NURS 6512 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment IN

Sample Answer for NURS 6512 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment IN Included After Question

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

NURS 6512 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment IN
NURS 6512 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment IN
  • 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.

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A Sample Answer For the Assignment: NURS 6512 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment IN

Title: NURS 6512 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment IN

Patient Information:

Initials: H.F.                Age: 47 Years             Sex: Female                Race: Caucasian

S.

CC (chief complaint): “I am experiencing pain in my right wrist”

HPI: H.F., a 47-year-old Caucasian female with obesity, sought medical attention at the clinic due to her primary concern of experiencing pain in her right wrist, accompanied by sensations of numbness and tingling in the index, middle finger, and thumb. The patient has provided an account of experiencing these symptoms approximately fourteen days prior. Nevertheless, she expresses apprehension regarding the discomfort, as it causes her to inadvertently release her hairstyling implements.

Location: Right wrist

Onset: two weeks ago

Character: Numbness and pain in her right wrist

Associated signs and symptoms: Thumb, middle, and index finger tingling

Timing: the whole day

Exacerbating/ relieving factors: Worse while doing tasks with the wrist joint. When the wrist is stationary, the discomfort is reduced.

Severity: 6/10

Current Medications:

  • Ibuprofen at a dosage of 400mg taken orally as needed,
  • Hydrochlorothiazide at a dosage of 25mg taken orally every morning
  • Amlodipine at a dosage of 10mg taken orally once daily.

Allergies: Allergic to sulfur. No environmental or food allergies.

PMHx: The patient exhibits obesity and has a documented history of hypertension.

  • Immunization status: The patient has received all necessary vaccinations, including Tdap in October 2020, the Influenza Vaccine during the current season, and completed the COVID-19 Vaccines with Boosters in 2021.
  • Surgeries: without any prior surgical history
  • Hospitalization: There is no record of any hospitalizations.

Soc Hx: The patient is a hairdresser who works five blocks from her house in a neighborhood spa. She claims to have a history of sometimes consuming alcohol while smoking cigarettes. She does not, however, admit to using marijuana or any other illegal substance. She presently lives as a family with her husband and three kids. During her free time, she enjoys singing and reading. She exercises by taking the dog for a 30-minute walk every evening. She affirms that she eats a healthy diet and sleeps well for around 8 hours each night.

Fam Hx: The patient has two siblings, the younger of whom has just received an asthma diagnosis while the other is well. Both of her parents are still living; the mother has a history of T2DM and HTN, while the father has a history of HTN and esophagostomy. She is unaware of the medical history of her grandparents.

ROS:

GENERAL: denies any symptoms of heat or cold sensitivity, reduced appetite, sluggishness, chills, fever, or recent weight changes.

HEENT: Head: denies experiencing seizures, headaches, or dizziness. Eye: denies any discomfort, discharge, vision disturbances, photophobia, or blurriness. Ear: denies discharge, tinnitus, discomfort, or hearing loss. Nose: denies having sneeze fits, sinus pain, a runny nose, or nose bleeding. Throat: denies pain, swallowing issues, or voice hoarseness.

SKIN: denies rash or itching.

CARDIOVASCULAR: denies having orthopnea, arrhythmias, elevated blood pressure, or palpitations.

RESPIRATORY: denies having a cough, producing phlegm, having breathing problems, or breathing quickly.

GASTROINTESTINAL: denies experiencing vomiting, heartburn, heartburn pain, discomfort, or abdominal distention.

GENITOURINARY: denies having hematuria, vaginal discharge, incontinence, dysuria, oliguria, frequent urination, or burning pain.

NEUROLOGICAL: denies experiencing ataxia, a headache, paralysis, syncope, or abnormalities in bowel or bladder control. reports tingling and numbness in the middle, index, and thumb fingers.

MUSCULOSKELETAL: a right wrist ache is reported. denies muscular pain, joint stiffness, or joint swelling. demonstrates the complete range of motion in other joints.

HEMATOLOGIC: denies bleeding issues, easy bruising, or anemia.

LYMPHATICS: denies splenectomy or lymphadenopathy.

PSYCHIATRIC: denies experiencing hallucinations or other psychological symptoms such as anxiety, sadness, or thoughts of homicide or suicide.

ENDOCRINOLOGIC: denies a tendency to sweat excessively, polyuria, polydipsia, or sensitivity to heat and cold.

ALLERGIES: Sulfur allergy is reported.

O.

Physical exam: Vital signs: BP- 138/86 mmHg, PR-86, RR-19, Temp- 98.9, SpO2-98% on room air, Ht- 5’9”, Wt- 210 lbs., BMI-31.01

GENERAL: a female who is obese and adequately attired. Clear speaking, the patient is focused and aware X4. The patient responds to inquiries adequately and is not visibly distressed.

HEENT: Head: normal-sized, trauma-free, and without scars. Eye: Sclera and conjunctiva are clear. No significant redness, discharge, or tearing. Ear: Typical pinna with an unobstructed tympanic membrane. It is normal for the external auditory canal. Nose: nasal mucous membrane that is wet. No sinuses or discomfort to the touch. Throat: pink, wet mucous membrane in the mouth. The tonsils and posterior pharynx are not erythematous, and the uvula is in the middle.

MUSCULOSKELETAL: Gait and musculoskeletal development are normal. displays a healthy body posture without any joint or bone swelling or abnormalities. Right thumb abduction shows weakness, with a 3/5 poor strength. Positive Hoffmann-Tinel and Phalen indicators. All the muscles of the other limb are strong and their tendon reflexes are normal.

NEUROLOGICAL: Aware and well-grounded in time, location, and people. quite helpful throughout the assessment. All of the cranial nerves are mostly unharmed. demonstrates typical reactions. The right hand’s middle finger, thumb, and index finger all feel numb and tingly.

Diagnostic results: The complete blood count (CBC) reveals a white blood cell count (WBC) of 8.9. Additionally, a comprehensive metabolic panel (CMP) including differentials is performed.  The glucose level is measured at 125, while the HgbA1c level is recorded as 4.5%, indicating the need to exclude any potential presence or occurrence. Neuropathy associated with type 2 diabetes mellitus (T2DM). The concentration of C-reactive protein in the sample is 4.2 mg/L (Attal & Didier Bouhassira, 2023).

Diagnostic Tests:

  • An X-ray examination of the right wrist was conducted to assess the presence of arthritic changes (Genova et al., 2020).
  • Test for bone density to rule out osteoporosis.
  • nerve conduction analysis.
  • Manual: Tinel sign and Durkans Test (Zhang et al., 2020).

A.

Differential Diagnoses:

  1. Carpal tunnel syndrome (CTS): This condition is characterized by symptoms such as tingling and numbness in the fingers, which occur due to compression of the median nerve within the carpal tunnel (Malakootian et al., 2022). This condition is commonly regarded as an occupational disease characterized by repetitive wrist and finger extension and flexion. However, certain cases of CTS may have an unknown cause, and the risk of developing CTS can be influenced by various factors, including genetic and acquired factors. A nerve conduction study is a precise diagnostic tool used to identify both normal and abnormal values of nerve function. Diagnostic laboratory results can also be utilized for the identification of increased levels of inflammatory markers. The patient exhibits multiple risk factors for developing this disease, including occupational factors and obesity.
  2. Peripheral neuropathy: This condition is linked to hand numbness. The patient’s gender, familial history, and weight contribute to their increased risk of developing type 2 diabetes mellitus (T2DM) (Selvarajah et al., 2019). Peripheral neuropathy is a frequently observed symptom associated with T2DM, characterized by a gradual onset. A two-point discrimination test was conducted, revealing decreased sensitivity in the patient’s right arm. The patient reports no decrease in sensation in the lower extremities. If the patient experiences altered symptoms and exhibits new-onset neuropathy in the lower extremities, I will contemplate reevaluating the A1C levels and potentially diagnose diabetic peripheral neuropathy based on diagnostic assessments. Diabetic individuals exhibit significant declines in hand and finger dexterity relative to their healthy counterparts.
  3. Wartenberg’s syndrome: This condition presents as paresthesia or pain occurring along the radial aspect of the forearm, with symptoms radiating toward the thumb and middle fingers. The pain arises due to the compression of the superficial radial nerve. Potential external factors may include the presence of a wristwatch or objects exerting pressure on the nerve (Kuschner & Berihun, 2021). The technique of palpation in the vicinity of the radial nerve region is employed to detect potential masses located both superficially and deeply. The utilization of the Tinel’s sign aids in the confirmation of this particular diagnosis.
  4. Lupus: This is an autoimmune disease characterized by immune system dysfunction, resulting in inflammation, a high body temperature, joint pain, malaise, and rash. DNA methylation is a specific and reliable biomarker for the diagnosis of lupus, exhibiting cell-type specificity (Fanouriakis et al., 2020). DNA methylation is more prominent in patients with active disease compared to those in remission. The lupus band test (LBT) is a direct immunofluorescent approach conducted through skin biopsy. It is particularly valuable in cases where clinical and laboratory data are inconclusive for diagnosing lupus.
  5. Type 2 Diabetes Mellitus (T2DM): The patient is at a heightened risk of developing T2DM. In the event of a gradual increase in the patient’s HbA1c, it is recommended to implement a prediabetes protocol involving lifestyle modifications such as dietary changes, exercise, and regular monitoring of HbA1c levels. Diabetic peripheral neuropathy (DNP) is characterized by progressive metabolic and inflammatory alterations that result in impaired daily functioning and reduced independence (Wu et al., 2021). Fasting lipid levels should be included in laboratory tests to assess cholesterol levels and provide education on cholesterol, triglycerides, LDL, and HDL levels.

 

 

References

Attal, N., & Didier Bouhassira. (2023). Neuropathic Pain. https://doi.org/10.1093/med/9780197616345.001.0001

Fanouriakis, A., Tziolos, N., Bertsias, G., & Boumpas, D. T. (2020). Update Οn the Diagnosis and Management of Systemic Lupus Erythematosus. Annals of the Rheumatic Diseases80(1), annrheumdis-2020-218272. https://doi.org/10.1136/annrheumdis-2020-218272

Genova, A., Dix, O., Saefan, A., Thakur, M., & Hassan, A. (2020). Carpal Tunnel Syndrome: A Review of Literature. Cureus12(3). https://doi.org/10.7759/cureus.7333

Kuschner, S. H., & Berihun, H. (2021). Robert Wartenberg Syndrome and Sign: A Review Article. The Open Orthopaedics Journal15(1), 13–16. https://doi.org/10.2174/1874325002115010013

Malakootian, M., Soveizi, M., Gholipour, A., & Oveisee, M. (2022). Pathophysiology, Diagnosis, Treatment, and Genetics of Carpal Tunnel Syndrome: A Review. Cellular and Molecular Neurobiology. https://doi.org/10.1007/s10571-022-01297-2

Selvarajah, D., Kar, D., Khunti, K., Davies, M. J., Scott, A. R., Walker, J., & Tesfaye, S. (2019). Diabetic peripheral neuropathy: advances in diagnosis and strategies for screening and early intervention. The Lancet Diabetes & Endocrinology7(12), 938–948. https://doi.org/10.1016/s2213-8587(19)30081-6

Wu, B., Niu, Z., & Hu, F. (2021). Study on Risk Factors of Peripheral Neuropathy in Type 2 Diabetes Mellitus and Establishment of Prediction Model. Diabetes & Metabolism Journal45(4), 526–538. https://doi.org/10.4093/dmj.2020.0100

Zhang, D., Chruscielski, C., Blazar, P., & Earp, B. (2020). Accuracy of Provocative Tests for Carpal Tunnel Syndrome. Journal of Hand Surgery Global Online2(3), 121–125. https://doi.org/10.1016/j.jhsg.2020.03.002

A Sample Answer 2 For the Assignment: NURS 6512 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment IN

Title: NURS 6512 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment IN

 

OBJECTIVE DATA

Vital signs: Respiration- 15

Temp- 37.2 C

Heartrate – 78

SpO2- 99%

  • Height: 170 cm
  • Weight: 84 kg
  • BMI: 29.0
  • Blood Glucose: 100
  • RR: 15
  • HR: 78
  • BP:128 / 82
  • Pulse Ox: 99%
  • Temperature: 99.0 F

General: Jones is alert oriented, seated upright on examination table, and is in no distress. She is well-nourished, developed, and dressed appropriately with good hygiene.

HEENT: Head is normocephalic, atraumatic. Eyes bilateral with equal hair distribution on lashes and eyebrows. No lesions on lids, no edema or ptosis. Pink conjunctiva, white sclera, PERRLA bilaterally, intact extraocular eye movements, and no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection.

Neck: Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Chest/Lungs: Lung sounds clear and voice is present in all areas. Spanish symmetrically. Chest anterior and posterior normal upon inspection. fremitus equal bilaterally. Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Heart/Peripheral Vascular: Pirated 2 + with no thrill or bruit bilaterally. PMI non-discplaced. S1 and S2 only regular rhythm. No bruit in aorta or any other arteries. Capillary refill is less than 3 seconds in fingers and toes no edema is present. Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than 3 seconds. No peripheral edema.

Abdomen: bowel sounds are normal in all quadrants. moves bowels regularly. Abdomen is soft with no Masses. liver is one centimeter below the right costal margin. Quadrants are tympanic and spleen is Not dull in sound. Kidney is not palpable no masses are present

 

Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Genital/Rectal:

Musculoskeletal: Range of motion in all areas of full or muscle strength or 5 out of 5 no CVA tenderness. DTR 2+. Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.

 

Neurological: for the feet especially left foot area. Patient is able to sense position of body fingers and toes. Graphesthesia normal sense. Patient is oriented to time person and place. Heel to Shin normal. Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin: Acne is present on the face. Skin is normal. Norwegians or abnormalities in the nails. Old scar is present on the left shin.

Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities.

 

Diagnostic results: None

 

ASSESSMENT: Jones is a 28-year-old female that has come today for her pre-employment assessment. She appears well dressed and responsive. She is diabetic and asthmatic, which are controlled. She uses corrective lenses. She has normal sleeping cycle. She engages in active physical activity and has dietary modifications for diabetes control. She monitors her blood glucose levels on a daily basis. She also monitors her peak flow to track asthma and uses albuterol inhaler to manage its symptoms. She denies any current acute health problems.  

 

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

S.

CC: “I have a headache around my forehead.”

HPI: J.K.L is a 40-year-old African American female who presents with a complaint of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It is non-radiating. The headache is constant and varies in severity ranging from 2/10 at its best to 8/10 at its worst. It is usually worse in the morning and while bending. Acetaminophen reduces the severity of the headache to 4/10 and occasionally 2/10. It is associated with fever, postnasal drip, nasal congestion, sneezing, and occasional non-productive cough. She takes Sudafed HCL 120 mg every 12 hours to obtain some relief. The symptoms have significantly impaired her concentration at work and made her feel very tired. Finally, she reports 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.

ROS:

GENERAL: Reports fatigue and occasional fever. Denies weight loss, night sweats, and chills.

HEENT:  Reports headaches, nasal congestion, post nasal drip, and sneezing. No blurring of vision, visual loss, hearing loss, tinnitus, nose bleeds, ear pain, mouth sores, or sore throat.

SKIN:  no skin lesion or rashes. No abnormal pigmentation.

CARDIOVASCULAR: Negative for palpitations, chest pain, paroxysmal nocturnal dyspnea, and peripheral limb edema.

RESPIRATORY:  Occasional non-productive cough. No difficulty in breathing, dyspnea, or orthopnea.

GASTROINTESTINAL: Reports loss of appetite and occasional nausea and vomiting. Denies change in bowel habits, abdominal pain, or distention.

GENITOURINARY: No frequency, dysuria, nocturia, and polyuria. No vaginal itchiness or abnormal vaginal discharge.

NEUROLOGICAL: Reports headache. Denies dizziness, lightheadedness, numbness, tingling, loss of sensation, syncope, and convulsion.

MUSCULOSKELETAL: No muscle pain, joint pains, muscle weakness, or muscle swelling.

HEMATOLOGIC:  No anemia, easy bruising, or bleeding.

LYMPHATICS: Normal lymph nodes

PSYCHIATRIC:  Denies anxiety, depression, suicidal ideations, or hallucinations.

ENDOCRINOLOGIC: Denies heat or cold intolerance, polyphagia, and polydipsia.

ALLERGIES:  Reports no allergies.

O.

Physical exam:

VITAL SIGNS: BP 125/78 mmHg, HR 88 b/min, Temp 99. 8 F, RR 20 b/min, saturation 95% on room air, Height 168 cm, weight 76 Kg. Pain level 5/10

GENERAL: A middle-aged African-American female, well kempt, not in any form of respiratory distress but slight discomfort. Maintains eye contact, coherent speech, and a stable mood. Well-hydrated and nourished. No palmar or conjunctival pallor, jaundice, central or peripheral cyanosis, cervical or inguinal lymphadenopathy, and peripheral limb edema.

HEENT: Normocephalic and atraumatic head. Non-tender scalp. Bilateral eyes with pink conjunctiva and white sclera. Pupils equally and bilaterally reacting to light, no ptosis or lid edema. Normal extraocular movements. Bilateral ears present, no impaction or skin lesions, tympanic membrane pearly grey bilaterally, and positive white reflex. Both nares are present and are discharging mucus, midline nasal septum, and pink and soft nasal mucosa. Tender maxillary and frontal sinus. Moist and pink oral mucosa, no oral lesions or ulceration. Normal dentition and teeth alignment.

NECK: Soft neck. The trachea is central. Full range of motion, non-tender, no cervical lymphadenopathy, and no thyroid enlargement.

CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse in the 5th intercostal space in the midclavicular line. S1 and S2 head, no murmurs, thrills, gallops, rubs, or heaves.

RESPIRATORY: Symmetrical chest that moves with respiration. No scars or skin lesions. Equal chest expansion and equal tactile fremitus bilaterally. Equal air entry, vesicular breath sounds, no wheezes, and crackles, and equal vocal fremitus in all lung zones.

NEUROLOGICAL: GCS 15/15, oriented to time, place, and person, intact short-term and long-term memory, good concentration, and a clear coherent speech. Cranial nerves 1 to 12 intact. Normotonic across all joints, normal bulk, and power 5/5 across all muscle groups in upper and lower extremities, deep tendon reflexes 2+ and equal bilaterally in upper and lower limbs. Intact monofilament sensation across all dermatomes, good bowel, and bladder function. No spinal tenderness, normal gait, coordination, graphesthesia, and stereognosis. Normal finger nose, heel to the shin, and rapid alternating movements tests.

Diagnostic results:

J.K.L appears to have an inflammatory/infectious condition. Consequently, complete blood count and inflammatory markers particularly CRP and ESR are paramount. Similarly, bacterial or fungal cultures obtained endoscopically or by direct sinus aspiration are required to identify the possible pathogen. Additionally, a skin prick test is essential to exclude allergic rhinitis. Imaging modalities principally Sinus CT and MRI are recommended to evaluate for rhinosinusitis and intraorbital or intracranial involvement.

 

A.

Differential Diagnoses

Acute Sinusitis- refers to the inflammation of sinuses lasting less than 4 weeks (DeBoer & Kwon, 2022). The condition is more common in females and particularly during early fall to early spring (DeBoer & Kwon, 2022). It is most commonly caused by viral infection following a common cold although bacteria and fungi are not uncommon etiologies. J.K.L presents with clinical features that are typical of acute sinusitis including fatigue, fever, headache, facial pain, and pressure worse on bending (DeBoer & Kwon, 2022). Maxillary sinuses and frontal sinuses appear to be the affected sinuses in her as evidenced by pain around the forehead and tenderness of the maxillary and frontal sinuses (DeBoer & Kwon, 2022).

Rhinitis- Refers to the inflammation of the nasal mucosa. J.K.L presents with clinical manifestations suggestive of rhinitis including sneezing, nasal congestion, postnasal drip, and rhinorrhea (Liva et al., 2021). Similarly, she reports a “head cold” three weeks ago. Rhinitis is mostly caused by an upper respiratory infection or type 1 hypersensitivity reaction (Liva et al., 2021). However, an upper respiratory tract infection is likely the cause in her case.

Cluster headache- Cluster headache is a type of primary headache that is usually unilateral retro-orbital and characterized by sharp and stabbing pain (Goadsby et al., 2018). Cluster headache may present with symptoms of lacrimation, nasal congestion, rhinorrhea, ptosis, or miosis (Goadsby et al., 2018). However, it is unlikely the diagnosis in her as cluster headache usually lasts for a brief period. Similarly, cluster headaches mostly awake the patient at night.

Migraine headache- Migraine headache is another type of primary headache that may be preceded with or without aura. It is usually pulsating and moderate to severe (Pescador Ruschel & O, 2022). It is common in young women. However, it is unlikely the diagnosis as migraines last 4 to 72 hours if untreated and are typically associated with nausea, vomiting, photophobia, and phonophobia (Pescador Ruschel & O, 2022).

Rebound headache– Commonly referred to as medication overuse headache. Rebound headache predominantly occurs in individuals with primary headaches who overuse analgesia (Micieli & Robblee, 2018). Rebound headaches are more common in females and individuals less than 50 years. Drugs precipitating this headache include barbiturates, acetaminophen, opioids, ergotamine, and triptans (Micieli & Robblee, 2018). However, this is an unlikely diagnosis in J.K.L as a diagnosis of primary headache hasn’t been established.

 

References

DeBoer, D. L., & Kwon, E. (2022). Acute Sinusitis. https://pubmed.ncbi.nlm.nih.gov/31613481/

Goadsby, P., Wei, D.-T., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology21(5), 3. https://doi.org/10.4103/aian.aian_349_17

Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine10(14), 3183. https://doi.org/10.3390/jcm10143183

Micieli, A., & Robblee, J. (2018). Medication-overuse headache. Journal de l’Association Medicale Canadienne [Canadian Medical Association Journal]190(10), E296–E296. https://doi.org/10.1503/cmaj.171101

Pescador Ruschel, M., & O, D. J. (2022). Migraine Headache. https://pubmed.ncbi.nlm.nih.gov/32809622/

 

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Content

Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric

Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.

  Excellent Good Fair Poor
Student DCE score

(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)

Note: DCE Score – Do not round up on the DCE score.

Points Range: 56 (56%) – 60 (60%)

DCE score>93

Points Range: 51 (51%) – 55 (55%)

DCE Score 86-92

Points Range: 46 (46%) – 50 (50%)

DCE Score 80-85

Points Range: 0 (0%) – 45 (45%)

DCE Score <79

No DCE completed.

Documentation in Provider Notes Area

Subjective documentation of the comprehensive exam in Provider Notes is detailed, organized, and includes documentation of identifying data, general survey, reason for visit/chief complaint, history of present illness, medications, allergies, medical history, health maintenance, family history, social history, mental health history, and review of systems.

The review of systems is clearly defined by each body system (skin, eyes, cardiac, etc.) and all conditions or illnesses asked of the patient are documented along with the patient response.

Points Range: 16 (16%) – 20 (20%)

Documentation is detailed and organized with all pertinent information noted in professional language.

Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Points Range: 11 (11%) – 15 (15%)

Documentation with sufficient details, some organization and some pertinent information noted in professional language.

Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Points Range: 6 (6%) – 10 (10%)

Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.

Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Points Range: 0 (0%) – 5 (5%)

Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.

No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

or

No documentation provided.

Objective Documentation in Provider Notes – this is to be completed in your documentation notes.

Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.

Diagnostic result- Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).

Points Range: 16 (16%) – 20 (20%)

Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.

Each system assessed is clearly documented with measurable details of the exam.

Points Range: 11 (11%) – 15 (15%)

Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.

Each system assessed is somewhat clearly documented with measurable details of the exam.

Points Range: 6 (6%) – 10 (10%)

Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.

Each system assessed is minimally or is not clearly documented with measurable details of the exam.

Points Range: 0 (0%) – 5 (5%)

Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.

None of the systems are assessed, no documentation of details of the exam.

or

No documentation provided.

Total Points: 100

Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric

Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.

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NURS 6512 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment IN 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.

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