made her have very painful menstrual cramps. The gynecologist that examined her recommended the use of a contraceptive known as YAZ.
Family History: Both of her parents had diabetes, and high cholesterol, but the father also had high blood pressure before he died at the age of 58. The mother is still alive and is managing the condition well. Her sister has asthma and she is only 14 while her brother who is 25 years has no medical issues but is overweight. Her paternal grandmother was diagnosed with high cholesterol and blood pressure and is still alive at the age of 82, while her paternal grandfather had colon cancer, high blood pressure, and diabetes mellitus, and he died at the age of 65. She lost her maternal grandmother to a stroke at the age of 73.
Social History: TJ is not married and does not have children. She has been independent since she was 19 years old, although she is currently living with her mother and sister but wants to move out soon. She is to begin working with Smith, Stevens, Stewart, Silver, & Company. Some of her hobbies include volunteering in church activities and engaging in bible study. She is an active member of her church and enjoys spending time with her family who she describes as being her greatest support system alongside her church. She is an occasional social drinker but denies the use of tobacco. She has a history of taking cannabis, but she stopped at the age of 21. Her eating habits are generally good but she reports taking 1-2 sodas daily. TJ has been in previous relations and she confirms that she recently started a new one. She however reports that she is taking time before she can be sexually active. However, the two have taken the HIV test, but she still insists on using condoms when they get intimate. She is physically active takes walks and as a form of exercise. Occasionally, she goes swimming too.
Mental health history: She is in a pleasant mood and is coherent in her speech. TJ was experiencing sleeping difficulties but reports that in the recent past, she as better coping skills in addition to reduced stress levels. She denies sadness and depression.
Review of systems
General: apparent weight loss attributed to exercise, no fever, and no headaches
HEENT:
Vision: denies changes in vision or blurring as well as irritation
Hearing: denies ear discharge or hearing changes
Nose and Throat: no runny nose, no sore throat, no loss of smell,
Mouth: no swelling, no dysphagia, no loss of taste. No dental issues
Skin: No rashes, no lesions, no itching.
Cardiovascular: Denies chest pain and chest pressure,
Respiratory: No shortness of breath, cough, or sputum.
Gastrointestinal: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
Genitourinary: no pregnancy, no changes in urine color, frequency, and pain. LMP is not provided.
Neurological: No headache, dizziness, no numbness in the extremities.
Musculoskeletal: No muscle, back pain. Denies joint pain.
Lymphatics: No enlarged nodes. No history of splenectomy.
Psychiatric: No history of depression or anxiety.
Endocrinologic: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Allergies: Allergic to penicillin and cats which cause hives and breathing issues respectively.
Objective Data
Vital signs
Temp 37.2 RR 15 BP pain level 0/10 Height: 170 cm Weight: 84 kg BMI: 29
HEENT:
General: the patient is alert and well-groomed.
HEENT:
Eyes: normal eyelids
Mouth: mouth moist tonsils 2, normal gag reflex present
Nose and throat: No rhinorrhea, no postnasal drainage
Respiratory: clear lung sounds and symmetrical expansion
Cardiovascular: No edema, PMI non-displaced, pulses 2+ in all areas. Normal sinus rhythm, no changes in ST. the heart rate is regular and there are no murmurs.
Lymphatic: No swollen lymph nodes, no palpations on lymph nodes.
Abdominal: no bruises or lesions, no visible masses, or scars on the abdomen.
Skin: normal skin, acanthosis nigricans on the neck
Hematologic: No chills, no fevers, no night sweats, No light-headedness, no dizziness,
Musculoskeletal: ROM in all areas, perfect muscle strength, and no tenderness.
Neurologic: bilateral strength in the upper and lower extremities s 5/5
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