Feb 23, 2024 Assignment 3: Digital Clinical Experience: 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
SUBJECTIVE DATA:
Chief Complaint (CC): ‘My right foot hurts’
History of Present Illness (HPI): The patient in the case study comes to the clinic with complains of a painful, swollen, red, warm scrape on her right foot for the last two days. The patient thought it would heal on its own but has been worsening over time. The patient reports that the pain worsened over the last two days. The patient sustained the injury a week ago while going down the back steps when she tripped and twisted her ankle. She also scrapped her foot on the edge of the step. The patient went to the ER an hour after falling because of the strained ankle. The x-ray performed was normal. She was prescribed pain medications.
The patient rates the pain 7/10 in the pain rating scale. She reports that the scrape is infected and worsening. The patient describes the pain as throbbing. It is associated with sharp pain when weight is applied. The pain radiates to the ankle. The patient reports that the affected foot is non-weight bearing. The patient reports that the wound drains pus, white in color, for the last two days. She has been treating the wound at home by cleaning twice daily and bandaging it. She has been cleaning it with soap, water, and some peroxide if irritated. She has also been applying Neosporin ointment twice daily. The problem has affected her functioning ability since she has missed her work because of the pain. She has also missed her class two days ago. Besides the current problem, she reports losing 10 pounds unintentionally, being thirsty, experiencing oliguria and polyphagia for the past month.
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Medications: She currently uses Proventil inhaler if symptoms of asthma persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management.
Allergies: She develops asthma symptoms when she is near cats. She is also allergic to dust and develops asthma symptoms with intensive physical activity. She is also allergic to penicillin.
Past Medical History (PMH): The patient was diagnosed with diabetes type 2 at the age of 24 years. She is also asthmatic since the age of two and half years. Her last asthmatic attack was when she was in high school. She developed breathing problems three days ago at her cousin’s place. She has a history of using Metformin, which she took it three years ago. The patient has history of five hospitalizations when she was 16 years because of asthma. She has a history of using nebulizer.
She manages asthma by avoiding triggers but uses Proventil inhaler if symptoms persist. She last used her inhaler three days ago. She is prescribed two puffs of inhaler, but at times needs three puffs for symptom management. She has also been using tramadol 100 mg three times a day for pain for the last two days. She takes Advil when her cramps het bad and Tylenol for headache.
Past Surgical History (PSH): The patient denies any history of surgeries
Sexual/Reproductive History: The patient denies history of sexually transmitted infections
Personal/Social History: The patient is a student currently finishing her bachelor’s degree in accounting. She lives with her mother and her sister. She is worried about her right foot. The patient denies barriers in accessing healthcare. Her family and church are her social support systems.
Immunization History: The patient believes that she received her childhood immunizations. She did not get her flu shot this year. Her tetanus booster was a year ago.
Health Maintenance: The patient reports that she started watching her sugar and avoiding regular
Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment
soda after she found out that she is diabetic. She only drinks diet coke. She rarely checks her sugars, with the last time being a month ago. She does not understand the meaning of blood glucose numbers. She rarely checks her blood pressure. She stopped taking Metformin because of its side effects and feeling overwhelmed remembering to take the pills and checking her blood sugar. Her typical breakfast comprises muffin or pumpkin bread obtained from a nearby café. Her typical lunch is a meal she usually picks from a nearby campus or subway to get turkey sandwich. Her typical dinner is meatloaf, pasta, casseroles, and chicken.
Her typical snacks include pretzels and French fries. She does not pay attention to the amount of salt she eats. She drinks about four-diet coke daily. She last took alcohol three weeks ago. She drinks alcohol once or twice a week during night outs. She is exposed to second-hand smoke from her friends. Her last eye and dental examination was when she was a child. She reports doing self-breast examination a couple times. She has never undergone mammography.
Significant Family History: Her mother has high cholesterol and diabetes. Her deceased father had type 2 diabetes, high cholesterol, and hypertension. Grandfather had colon cancer, diabetes, and hypertension. Paternal grandmother has high cholesterol and hypertension. Her sister is asthmatic. Her brother and father are overweight. Her uncle has alcohol addiction problem.
Review of Systems:
Vital signs: Height 170 cm, weight 90kg, BMI 31, Random blood glucose 238, Temperature 101.1F, O2 saturation 99%
General: The patient reports fatigue, fever and chills last night. She denies night sweat or suicidal thoughts.
HEENT: She denies headache, head injuries, changes in hearing, ringing ears, ear pain, and ear discharge. She denies changes in vision, double vision, itchy eyes, watery eyes, and dry eyes. She reports eye pain when she reads for too long. She reports occasional rhinorrhea. She denies sinus pain, changes in sense of smell, nosebleeds, or dental problems. She denies changes in sense of taste, dry mouth, mouth pain, mouth sores, or tongue problems.
Neck: She denies dysphagia, sore throat, lymphadenopathy, voice changes, or neck pain.
Breasts: She denies breast problems, such as pain, lumps, nipple changes, or nipple discharge.
Respiratory: The patient denies wheezing, chest tightness, dyspnea, cough, or chest pain.
Cardiovascular/Peripheral Vascular: The patient denies palpitations, easy bruising, edema, circulation problems, or vascular diseases.
Gastrointestinal: The patient denies nausea, vomiting, stomach pain, changes in bowel movements, heartburn, constipation or diarrhea.
Genitourinary: The patient denies dysuria, urgency, frequency, or history of sexually transmitted infections.
Musculoskeletal: The patient reports right ankle sprain, which is non-weight bearing. She denies fractures.
Psychiatric: The patient denies depression, anxiety, or stress.
Neurological: The patient denies ataxia, numbness, tingling, loss of balance, and difficulties in coordinating movement.
Skin: The patient denies rash. She reports swollen right foot with a wound draining pus.
Hematologic: The patient denies easy bruising or prolonged bleeding
Endocrine: The patient denies heat or cold intolerance. She reports unintentional weight loss, polydipsia, polyphagia, and polyuria.
ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
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.
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 and Grading Information
By Day 7 of Week 9
Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment in
Shadow Health via the Shadow Health link in Blackboard.
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.
(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
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.
Download, sign, date, and submit your Student Acknowledgement Form found in the
Learning Resources for this week.
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.
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 sumit this required part of the Assignment:
Week 9 Documentation Notes for Assignment 3
To Submit your Student Acknowledgement Form:
Submit your Week 9 Assignment 3 DCE Student Acknowledgement Form
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.
Chapter 7, “Mental Status”
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.
·Chapter 23, “Neurologic System”
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 Changes”
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 Adults”
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, “Dizziness”
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, “Headache”
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 Problems”
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.
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/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to Walden
University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for Comprehensive
(Head-to-Toe) Physical Assessment (Word document)
Use this template to complete your Assignment 3 for this week.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic
examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 14, “The Neurologic Examination” (pp. 683–765)
This chapter provides an overview of the nervous system. The authors also
explain the basics of neurological exams.
Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp.
766–786)
In this chapter, the authors provide a list of common psychiatric
syndromes. The authors also explain the mental, psychiatric, and social
evaluation process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi,
K. (2010). Significance of MRI in diagnosis and differential diagnosis of
Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.
Required Media (click to expand/reduce)
Neurologic System – Week 9 (16m)
Online media for Seidel's Guide to Physical Examination
It is highly recommended that you access and view the resources included with the
course text, Seidel's Guide to Physical Examination. Focus on the videos and
animations in Chapters 7 and 23 that relate to the assessment of cognition and the
neurologic system. Refer to the Week 4 Learning Resources area for access instructions
on https://evolve.elsevier.com/
SUBJECTIVE DATA:
Chief Complaint (CC):
“I came in because I’m required to have a recent physical exam for the health insurance at my new job.’’
History of Present Illness (HPI):
Patient is a 28-year-old African American female who came to the facility for a routine physical examination in preparation for her new position at Smith, Stevens, Silver & Company. Patient reports having no acute health problems. The patient takes a well-tolerated birth control medication called drospirenone at the exact same time every day. During the yearly gynecological exam a few months ago, the patient received a PCOS diagnosis and was prescribed drospirenone/ethinyl estradiol.
In addition, the patient takes metformin for her diabetes and uses an inhaler for her asthma. In order to improve her vision, the patient saw an eye doctor and received prescription glasses. Also, the patient regularly checks her blood sugar levels and states that the medication metformin is helping in the management of her diabetes and to due to this condition she engages in exercise and has made dietary changes to further help her.
Medications:
90mcg proventil PRN for wheezing.
P.O 200 mg ibuprofen every 8 hours PRN when she has menstrual cramps.
1 tablet of drospirenone pill taken every day.
P.O 850 mg metformin two times daily.
88mcg flovent twice daily.
Allergies:
Penicillin
Cats
Patient not allergic to any food.
Patient not allergic to latex.
Past Medical History (PMH):
Asthma
Type 2 diabetes
Hypertension
PCOS
Past Surgical History (PSH):
Patient has not had a previous surgical procedure.
Sexual/Reproductive History:
Patient had her last menstrual period 2 weeks ago.
Patient is on a birth control pill known as drospirenone
Patient first engaged in sexual intercourse when she was 18 years old.
Patient sexual preference is to males.
Personal/Social History:
Patient lives with her mother and sister.
Patient consumes alcohol on occasion with her friends.
Patient is about to be employed at Smith, Stevens, Silver & Company.
Patient does not use tobacco.
Health Maintenance:
Patient got a pap smear a few months ago.
3 months ago patient underwent an eye exam.
Patient adheres to her prescribed medication.
Patient has made changes to her diet and lifestyle to help manage her diabetes condition
Immunization History:
Patient received a tetanus booster.
Patient has received all expected immunizations.
Significant Family History:
Paternal grandfather: passed away.
Paternal grandmother: hypertensive and with high cholesterol.
Maternal grandfather: died.
Maternal grandmother: 82 and healthy.
Father: died due to a car accident.
Mother: hypertensive and with high cholesterol.
Brother: overweight.
Sister: asthmatic.
Review of Systems:
General:
She has intentionally lost weight.
She has not been recently ill.
She is not fatigued.
HEENT:
She has not had a head injury.
She has not had ear pain.
She has not had nose problems.
She has not had throat problems.
Respiratory:
She has not had recent breathing problems.
Cardiovascular/Peripheral Vascular:
She has not had palpitations.
She has not had edema.
She has not had chest pain.
Gastrointestinal:
She is not vomiting.
She has not felt nausea.
She is not constipating.
Genitourinary:
She is urinating less at night than before.
She does not have blood in the urine.
She does not feel pain while urinating
Musculoskeletal:
She is not having pain in the muscles.
She is not having pain at the joints.
She is not swelling in the limbs.
Neurological:
She does not get periods when she is dizzy.
She has not had seizures.
She has not experienced loss of coordination.
Psychiatric:
She is not anxious.
She is not depressed.
She is not stressed.
She has no difficulty falling asleep.
Skin/hair/nails:
She has some male-pattern hair growth,
She has no dry skin.
Her acne is improving.
She has no rashes.
OBJECTIVE DATA:
Physical Exam:
Vital signs:
B.P-128/82mmHg
SPo2-99%
H.R- 78 bpm
R.R-15
Temp.-37.2 C
Weight- 90kg
Height- 5’7”
General:
Patient is alert and oriented. Patient is well groomed. Patient is sitted upright without signs of distress. Patient has appropriate hygiene.
HEENT:
Scattered pustules observed on the face and facial hair noted on upper lip.
Eyes have normal reaction to light.
Visual acuity is at 20/20 while using corrective lenses.
Tympanic membrane is pearly grey.
The nasal mucosa is moist and pink
Nasal mucosa moist.
Oral mucosa is without le
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