Shadow Health Comprehensive SOAP Note Assignment

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. Shadow Health Comprehensive SOAP Note Assignment

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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. Shadow Health Comprehensive SOAP Note 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.

Shadow health for Tina jones pre-employment exam, week 9 nurs6512
TINA JOANS IS HERE TO RECIVE A PRE EMPLOYMRNT PHYSICAL . IN THIS ASGINMENT YOU WILL PERFORM HEAD TO TOES ASSESSMENT OF TINA JOANS

 Patient Initials:        TJ                         Age: _28                                  Gender: _Female         

SUBJECTIVE DATA:

 Chief Complaint (CC): pre-employment physical

History of Present Illness (HPI): TJ visits the clinic for a pre-employment exam in preparation for a job that she just obtained. She claims that she is not dealing with any significant health problems at the moment. The last time she went to the doctor was for her annual gynecological appointment, which took place around four months ago. After TJ’s most recent appointment for a complete medical exam, which took place five months ago, the attending physician prescribed her metformin and recommended that she use a daily inhaler. Shadow Health Comprehensive SOAP Note Assignment

 Medications:

Metformin- 850mg twice daily for diabetes

Proventil 90mcgs inhaler- 2-3 puffs PRN

Flovent inhaler- twice daily for asthma

Yaz– daily for birth control

Advil 600mg – three times daily PRN for cramps

 Allergies: Reports penicillin, dust, and cat allergies.

Past Medical History (PMH): Diabetes, asthma, PCOS

Past Surgical History (PSH): denies surgical history

Sexual/Reproductive History: The 14th of October, 2021 was the date of her LMP. She identifies as a heterosexual woman. She claims that she has not had any sexual relations recently. She plans to always use condoms, if she does engage in sexual activity in the future. Takes oral contraceptive everyday.

Personal/Social History: TJ was hired by a corporation not so long ago to work in their accounting department. Within the next two weeks, she will begin working at the new job that she has been offered. She earned a bachelor’s degree in accounting after completing her studies at  college. Currently, she lives at home with her mother and sister. She states that she has many connections and strong familial ties, in addition to a big church family that serves as a reliable support system for her. Efforts to reduce the amount of caffeine that is consumed. She does not drink coffee and instead sticks to drinking only two Diet Cokes on a daily basis. On a monthly basis, she consumes alcohol around twice. Denies tobacco or illicit drug use. Shadow Health Comprehensive SOAP Note Assignment

Health Maintenance: Through proper food and regular exercise, she hopes to get her diabetes under control. Walks for periods of thirty to forty minutes at a time, four to five times a week. Has the opportunity to participate in a health insurance plan via her place of work. She states that she does a once-daily check of her blood sugar first thing in the morning. She does her best to avoid being around pets, since her asthma is worsened by them. Diet and exercise have been quite beneficial to her in the management of her hypertension, and as a result, she has not required the use of medication in order to control her blood pressure.

Immunization History: childhood immunizations are current. Tetanus vaccine is current. Flu vaccine not current.

Significant Family History:

Mother- hypertension, hypercholesterolemia

Father- diabetes, obesity, hypertension, hypercholesterolemia (deceased- car accident)

Sister- asthma

Brother- obesity

Paternal Grandmother- hypertension, hypercholesterolemia

Paternal Grandfather- diabetes, hypercholesterolemia, hypertension (died of colon cancer)

Maternal Grandmother- hypercholesterolemia, hypertension (died of stroke)Shadow Health Comprehensive SOAP Note Assignment

Review of Systems:

 General: Reports recent weight loss. Denies fever, fatigue, or  chills

HEENT: Denies headache or head injury. Denies any ear problems or changes in hearing. Denies eye or vision problems. Denies nose problems or change in sense of smell. Denies sore throat or difficulty swallowing.

Respiratory: Denies shortness of breath, wheezing, or cough

Cardiovascular/Peripheral Vascular: Denies palpitations, edema, or chest pain.

Gastrointestinal: Denies nausea, vomiting, constipation, diarrhea, or stomach pain.

Genitourinary: Denies polyuria, dysuria, or hesitancy. Denies vaginal itching or discharge.

Breasts: Denies breast pain or lumps.

Musculoskeletal: Denies muscle pain, joint pain, weakness, and swelling. Neurological: Denies dizziness, seizures, or loss of coordination.

Psychiatric: Denies depression or anxiety

Skin/hair/nails: Denies rash or lesions. Reports improved acne

OBJECTIVE DATA:

 Physical Exam:

Vital signs: H: 170cm W: 84kg BMI: 29 Temp: 99.0F BP: 128/82 HR: 78 RR: 15

SpO2: 99%

General: Pleasant, no acute distress. Well-dressed or well-groomed.

HEENT: normocephalic and atraumatic head. White sclera, pink conjunctiva, PERRLA. Bilateral TM pearly gray. Bilateral nasal mucosa pink and moist and pink.

 Chest/Lungs: symmetric chest wall, no abnormalities. Lungs clear to auscultation.Heart/Peripheral Vascular: S1, S2, no rubs, gallops or murmurs. Carotid pulses 2+, no bruits or thrill. Capillary refill less than 3 seconds. No edema. Shadow Health Comprehensive SOAP Note Assignment

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Abdomen: Symmetric, protuberant abdomen, no visible abnormalities. Normoactive bowel sounds. No CVA tenderness.

Genital/Rectal: deferred

Musculoskeletal: BUE and BLE with no masses, swelling, or deformity with full ROM. Neck and spine full ROM. Neck: 5/5, BUE: 5/5, BLE: 5/5

Neurological: Graphesthesia and stereognosis intact. Sensation to sharp pain intact. Sensation to dull pain intact Sensation to light touch intact. Decreased sensation per monofilament in bilateral feet.

Skin and Hair: Acanthosis nigricans noted on neck. Scattered pustules on face. No nail abnormalities.

Diagnostic results:

Spirometry: FVC 3.91L, FEV1/FVC ratio: 80.56%

Blood Glucose: 100

ASSESSMENT:

Encounter for pre-employment examination

Type 2 Diabetes Mellitus

Asthma

Hypertension

PCOS

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

Shadow Health Comprehensive SOAP Note Assignment