NU 610 Digital Clinical Experience (DCE) Comprehensive Assessment

NU 610 Digital Clinical Experience (DCE) Comprehensive Assessment

Instructions

Return to your Shadow Health Advanced Health Assessment course.

Complete the following Digital Clinical Experience (DCE) – Comprehensive Assessment

Location: Shadow Health – Advanced Health Assessment.

Points: 100 points are available; The Student Performance Index (SPI %) score will be your overall assignment score.

As you can see it is in your best interest to repeat your DCE activity if you are not satisfied with your SPI score on your initial attempt. There is no limit on the number of times you can repeat the DCE activity. Be sure to submit the ‘Lab pass’ that demonstrates the highest score.

Shadow Health Support

Contact Shadow Health with any questions or technical issues regarding Shadow Health before contacting your instructor.

If at any time you have any questions or encounter any technical issues regarding the Digital Clinical Experience, please contact the Shadow Health support specialists by visiting the Learner Support Page at http://support.shadowhealth.com (Links to an external site.)for contact information and hours.

You may email the Learner Support team directly at [email protected] at any time or by calling 800.860.3241.

Health History of Tina Jones

Student Name

College

Course

Faculty Name

Assignment Due Date

NU 610 Digital Clinical Experience (DCE) Comprehensive Assessment

Digital Clinical Experience (DCE)_ Health History Assessment Tina Jones

Identifying Data

Ms. Jones, a pleasant 28-year-old lady of African American descent, arrived at the clinic to begin treatment for a recent injury to her right foot. She identified herself as the primary information provider. Throughout the evaluation, she speaks well and coherently while being open with her communication. She maintains amazing eye contact the whole exam.

General Survey

The patient is awake and has a good sense of place, time, and other people. As she takes a seat upright, she doesn’t exhibit any indications of concern. She has dressed appropriately for her age and appears to be well-developed, fed, and quite sanitary.

Subjective Data

Chief Complaint (CC): A painful wound on the right foot.

History of Present Illness: An African American woman named Tina, 28, alleges that a week ago while walking, she stumbled over a concrete step and twisted her right ankle, scraping the ball of her foot in the process. She went to a neighboring emergency unit, where an X-ray was ordered and found to be negative. Tramadol was nonetheless provided to her to help with the discomfort. She says she cleans the wound twice daily, applies antibiotic cream, and wraps it in a bandage. Even though the pain and swelling at the location of the injury have fully subsided, she claims that the bottom of her foot is still quite uncomfortable. She describes the discomfort as being weight-bearing, throbbing, and intense. But, the discomfort in her ankle has already subsided. She continues to rate the pain as 7/10 even after a recent dose of tramadol. She gives the pain when bearing weight, a 9 out of 10. She describes a swollen football that has become redder over the last two days. A day before the current appointment, the wound was already dripping with an odorless discharge. She claims that recently, her shoes have been uncomfortable, so she has started wearing slippers instead. Her fever was 1020F last night. She, though, denies having been unwell recently. She reports an increase in hunger and an unintentional 10-pound weight reduction over the past month. She asserts that her diet and energy levels have not changed.

Medications

Ibuprofen 600mg orally three times each day for menstrual cramps.

Acetaminophen 500-100 mg orally, as needed for headaches.

Tramadol 50 mg orally twice a day if foot pain persists.

Albuterol 90mcg/spray multiple-dose inhalation up to two puffs every 6 hours for wheeze caused by cat allergies. She had last used the medication around three days before the current appointment.

Allergies

There are no documented latex or food sensitivities.

Penicillin hypersensitivity

Establishes dust and cat allergies

Allergic reaction: runny nose, puffy and itchy eyes, and worsening asthma symptoms.

Medical History

At the age of two and a half years, was given an asthma diagnosis. Two to three times each week, she utilizes an Albuterol inhaler to control her symptoms when she is exposed to dust or cats. She was exposed to cats three days ago, and she used an inhaler, which was quite efficient in controlling the symptoms. She was hospitalized for asthma the last time she was in high school. She, on the other hand, denies ever being intubated. When she was 24, she was diagnosed with diabetes mellitus. She had been taking metformin but had discontinued roughly three years ago because of flatulence adverse effects. She also reports that taking the tablets and checking her blood glucose simultaneously has been exhausting. She denies that she has been monitoring her blood glucose levels since then. She claims that the last time her levels of sugar in her blood soared was a week ago at the emergency department.
Surgery: None

OB/GYN: At the age of 11, she had her first menstrual cycle. heterosexual; first sexual experience occurred at the age of 18. denies ever becoming a mother. Menstrual cycles have been heavy and irregular in the last year, lasting 9 to 10 days every 4 to 8 weeks, with the most recent period starting around 3 weeks before the current appointment. She acknowledges using oral contraceptives mostly in past, but she is now single. denies wearing condoms when engaging in sexual activity. Has no history of STIs and denies ever having had an HIV/AIDS test before. Her previous pap smear exam was roughly four years ago, according to her.

Health Maintenance

Her most recent eye exam was when she was a little child. A few years ago, she had her most recent dental examination. Two years ago, a PPD test turned out to be negative.
Physical activity: No physical activity
Nutrition: She recalls her nutrition over the previous 24 hours. The day before the current visit, he claims to have skipped breakfast and had a lunch of a sandwich and chicken or steak for dinner. She brings mostly French fries or pretzels as snacks.

Vaccination: She had a tetanus booster last year. Her influenza vaccination is out of date. Her human papillomavirus vaccination was not given to her. She received her meningococcal vaccine when she was still attending college and believes she was immunized as a youngster.
Safety: Smoke detectors have been put in her home. She admits to wearing a seatbelt in the automobile but denies riding a bike. He denies wearing sunblock. Her father’s firearms are still in the house, but they are locked up in their parents’ room.

Family History: The mother, who is 50, has high cholesterol. Her Father died in an automobile accident when he was 58 years old. Diabetes and hypertension were present. Her sister suffers from asthma. Brother has no medical issues. At the age of 73, her maternal granny passed away after a stroke. At the age of 78, her maternal grandfather passed away after a stroke. At the age of 65, her paternal grandfather passed away from colon cancer. Her paternal grandmother is still living. There is no history of addiction, mental health problems, headaches, malignancies, or thyroid problems.

Social History: The patient enjoys going to clubs and drinking alcohol on occasion. Her bachelor’s degree is in accountancy. She has a loving family and friends. There will be no cigarette or marijuana use. He goes to a Baptist church.

Review of Symptoms (ROS)

General: Tina is polite, friendly, and well-organized in general. She is also well-groomed, responds well to queries, and is not depressed.

HEENT: The patient complains of headaches when studying. He has impaired eyesight but does not use glasses. There is no runny nose or ear discharge. There is no swelling or painful throat.

Neck: There are no lymphatic problems or inflammation around the neck.

Breasts: There is no nipple discharge or soreness in the breasts.

Respiratory: No breathlessness, chest pain, or tightness.

Cardiovascular/peripheral: There are no blood clots in the cardiovascular or peripheral systems.

Gastrointestinal: No constipation, bowel disturbances, or watery stools. The patient feels thirsty and has an increased appetite.

Gastrointestinal: No bowel changes, constipation, or watery stool. The patient has an increased appetite and is thirsty.

Genitourinary: The patient’s periods are irregular.

Musculoskeletal: No back or muscular discomfort. Psychiatric: There are no signs of depression or hallucinations.

Neurological: There is no tingling or dizziness.

Skin: Acne-free skin with no chin hair.

Hematologic: There is no history of significant bleeding in the patient. There is no sweating, shivers, or fever.

Objective data

Vital signs: Wt., 90 kg. BMI 31, HR 86: BP 142/82 RR 19: Pulse oximetry 99%: T 101.1.

Diagnostic findings: Wound dimensions are 2cm x 1.5cm, with a depth of 2.5mm. Serosanguinous discharge from the right ball of the foot, as well as red wound margins. There was no monitoring and no edema. Erythema around the wound is mild.

Differential Diagnosis

Asthma: This respiratory disorder develops when the small airways release excessive mucus, making breathing difficult. Breathlessness, wheezing, coughing, and difficulty sleeping are all symptoms (Nakamura et al., 2020). Flu, colds, and allergens such as dust, pollen, and animal hair can all induce asthma. Drugs can be used to treat the illness. Because the patient is prone to cat dander and dust, asthma is the major diagnosis. She further complains of breathlessness and wheezing, both of which are asthma symptoms.

Local infection of the skin and subcutaneous tissue of the foot: The bacterium staphylococcus aureus is the primary cause of this illness. The disorder develops because of skin irritation generated by wounds or cuts (Polk et al., 2021). When the patient reports a wound on her right leg, she may have this ailment.

Acute pain of the foot: A fall is usually the main reason for this ailment. Pain that comes on suddenly and severely (Chung et al., 2021). The ailment may be temporary or persistent for the sufferer. The patient reported that she is in significant pain, rating it a 7 out of 10.

Uncontrolled type 2 diabetes: This sickness causes the patient to urinate often and lose weight. She may have unmanaged type 2 diabetes since she had an excessive thirst and quit taking her diabetic medicines three years ago (Pamungkas et al., 2019). Uncontrolled diabetes might result from the same.

Polycystic ovary syndrome: An excessive amount of androgen hormones in one’s system is the root cause of this illness. Period irregularities are a defining feature of the illness (Azziz, 2018). The woman claims to have irregular cycles every three months; thus, she most definitely has this issue.

References

Azziz, R. (2018). Polycystic Ovary Syndrome. Obstetrics & Gynecology, 132(2), 321–336. https://doi.org/10.1097/aog.0000000000002698

Chung, C. L., Paquette, M. R., & DiAngelo, D. J. (2021). Impact of a dynamic ankle orthosis on acute pain and function in patients with mechanical foot and ankle pain. Clinical Biomechanics, 83, 105281. https://doi.org/10.1016/j.clinbiomech.2021.105281

Polk, C., Sampson, M. M., Roshdy, D., & Davidson, L. E. (2021). Skin and Soft Tissue Infections in Patients with Diabetes Mellitus. Infectious Disease Clinics of North America, 35(1), 183–197. https://doi.org/10.1016/j.idc.2020.10.007

Nakamura, Y., Tamaoki, J., Nagase, H., Yamaguchi, M., Horiguchi, T., Hozawa, S., Ichinose, M., Iwanaga, T., Kondo, R., Nagata, M., Yokoyama, A., & Tohda, Y. (2020). Japanese guidelines for adult asthma 2020. Allergology International, 69(4), 519–548. https://doi.org/10.1016/j.alit.2020.08.001

Pamungkas, R. A., Chamroonsawasdi, K., Vatanasomboon, P., & Charupoonphol, P. (2019). Barriers to Effective Diabetes Mellitus Self-Management (DMSM) Practice for Glycemic Uncontrolled Type 2 Diabetes Mellitus (T2DM): A Socio Cultural Context of Indonesian Communities in West Sulawesi. European Journal of Investigation in Health, Psychology and Education, 10(1), 250–261. https://doi.org/10.3390/ejihpe10010020

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NU 610 Digital Clinical Experience (DCE) Comprehensive Assessment Grading Rubric

Performance Category	100% or highest level of performance 100% 16 points	Very good or high level of performance 88% 14 points	Acceptable level of performance 81% 13 points	Inadequate demonstration of expectations 68% 11 points	Deficient level of performance 56% 9 points	Failing level of performance 55% or less 0 points
Total Points Possible= 50	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Scholarliness Demonstrates achievement of scholarly inquiry for professional and academic topics.	Presentation of information was exceptional and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was good, but was superficial in places and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was minimally demonstrated in all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in one of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in two of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in three or more of the following elements Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information
	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Application of Course Knowledge Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations	Presentation of information was exceptional and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was good, but was superficial in places and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was minimally demonstrated in the all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in one of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from and scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in two of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in three of the following elements Applies principles, knowledge and information and scholarly resources to the required topic. Applies facts, principles or concepts learned scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.
	10 Points	9 Points			6 Points	0 Points
Interactive Dialogue Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic.	Demonstrated all of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 3 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.			Demonstrated 2 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 1 or less of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.
	8 Points	7 Points	6 Points	5 Points	4 Points	0 Points
Grammar, Syntax, APA Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error.	The following was present: 0-3 errors in APA format AND Responses have 0-3 grammatical, spelling or punctuation errors AND Writing style is generally clear, focused on topic,and facilitates communication.	The following was present: 4-6 errors in APA format. AND/OR Responses have 4-5 grammatical, spelling or punctuation errors AND/OR Writing style is somewhat focused on topic.	The following was present: 7-9 errors in APA format. AND/OR Responses have 6-7 grammatical, spelling or punctuation errors AND/OR Writing style is slightly focused on topic making discussion difficult to understand.	The following was present: 10- 12 errors in APA format AND/OR Responses have 8-9 grammatical, spelling and punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand.	The following was present: 13 – 15 errors in APA format AND/OR Responses have 8-10 grammatical, spelling or punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand. AND/OR The student continues to make repeated mistakes in any of the above areas after written correction by the instructor.	The following was present: 16 to greater errors in APA format. AND/OR Responses have more than 10 grammatical, spelling or punctuation errors. AND/OR Writing style does not facilitate communication
	0 Points Deducted					5 Points Lost
Participation Requirements	Demonstrated the following: Initial, peer, and faculty postings were made on 3 separate days					Failed to demonstrate the following: Initial, peer, and faculty postings were made on 3 separate days
	0 Points Lost					5 Points Lost
Due Date Requirements	Demonstrated all of the following: The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.					Demonstrates one or less of the following. The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.