(Solution) NR509 Week 3: Shadow Health Assessment Assignment

Introduction and Pre-brief

Two days after a minor, low-speed car accident in which Tina Jones was a passenger, she noticed daily bilateral headaches along with neck stiffness. She reports that it hurts to move her neck, and she believes her neck might be swollen. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. She states that she gets a headache every day that lasts approximately 1-2 hours. She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. This case study will allow you the opportunity to examine the patient’s optic nerve via use of the ophthalmoscope as well as assess her visual acuity. You will need to document your findings using appropriate medical terminology. Careful assessment of documentation of EACH cranial nerve is integral to performing a comprehensive neurological assessment. Be sure to assess for foot neuropathy using the monofilament test.

Tips and Tricks

By now you are very familiar and comfortable with navigating the Shadow Health virtual learning environment. The simulated patients are similar to actual patients and can respond to over 70,000 initial and follow-up questions. Your patients will never get frustrated when you ask multiple questions and they will never get embarrassed or withhold information if you address sensitive subjects, like sexual activity.

Be sure to practice asking interview questions in Shadow Health using the talk-to-text feature and the Google Chrome browser. This will assist with reducing the time commitment for each assignment and enhance the fidelity of your patient-provider experience.

When writing up your physical examination findings, it is insufficient to simply document that the cranial nerve assessed was “intact” or “normal”. What does this mean? Document exactly what you assessed and the findings. Documentation of pertinent negative findings, which denote what you expect to find during the examination and not an abnormality, are just as important as pertinent positive, or abnormal, findings.

Purposes

The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the individual needs of the patient, (d) apply assessment skills and techniques to gather subjective and objective data, (e) differentiate normal from abnormal physical examination findings, (f) summarize, organize, and appropriately document findings using correct professional terminology, (g) practice developing primary and differential diagnoses, (h) practice creating treatment plans which include diagnostics, medication, education, consultation/referral, and follow-up planning; and (i) analyze and reflect on own performance to gain insight and foster knowledge.

Activity Learning Outcomes

Through this assignment, the student will demonstrate the ability to:

  1. Apply knowledge and understanding of advanced practice physical assessment skills and techniques (CO1)
  2. Perform focused and comprehensive histories and physical assessments for various patient populations (CO4 and CO5)
  3. Adapt skills and techniques to suit the individual needs of the patient (CO4)
  4. Differentiate normal from abnormal physical examination findings (CO2)
  5. Summarize, organize, and document findings using correct professional terminology (CO3)

Due Date

Sunday 11:59 PM MT at the end of each respective week.

Students are expected to submit assignments by the time they are due. Assignments submitted after the due date and time will receive a deduction of 10% of the total points possible for that assignment for each day the assignment is late. Assignments will be accepted, with penalty as described, up to a maximum of three days late, after which point a zero will be recorded for the assignment. 

In the event of an emergency that prevents timely submission of an assignment, students may petition their instructor for a waiver of the late submission grade reduction. The instructor will review the student’s rationale for the request and make a determination based on the merits of the student’s appeal. Consideration of the student’s total course performance to date will be a contributing factor in the determination. Students should continue to attend class, actively participate, and complete other assignments while the appeal is pending. 

Total Points Possible: 75 Points

Assignment

Step One: Complete the designated Shadow Health (SH) Assignment on the SH platform.

Step Two: Document your findings on the  Fillable Soap Note Template  download or the Printable Soap Note  download.

Step Three:  Upload the Lab Pass and completed SOAP Note as separate documents to the same assignment tab in the gradebook.

Requirements

NOTE: Before initiating any activity in Shadow Health, complete the required course weekly readings and lessons as well as review the introduction and pre-brief.

  1. Complete the Shadow Health Concept Lab (Weeks 2, 4, and 5) prior to beginning the graded assignment.
  2. Gather subjective and objective data by completing a focused, detailed health history and physical examination for each physical assessment assignment.
  3. Critically appraise the findings as normal or abnormal.
  4. Complete the post activity assessment questions for each assignment .
  5. Complete all reflection questions following each physical assessment assignment.
  6. Digital Clinical Experience (DCE) scores do not round up. For example, a DCE score of 92.99 is a 92, not a 93.
  7. You have a maximum of two (2) attempts per Shadow Health assignment to improve your performance. However, you may elect not to repeat any assignment. NOTE: If you repeat an attempt, ONLY the second attempt will be graded, regardless of the DCE score. Please refer to the grading rubric categories for details.
  8. Download the Lab Pass for the final attempt on the assignment.

Solution:

S:Subjective

Information the patient or patient representative told you

SOAP Note Template

 

 

InitialsT.J Age: 28 Gender:Female
Height Weight BP HR RR Temp SPO2 Pain Rating Allergies (and reaction)
170cm 88kg 139/87 82 16 98.9 99% 3/10 Medication: PCN (rash/hives)

Food: No known food allergies

Environment: Cats; dust (causes asthma exacerbation)
History of Present Illness (HPI)
Chief Complaint (CC) Headaches and sore neck CC is a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.  Sometimes a patient has more than one complaint.  For example: If the patient presents with cough and sore throat, identify which is the CC  and which may be an associated symptom
Onset Low speed car accident 1 week ago; symptoms began 2 days after accident
Location Headache: crown and back of head; pain 3/10

Neck: back of neck into head; pain 3/10
Duration Five days – every day lasting 1-2 hours
Characteristics Headache: dull

Neck: stiff
Aggravating Factors Neck movement
Relieving Factors Medication (Tylenol) and rest
Treatment Medication (Tylenol)
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication

(Rx, OTC, or Homeopathic)

 Dosage Frequency Length of Time Used Reason for Use

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