NR 509 Shadow Health Physical Assessment Assignments

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NR 509 Advanced Physical Assessment

NR 509 Shadow Health Assignments (Complete Week 1-7)

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NR 509 Shadow Health Physical Assessment Assignments

NR-509 Week 1 Health History (Tina Jones)  NR 509 Shadow Health Assignments

Pre-brief: Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness…… Interviewing patients is an art and should remain an essential skill for successful practice.

In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem listusing evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation.

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview.

Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.

  • | Overview
  • | Transcript
  • | Subjective Data Collection
  • | Objective Data Collection
  • | Education & Empathy
  • | Documentation / Electronic Health Record
  • | Information Processing
  • | Lab Pass: Certificate of Completion

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NR 509 Week 2 HEENT and Respiratory Assessment (Tina Jones)

NR 509 Week 2 Shadow Health HEENT Physical Assessment Assignment

Pre-Brief: For the last week, Tina has experienced sore, itchy throat, itchy eyes, and runny nose. She states that these symptoms started spontaneously and have been constant in nature. … has treated her throat pain with occasional throat lozenges which has “helped a little”. She states that her nose “runs all day” and has clear discharge. … denies cough and recent illness. … denies fevers, chills, and night sweats. This case study will allow you to use standard office equipment to physically examine the patient’s eyes, ears, nose, and throat. You will need to document what you find in the Electronic Health Record (EHR). Be certain to use medically appropriate terminology, such as “erythematous” to describe redness of the skin, mucous membranes, or conjunctiva.

NR 509 Shadow Health Physical Assessment Assignments

Results Available:
| Overview
| Subjective Data Collection
| Objective Data Collection
| Education & Empathy
| Documentation / Electronic Health Record
| Lifespan
| Review Questions
| Self-Reflection

NR 509 Week 2 Shadow Health Respiratory Physical Assessment Assignment

Pre Brief: Tina had an asthma episode 2 days ago. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had ten episodes of wheezing and has shortness of breath approximately every four hours. Tina presents with continued shortness of breath and wheezing. Be sure to ask pertinent questions during the interview about related body systems. This case study will provide the opportunity to carefully assess lung sounds during the physical examination. Be sure to appropriately document your findings using correct medical terminology.

Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved.

Results Available:
| Overview
| Transcript
| Subjective Data Collection
| Objective Data Collection
| Education & Empathy
| Documentation / Electronic Health Record
| Student Pre-Survey
| Lifespan Activity
| Review Questions
| Self-Reflection Activity

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NR-509 Week 3 Musculoskeletal and Neurological Assessment (Tina Jones)

Pre Brief
Two days after a minor, low-speed car accident in which Tina 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 … swollen. She did not lose consciousness in the accident and denies changes in level of consciousness since that time. … that she gets a headache every day that lasts approximately 1-2 hours. … 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. Be sure to assess for foot neuropathy using the monofilament test. Reason for visit: Patient presents complaining of headache.

| Transcript
| Subjective Data Collection
| Objective Data Collection
| Education & Empathy
| Documentation/Electronic Health Record
| Pre-Survey Lifespan
| Review Questions
| Self-Reflection

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NR 509 Week 4 Cardiovascular (Tina Jones) and Chest Pain (Brian Foster)

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NR-509 Week 5 Gastrointestinal Assessment (Tina Jones) and Abdominal Pain (Esther Park)

Pre Brief: Ms. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain. She reports that the pain isn’t severe, but that her daughter was concerned and brought her in. It is very important to determine whether or not the situation is an emergency and that the underlying cause of Esther’s discomfort. Be sure to inquire about a variety of psychosocial factors related to the GI system, including her diet, toilet habits, immunizations, recent travel, etc. This case study will offer you the opportunity to take a complete surgical, reproductive, and current sexual history. During her physical examination, take particular note as to where Mrs. Park verbalizes pain during palpation so that you may synthesize verbal and non-verbal cues. Be sure to apply the supportive information learned in this week’s concept lab to your critical thinking process in this case study.

Reason for Visit: Patient presents complaining of abdominal pain.

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NR 509 Week 6 Mental health (Tina Jones), Pediatric Physical assessment, Cough (Daniel Rivera)

Daniel “Danny” Rivera is an 8-year-old boy who comes to the clinic with a cough. Students determine if Danny is in distress, explore the underlying cause of his cough, and look for related symptoms in other body systems.

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NR-509 Week 7 Comprehensive Health History and Physical examination (Tina Jones)

Pre Brief: In this case study, you will complete the Plan My Exam activity to organize the exam procedures you will use into a sequence that moves smoothly from head to toe by mapping them to the region of the body where you will perform them. After you have planned your exam, you will enter the clinic room and conduct a Comprehensive Assessment by interviewing and examining your Digital Standardized Patient. When collecting information for the comprehensive assessment, be sure to include the following: ……………..

As you complete the case study this week, be cognizant of the time that it takes you to conduct the history and physical. In family practice, you are generally allocated a total of 15-minutes for an entire patient visit, which includes taking a history, performing a physical examination, and developing/implementing a treatment plan. You also need to incorporate health promotion into the visit when possible. Be certain to follow a systematic approach during your interview and inquire about each system on the ROS. During the physical exam, be sure to apply the examination skills that you have learned in this course to assess your virtual patient.

Ms. Tina Jones is a pleasant, 29-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

Reason for visit: Patient requests a complete health assessment for a pre-employment.

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