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.
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. 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.
Age 28 years
History of Present Illness
The chief complaints from the patient included headache and neck stiffness.
When asked about the onset of the present illness, neck and head pain began just a few days after a minor fender lot collision a week ago. Five days ago, to be precise.
Pain at the back of the neck on both sides was the patient’s primary location of the neck stiffness complaint. For headaches, the location was the crown of the head.
The patient reported the duration of the headache to be between one to two hours every day. However, when questioned about neck pain, the patient confirmed that the pain is constant throughout.
According to the patient, the main characteristics are stiffness and sourness of the neck, reporting three out of ten pain levels. In addition, the patient complained of dull headaches that occur every day with pain levels of three out of ten.
Some of the aggravating factors of the chief complaints included movement for neck pain. The patient reported that pain usually aggravates during the daytime for the headache.
When asked about factors that relieve pain, the patient reported that taking Tylenol helps to reduce the severity of the neck pain. There was no identified relieving factor for the headache.
Current treatment and interventions for the chief complaints included taking Tylenol as well as the limiting movement of the neck and the head in general.
The patient reported taking medications to help her relieve the symptoms. The first medication was three tablets of Advil, each two hundred milligrams. Advil frequency of administration was three times a day. The length of time used for this medication was unknown. However, the identified reason for the use was cramps. The patient also reported taking two Tylenol tablets, each three hundred and sixty-five milligrams, four times a day. The identified time of use for Tylenol was seven days. The main factors for its use were daily neck and headache pain. In addition, the patient was taking two 90mcg puffs of Proventil inhaler since she was two and half years old. Other medication included two puffs of 44mcg Flovent twice a day.
Past Medical History
Hospitalized: for recent foot wound and asthma attacks
Immunization: up to date
Surgeries: No major surgeries were reported
Occupation: Mid-American Copy & Ship supervisor
Hobbies: Watching documentaries, free talks at church, and reading
Denies changes in sleep or more significant drowsiness or yawning;
Denies financial load from the automobile accident; and reports wearing a seatbelt at the time of the accident.
Denies to acknowledge the role that drugs or alcohol played in the collision, denies that headaches and neck pain are interfering with daily activities
Denies to acknowledge the existence of any head injuries sustained in the collision and refuses to acknowledge the presence of pain radiating to the shoulders, back, or arms.
Denies family history of Parkinson’s disease, migraine, and seizures
Dad & Grandfather: Diabetes mellitus
Grandfather: colon cancer
Mom & Dad: Hypertension and Hypersensitivity Lung Disease
Sexual History: No pregnancy. Not lactating. Sexually active. No contraceptives
Mental Diagnosis: No mental history of depression or anxiety
Violence History: No safety concerns
Review of Systems
GENERAL: Positive for weakness. Denies weight loss
Head: positive for headaches
Eyes: Right eye visually deficient 20/40.
Ears: Denies hearing loss
Nose: Denies runny nose
Throat: No sore throat.
SKIN: No itching or rash.
CARDIOVASCULAR: Denies chest pain and pressure.
RESPIRATORY: Denies cough and shortness of breath.
GASTROINTESTINAL: Denies vomiting, nausea, anorexia, or diarrhea as well as abdominal pain.
GENITOURINARY: Denies increased urination
NEUROLOGICAL: Reports headache and dizziness.
MUSCULOSKELETAL: Positive for head back pain and neck stiffness.
HEMATOLOGIC: Negative for anemia.
LYMPHATICS: Denies history of splenectomy.
PSYCHIATRIC: Denies depression or anxiety history.
ENDOCRINOLOGIC: Denies polydipsia or polyuria
REPRODUCTIVE: Sexually active. Denies pregnancy.
ALLERGIES: Positive history of asthma.
Blood Pressure: 110/65
T: 97.8 F,
GENERAL: No acute distress.
SKIN: Skin rashes absent.
HEENT: Right eye visually deficient 20/40
NECK: Neck stiffness present.
CARDIAC: Regular heart rate.
PULMONARY: Wheezes are absent.
GI: Bowel sounds are active.
GU: Genitalia discharge absent
Extremities: No edema
NEUROLOGICAL: Numbness absent.
MUSCULOSKELETAL: Neck pain present.
HEMATOLOGIC: anemia absent.
LYMPHATICS: Nodes are not enlarged.
PSYCHIATRIC: No splenectomy.
ENDOCRINOLOGIC: No increased sweating.
REPRODUCTIVE: Pregnant absent.
ALLERGIES: Asthma present.
Assessment and Diagnostic Results
Right eye inspection: Twenty out of forty
Sprain of ligaments of cervical
spine, initial encounter
Sprain of ligaments of cervical
spine, initial encounter
Sprain of ligaments of the cervical spine, initial encounter: Neck pain 3/10
Concussion without loss of consciousness, initial encounter: Acute headaches, usually during the daytime. Acute neck sourness and stiffness worsening with movements
Acute Post Traumatic Headache: Neck Stiffness and severe headache. Headache is located in the crown and back of the head. Headache occurs twice a day. Neck pain lasts between one and two hours.