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NURS 6512 Assessing The Neurologic System

NURS 6512 Assessing The Neurologic System

Patient Information:

R.R., 47 years, Male, African American

S.

CC (chief complaint) ‘headache’

HPI: R.R. is a 47-year-old African-American male who came to the facility with complaints of headaches for the last ten days. The patient reports that the headaches diffuse all over his head but the greatest intensity and pressure occur above the eyes and spread through the nose, jaw, and cheekbones. The patient described the pain as dull, with intense pressure. The associated symptoms include nausea. The onset of the headache varies. He reported that taking Tylenol and avoiding strenuous activities relieve the headaches. He rates pain severity as 7/10 on the pain rating scale.

Current Medications: R.R. reported that he has been taking oral Tylenol 1gm thrice daily for the headaches. He denied any other current use of medications.

Allergies: R.R. reported seasonal allergies. He is also allergic to penicillin. He developed acute respiratory distress the last time he was administered with penicillin at the age of 11 years old. He denied food allergies.

PMHx: R.R. was admitted to the hospital at the age of 35 due to pneumonia. He underwent an appendectomy 10 years ago. His immunization record is up-to-date.

Soc Hx: R.R. is a truck driver. He is married with three children. He lives with his spouse and one child in a rented apartment. His other children are in college. R.R. reports that he stopped taking alcohol ten years ago. He denied tobacco use. R.R. engages regularly in active physical activities. He uses seat belts when driving. They live in a clean community.

Fam Hx: R.R.’s grandfather died of coronary artery disease. His grandmother, aged 90 years has dementia. His wife has controlled hypertension. His mother died of breast cancer.

ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, or sore throat. Reports rhinorrhea for the last five days

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough, or sputum. GASTROINTESTINAL:  Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Denies burning on urination, urgency, and frequency

NEUROLOGICAL:  Reports dull headache. He denies dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding, or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies a history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Reports seasonal allergies.

O.

Physical exam:

Vitals: BP 127/82, P 84, RR 21, T 99.9F, SPO2 96% room air,

General: R.R. is dressed appropriately for the occasion. He is alert and oriented to himself, time, others, and events. He denies chills, fever, and fatigue.

HEENT: Head: The head is atraumatic with normal hair distribution. There are no altered facial features such as drooping and tremors. Frontal sinuses tender to palpation. Ears: Ears are symmetric, with no erythema and bulging tympanic membranes. Eyes: The sclera is clear with no discharge and normal pupil reaction to light. Nose: There is mild rhinorrhea with no nasal flaring, septum deviation, or crusts. Throat: There is no tonsillitis or exudate. There is post-nasal drainage. Neck: There is no neck rigidity, masses, or webbing.

Cardiovascular: There are regular heart rate and rhythm with no adventitious heart sounds and peripheral edema.

Respiratory: There are clear lung sounds over all fields with no adventitious sounds

Neurological: R.R. responds appropriately to the questions asked. He is alert and oriented to himself, others, time, place, and event. His pupils reach equally to light. He has equal grip strength. His balance and posture are normal. He reports a headache rated at 7/10 on a pain rating scale. He denies photophobia, nausea, and vomiting.

 

Diagnostic results: A nasal smear is needed to determine if the patient has allergic rhinitis based on the presence or absence of eosinophils. A radiograph such as a head CT scan may be needed if the symptoms do not respond to the prescribed treatment. Sinus aspiration may be needed to determine if the patient has bacterial sinusitis.

A.

Differential Diagnoses

Sinusitis: Sinusitis is R.R.’s primary diagnosis. Sinusitis refers to an inflammation of the nasal cavities. Sinusitis develops from causes such as bacterial and viral infections and exposure to allergens. Patients often complain of frontal headaches, feelings of fullness, ear pain, fever, cough, bad breath, stuffy nose, runny nose, and tiredness. Physical examination findings include the presence of a postnasal drip and sinus tenderness (Craig et al., 2021; Psillas et al., 2021; Wyler & Mallon, 2019). R.R.’s symptoms align with those seen in sinusitis, hence, the primary diagnosis.

Migraine headache: Migraine headache is the other differential that should be considered for R.R. Patients with migraine headaches complain of severe throbbing headaches accompanied by symptoms such as vomiting, nausea, and light sensitivity. The pain is so severe that it interferes with the patient’s daily functioning. The additional symptoms seen among patients with migraine headaches include frequent yawning, increased urination, mood changes, aura, and confusion during the post-drome period (Ghorbani et al., 2019; Ghoreishy et al., 2022; Ha & Gonzalez, 2019). Despite R.R. reporting headaches, there are no other symptoms such as photophobia, which rules out migraine headaches as his problem.

Allergic rhinitis: Allergic rhinitis is the other differential that should be considered for R.R. Allergic rhinitis is a condition characterized by the inflammation of the nasal cavities. It develops following exposure to allergens such as dust and pollen. Patients often experience flu-like symptoms such as itchiness, sneezing, runny and blocked nose. The symptoms are always mild and resolve on their own (Bousquet et al., 2020; Zhang et al., 2021). Despite R.R. having symptoms such as a runny nose, allergic rhinitis is the least likely cause of his problems.

Tension headache: Tension headache is the other differential diagnosis to be considered for the patient. Tension headaches have a characteristic of pain described as a tight band all over the head (Burch, 2019). Patients also have scalp, neck, and shoulder muscle tenderness.

Brain abscess: Brain abscess is the other diagnosis to be considered for the patient. It develops from bacterial or fungal infection of the brain tissue (Corsini Campioli et al., 2021). The symptoms that patients experience include a fever, headache, neck rigidity, and seizures, which are not evident in the patient’s case.

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

 

References

Bousquet, J., Anto, J. M., Bachert, C., Baiardini, I., Bosnic-Anticevich, S., Walter Canonica, G., Melén, E., Palomares, O., Scadding, G. K., Togias, A., & Toppila-Salmi, S. (2020). Allergic rhinitis. Nature Reviews Disease Primers, 6(1), Article 1. https://doi.org/10.1038/s41572-020-00227-0

Burch, R. (2019). Migraine and Tension-Type Headache: Diagnosis and Treatment. Medical Clinics, 103(2), 215–233. https://doi.org/10.1016/j.mcna.2018.10.003

Corsini Campioli, C., Castillo Almeida, N. E., O’Horo, J. C., Esquer Garrigos, Z., Wilson, W. R., Cano, E., DeSimone, D. C., Baddour, L. M., Van Gompel, J. J., & Sohail, M. R. (2021). Bacterial Brain Abscess: An Outline for Diagnosis and Management. The American Journal of Medicine, 134(10), 1210-1217.e2. https://doi.org/10.1016/j.amjmed.2021.05.027

Craig, J. R., Poetker, D. M., Aksoy, U., Allevi, F., Biglioli, F., Cha, B. Y., Chiapasco, M., Lechien, J. R., Safadi, A., Simuntis, R., Tataryn, R., Testori, T., Troeltzsch, M., Vaitkus, S., Yokoi, H., Felisati, G., & Saibene, A. M. (2021). Diagnosing odontogenic sinusitis: An international multidisciplinary consensus statement. International Forum of Allergy & Rhinology, 11(8), 1235–1248. https://doi.org/10.1002/alr.22777

Ghorbani, Z., Togha, M., Rafiee, P., Ahmadi, Z. S., Rasekh Magham, R., Haghighi, S., Razeghi Jahromi, S., & Mahmoudi, M. (2019). Vitamin D in migraine headache: A comprehensive review on literature. Neurological Sciences, 40(12), 2459–2477. https://doi.org/10.1007/s10072-019-04021-z

Ghoreishy, S. M., Askari, G., Mohammadi, H., Campbell, M. S., Khorvash, F., & Arab, A. (2022). Associations between potential inflammatory properties of the diet and frequency, duration, and severity of migraine headaches: A cross-sectional study. Scientific Reports, 12(1), Article 1. https://doi.org/10.1038/s41598-022-06819-y

Ha, H., & Gonzalez, A. (2019). Migraine Headache Prophylaxis. American Family Physician, 99(1), 17–24.

Psillas, G., Papaioannou, D., Petsali, S., Dimas, G. G., & Constantinidis, J. (2021). Odontogenic maxillary sinusitis: A comprehensive review. Journal of Dental Sciences, 16(1), 474–481. https://doi.org/10.1016/j.jds.2020.08.001

Wyler, B., & Mallon, W. K. (2019). Sinusitis Update. Emergency Medicine Clinics, 37(1), 41–54. https://doi.org/10.1016/j.emc.2018.09.007

Zhang, Y., Lan, F., & Zhang, L. (2021). Advances and highlights in allergic rhinitis. Allergy, 76(11), 3383–3389. https://doi.org/10.1111/all.15044

HPI: J.K.L, a 40-year-old African American female, presents with a week-long headache across her forehead. The headache is squeezing and has the sensation of pressure behind the eyes. It emits no radiation. The headache is continuous and varies in severity from 2/10 to 8/10 at its worst. It is usually worse first thing in the morning and when bending. Acetaminophen reduces headache severity to 4/10 and, on rare occasions, 2/10. Fever, postnasal drip, nasal congestion, sneezing, and an occasional nonproductive cough are all symptoms. To get some relief, she takes Sudafed HCL 120 mg every 12 hours. Her concentration at work has suffered as a result of the symptoms, and she is extremely tired. Finally, she mentions having a head cold three weeks ago.

Current Medications: Pseudoephedrine 120 mg BID for nasal congestion and acetaminophen for headaches.

Allergies: She has no known food and drug allergies.

Past Medical History: During her last visit to the primary care physician 2 months ago, she was noted to be prehypertensive and was advised on lifestyle modifications. No prior hospitalization. No previous surgeries or blood transfusions.

Social History: She is married with two children both alive and well. She works as a secretary Her husband is a college teacher. She neither drinks alcohol nor smokes tobacco. She does not use marijuana or other illicit drugs. She strictly adheres to dietary advice from her nutritionist and she exercises regularly. Denies caffeine intake.

Family History: Father alive aged 60 years and with hypertension while her mother is 58 years old alive and well. Her brother and sister are 35 and 20 years old respectively, alive and well. Her paternal grandfather died at the age of 80 years due to a heart attack while her paternal grandmother is 78 years and is hypertensive. Her maternal grandfather is 77 years with a history of type 2 diabetes and high cholesterol while her maternal grandmother died at the age of 70 years due to a stroke. No family history of malignancies, mental illness, asthma, sickle cell, or diabetes.

A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.

An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.

This week, you will explore methods for assessing the cognition and the neurologic system.

Also Read:

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NURS 6512 ethical dilemmas Assessment

NURS 6512 History of Present Illness (HPI)

NURS 6512 provision of quality and effective healthcare services to the diverse population

NURS 6512 Discussion comprehensive health history for a patient is important in developing a treatment plan for them

Learning Objectives

Students will:

  • Evaluate abnormal neurological symptoms
  • Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
  • Assess health conditions based on a head-to-toe physical examination

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: 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.NURS 6512 assessing the neurologic system
  • 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.

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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/

Assignment 1: Case Study Assignment: Assessing Neurological Symptoms

Photo Credit: Getty Images/iStockphoto

Imagine not being able to form new memories. This is the reality patients with anterograde amnesia face. Although this form of amnesia is rare, it can result from severe brain trauma. Anterograde amnesia demonstrates just how impactful brain disorders can be to a patient’s quality of living. Accurately assessing neurological symptoms is a complex process that involves the analysis of many factors.

In this Case Study Assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

To Prepare

  • By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
  • Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.

With regard to the case study you were assigned:

  • Review this week’s Learning Resources, and consider the insights they provide about the case study.
  • Consider what history would be necessary to collect from the patient in the case study you were assigned.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Case Study Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

By Day 6 of Week 9

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK9Assgn1+last name+first initial.(extension)” as the name.
  • Click the Week 9 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 9 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK9Assgn1+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:

Week 9 Assignment 1 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 9 Assignment 1 draft and review the originality report.

Submit Your Assignment by Day 6 of Week 9

To participate in this Assignment:

Week 9 Assignment 1

Assignment 2: Lab Assignment: Practice Assessment: Neurological Examination

Short of opening a patient’s cranium or requesting a brain scan, what can an advanced practice nurse do to determine the cause of neurological symptoms? A multitude of techniques can be used to generate a neurological diagnosis.

In preparation for the Comprehensive (Head-to-Toe) Physical Assessment due this week, it is recommended that you practice performing a neurological examination.

Note: This is a practice physical assessment.

To Prepare

  • Arrange an appropriate time and setting with a volunteer “patient” to perform a neurological examination.
  • Download and review the Neurological Checklist provided in this week’s Learning Resources as well as review Seidel’s Guide to Physical Examination online media.

The Lab Assignment

Complete the following in Shadow Health:

  • Neurological (Practice)

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. 

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
  • Review the Week 9 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
  • Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
  • Complete the Code of Conduct Acknowledgement.
  • 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:

Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.

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

Name: NURS_6512_Week_9_Assignment1_Rubric

Excellent Good Fair Poor
Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.·  Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.
Points Range: 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Points Range: 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Points Range: 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.
Points Range: 0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Points Range: 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study and provides a thorough, accurate, and detailed justification for each of the five conditions selected.
Points Range: 24 (24%) – 29 (29%)
The response lists four to five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.
Points Range: 18 (18%) – 23 (23%)
The response lists three to four possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or some inaccuracy in the conditions and/or justification for each.
Points Range: 0 (0%) – 17 (17%)
The response lists three or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
Points Range: 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Points Range: 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
Points Range: 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
Points Range: 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Total Points: 100