Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Shadow Health Digital Clinical Experience Focused Exam Essay Paper
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC): In just a few words, explain why the patient came to the clinic.
History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (i.e. 34-year-old AA male). You must include the 7 attributes of each principal symptom: Shadow Health Digital Clinical Experience Focused Exam Essay Paper
- Location
- Quality
- Quantity or severity
- Timing, including onset, duration, and frequency
- Setting in which it occurs
- Factors that have aggravated or relieved the symptom
- Associated manifestations
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Medications: Include over the counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.
Allergies: Include specific reactions to medications, foods, insects, and environmental factors.
Past Medical History (PMH): Include illnesses (also childhood illnesses), hospitalizations, and risky sexual behaviors.
Past Surgical History (PSH): Include dates, indications, and types of operations.
Sexual/Reproductive History: If applicable, include obstetric history, menstrual history, methods of contraception, and sexual function.
Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s interests, ADL’s and IADL’s if applicable, and exercise and eating habits.
Immunization History: Include last Tdp, Flu, pneumonia, etc.
Significant Family History: Include history of parents, Grandparents, siblings, and children.
Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History). Remember that the information you include in this section is based on what the patient tells you. You will only need to cover systems pertinent to your CC, HPI (N/A, UNKNOWN is not acceptable, make up the information if you need to). To ensure that you include all essentials in your case, refer to Chapter 2 of the Sullivan text.
General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.
Cardiovascular/Peripheral Vascular:
Respiratory:
Gastrointestinal:
Musculoskeletal:
Psychiatric:
OBJECTIVE DATA: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P. Do not use WNL or normal. You must describe what you see. Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Physical Exam:
Vital signs: Include vital signs, ht, wt, temperature, and BMI and pulse oximetry.
General: Include general state of health, posture, motor activity, and gait. This may also include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of conscience, and affect and reactions to people and things.
Cardiovascular/Peripheral Vascular: Always include the heart in your PE.
Respiratory: Always include this in your PE.
Gastrointestinal:
Musculoskeletal:
Neurological:
Skin:
Diagnostic Test/Labs: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses with rationale for each one documented OR ones that were mentioned during the SH assignment.
ASSESSMENT: List your priority diagnosis(es). For each priority diagnosis, list at least 3 differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled.
Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack? Shadow Health Digital Clinical Experience Focused Exam Essay Paper
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation too, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
To Prepare
Review this week’s Learning Resources and the Advanced Health Assessment and Diagnostic Reasoning media program and consider the insights they provide related to heart, lungs, and peripheral vascular system.
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 Focused Exam: Chest Pain 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 7 DCE Focused Exam: Chest Pain Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
Consider what history would be necessary to collect from the patient.
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?
**Below is the transcript to create Soap note.
Hi Mr Foster, My name is , I am going to examine you today.
Greet
10/05/20 1:18 PM MDT
Brian Foster
Good morning.
Your avatar
What brought you here today ?
Question
10/05/20 1:18 PM MDT
Brian Foster
I have been having some troubling chest pain in my chest now and then for the past month.
Your avatar
Oh I’m sorry to hear that, it should be very uncomfortable to have that pain for a whole month.
Empathize
10/05/20 1:22 PM MDT Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Brian Foster
Thanks. I appreciate that.
Your avatar
? (No matching questions found.)
Question
10/05/20 1:22 PM MDT
Your avatar
What is the onset of your pain ?
Question
10/05/20 1:23 PM MDT
Brian Foster
I first noticed it earlier this month. I thought it might just be heartburn and it passed after about a couple of minutes.
Your avatar
What is the exact location of the pain ?
Question
10/05/20 1:24 PM MDT
Brian Foster
When the pain happens, I feel it mostly in the middle of my chest, over my heart.
Your avatar
When did you chest pain start ?
Question
10/05/20 1:25 PM MDT
Brian Foster
I first noticed it earlier this month. I thought it might just be heartburn and it passed after a couple of minutes.NURS6512 Week 7 – Focused Exam: Chest Pain Brian Foster Results
Your avatar
What is the exact location of the pain ?
Question
10/05/20 1:25 PM MDT
Brian Foster
When the pain happens, I feel it mostly in the middle of my chest, over my heart.
Your avatar
Sorry to hear that
Empathize
10/05/20 1:26 PM MDT
Brian Foster
Thanks. I appreciate that.
Your avatar
Easter pain radiates anywhere ? (Clarified to Is your pain radiating?.)
Question
10/05/20 1:26 PM MDT
Brian Foster
The pain doesn’t radiate anywhere. It’s mostly just right in the middle of my chest. (Clarified to if the pain is radiating.)
Your avatar
If your arm hurts (Clarified to Do you have pain in your arm?.)
Question
10/05/20 1:26 PM MDT
Brian Foster
No, when I am having the chest pain, it’s mostly just in middle of my chest. (Clarified to if I have pain in my arm.)
Your avatar
Do you have a pain in your shoulder ?
Question
10/05/20 1:27 PM MDT
Brian Foster
No, the pain hasn’t been in my shoulder.
Your avatar
Do you have a back pain ?
Question
10/05/20 1:27 PM MDT
Brian Foster
I haven’t had back pain, no. Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Your avatar
Can you tell me the duration of the pain ? (No matching questions found.)
Question
10/05/20 1:28 PM MDT
Your avatar
Can you describe the duration of the pain ? (Clarified to Can you tell me what the pain is like?.)
Question
10/05/20 1:28 PM MDT
Brian Foster
Well, it mostly feels tight and uncomfortable right in the middle of my chest. (Clarified to if I can tell you what the pain is like.)
Your avatar
How often pain occurs ? (Clarified to How often do you have pain?.)
Question
10/05/20 1:29 PM MDT
Brian Foster
Well, it has happened three times the past month. It usually goes away after about a couple of minutes. (Clarified to how often I have pain.)
Your avatar
Can you describe your pain from 0 to 10 scale ?
Question
10/05/20 1:29 PM MDT
Brian Foster
I’d say maybe a . . . 5? It’s just really uncomfortable . . . like there’s nothing I can do about it. Right now it’s like a zero though.
Your avatar
Sorry to hear that
Empathize
10/05/20 1:30 PM MDT
Brian Foster
Thanks. I appreciate that.
Your avatar
Can you describe your pain ?
Question
10/05/20 1:31 PM MDT
Brian Foster
Well, it mostly feels tight and uncomfortable right in the middle of my chest.
Your avatar
ASA pain crashing ? (Clarified to Do you take aspirin?.)
Question
10/05/20 1:31 PM MDT
Brian Foster
I usually just take Tylenol or ibuprofen. (Clarified to if I take aspirin.)
Your avatar
What is the dosage of Tylenol are you taking ?
Question
10/05/20 2:35 PM MDT
Brian Foster
Just whatever the bottle recommends for an adult.
Your avatar
What is the dosage of ibuprofen you taking ? (Clarified to What is the strength of the ibuprofen you take?.)
Question
10/05/20 2:35 PM MDT
Brian Foster
Just whatever the bottle recommends for an adult. (Clarified to What strength ibuprofen I take.)NURS6512 Week 7 – Focused Exam: Chest Pain Brian Foster Results
Your avatar
Is it Tylenol helps ? Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Question
10/05/20 2:35 PM MDT
Brian Foster
Just a couple when I get a headache, which is not very often.
Your avatar
How often do you take Tylenol ?
Question
10/05/20 2:36 PM MDT
Brian Foster
I took some today . . . maybe every couple days for mild pain.
Your avatar
What is the reason you’re taking ibuprofen ?
Question
10/05/20 2:36 PM MDT
Brian Foster
Just when I need it for various aches and pains. Probably not more than 3 or 4 times a month.
Your avatar
Where else do you have a pain ?
Question
10/05/20 2:36 PM MDT
Brian Foster
No, when I am having the chest pain, it’s mostly just in middle of my chest.
Your avatar
Do you have a pain somewhere else in your body ?
Question
10/05/20 2:37 PM MDT
Brian Foster
No, when I am having the chest pain, it’s mostly just in middle of my chest.
Your avatar
What is the aggravating factors ? (Clarified to Are there any aggravating factors?.)
Question
10/05/20 2:37 PM MDT
Brian Foster
Well, the pain seems to start when I’m doing something physical . . . the first time it happened while I was doing yard work, and the second time . . . I had to take the stairs at work because the elevator broke. Both times it got better if I took a break or sat down to rest. (Clarified to if there are aggravating factors.)
Your avatar
What activity triggers pain ? Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Question
10/05/20 2:39 PM MDT
Brian Foster
If I’m up and moving around I definitely notice it more and it makes me feel like I should sit down and take a deep breath or something.
Your avatar
He’s a pain worse when you eat ?
Question
10/05/20 2:40 PM MDT
Brian Foster
I don’t think eating has anything to do with it. One episode did happen when my wife and I were out for dinner, but it seemed to happen before we even settled. The episodes don’t seem all that related, to be honest.
Your avatar
It can be a lot of triggers in your diet which would aggravate and trigger your pain Mr.Foster.
Educate
10/05/20 2:43 PM MDT
Brian Foster
Good to know. Thank you.
Your avatar
Do you like spicy food ? Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Question
10/05/20 2:43 PM MDT
Brian Foster
Sure, I like spicy food. I don’t eat it very often, though. Maybe once or twice a month.
Your avatar
Do you like high-fat food ? (Clarified to Do fatty foods cause the pain?.)
Question
10/05/20 2:44 PM MDT
Brian Foster
I don’t think that has anything to do with it, but I guess I don’t know. (Clarified to if fatty foods cause the pain.)
Your avatar
What relieves your pain ?
Question
10/05/20 2:44 PM MDT
Brian Foster
I’m not sure. I think lying still seems to help a little.
Your avatar
Take anything for chest pain ?
Question
10/05/20 2:46 PM MDT
Brian Foster
No, not yet.
Your avatar
Do you take medication for hypertension ?
Question
10/05/20 2:46 PM MDT
Brian Foster
I take metoprolol, yes. [AUDIO COMING SOON]
Your avatar
Is a dosage of Metoprolol ? (Clarified to What dose of Lopressor do you take?.)
Question
10/05/20 2:47 PM MDT
Brian Foster
I think it’s 100 mg, once a day. (Clarified to what dose of Lopressor I take.)
Your avatar
Do you take any medication for hyperlipidemia ?
Question
10/05/20 2:47 PM MDT
Brian Foster
I take atorvastatin. [AUDIO COMING SOON]
Your avatar
What is the dosage of atorvastatin are you taking ?
Question
10/05/20 2:48 PM MDT
Brian Foster
I think it’s twenty milligrams a day.
Your avatar
Do you take over-the-counter medications ?
Question
10/05/20 2:48 PM MDT
Brian Foster
Oh, just ibuprofen or Tylenol occasionally for pain.
Your avatar
Do you take any supplements ?
Question
10/05/20 2:48 PM MDT
Brian Foster
I take fish oil, that’s it.
Your avatar
How frequently you take medication for hyperlipidemia ? (Clarified to Do you take cholesterol medication?.)
Question
10/05/20 2:49 PM MDT Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Brian Foster
I take atorvastatin. [AUDIO COMING SOON] (Clarified to if I take cholesterol medication.)NURS6512 Week 7 – Focused Exam: Chest Pain Brian Foster Results
Your avatar
How often do you take atorvastatin ?
Question
10/05/20 2:50 PM MDT
Brian Foster
I take them daily. I’m pretty good about following the doctor’s orders.
Your avatar
When have you been diagnosed with high blood pressure ?
Question
10/05/20 2:51 PM MDT
Brian Foster
Yes, I supposedly have moderately high blood pressure.
Your avatar
When you started to take metoprolol ?
Question
10/05/20 2:51 PM MDT
Brian Foster
I think it’s been about one year.
Your avatar
When have you been diagnosed with hyperlipidemia ? (Clarified to Do you have an anxiety disorder?.)
Question
10/05/20 2:51 PM MDT
Brian Foster
I’ve never had any anxiety problems before. [AUDIO COMING SOON] (Clarified to if I have an anxiety disorder.)
Your avatar
When have you been diagnosed with hyperlipidemia ? (Clarified to Are you diagnosed with high blood pressure?.)
Question
10/05/20 2:52 PM MDT
Brian Foster
Yes, I supposedly have moderately high blood pressure. (Clarified to if I have been diagnosed with hypertension.)
Your avatar
I’m sorry to hear that
Empathize
10/05/20 2:52 PM MDT
Brian Foster
Thanks. I appreciate that.
Your avatar
Do you do exercise ?
Question
10/05/20 2:53 PM MDT
Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.
Your avatar
I’m sorry to hear that your bike was stolen
Empathize
10/05/20 2:53 PM MDT
Brian Foster
Thanks. I appreciate that.
Your avatar
When did the exercise last time ?
Question
10/05/20 2:53 PM MDT
Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.
Your avatar
What type of food do you like ?
Question
10/05/20 2:54 PM MDT
Brian Foster
Um, let’s see . . . For breakfast I usually eat a granola bar and drink an instant breakfast shake. I’ve been doing that a while since it saves time in the morning. Most days for lunch I get a sandwich from the sub shop near work. That’s usually a turkey sub, but sometimes I get a spicy Italian sub. My wife and I grill a lot, and usually have some grilled meat with veggies for dinner. Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Your avatar
United include a lot of processed and fast food which is not good for your body. To have the same fast food diet may affect you over the time. You need to change your diet.NURS6512 Week 7 – Focused Exam: Chest Pain Brian Foster Results
Educate
10/05/20 2:57 PM MDT
Brian Foster
Good to know. Thank you.
Your avatar
You need to exercise.Not essential to do that with a bike. You can do sit ups, running or just simple indoor exercises in your home.
Educate
10/05/20 2:59 PM MDT
Brian Foster
Good to know. Thank you.
Your avatar
Did you lose any weight ? (Clarified to Have you lost weight?.)
Question
10/05/20 2:59 PM MDT
Brian Foster
Not exactly . . . I’ve gained about fifteen to twenty pounds in the last couple years. (Clarified to if I have lost weight.)
Your avatar
It’s not good to gain the weight. You need to change the diet and start doing the exercises.
Educate
10/05/20 3:10 PM MDT
Brian Foster
Good to know. Thank you.
Your avatar
What’s what’s your fathers health ?
Question
10/05/20 3:14 PM MDT
Brian Foster
He really wasn’t doing so great in the last few years. He died when he was 75 of colon cancer, but even before that, his weight and his blood pressure and cholesterol were getting the best of him. It was rough. He didn’t last too long after the cancer diagnosis, unfortunately. I think he was tired of fighting.
Your avatar
I’m sorry to hear that it should be very difficult to lose the father
Empathize
10/05/20 3:15 PM MDT
Brian Foster
Thanks. I appreciate that.
Your avatar
How did you cope with a losing father ? (No matching questions found.)
Question
10/05/20 3:15 PM MDT
Your avatar
How did you cope after you lost your father ?
Question
10/05/20 3:16 PM MDT
Brian Foster
Yeah. He died of colon cancer. He also had high blood pressure and high cholesterol.
Your avatar
Sorry to hear that
Empathize
10/05/20 3:16 PM MDT
ORDER HERE NOW
Brian Foster
Thanks. I appreciate that.
Your avatar
Who’s your mother’s health ?
Question
10/05/20 3:16 PM MDT
Brian Foster
She has type 2 diabetes and some high blood pressure, but I think she’s doing pretty well for 80.
Your avatar
Do you have a brothers and sisters ?
Question
10/05/20 3:17 PM MDTShadow Health Digital Clinical Experience Focused Exam Essay Paper
Palpated left radial pulse: No thrill, 2+
Exam Action
10/06/20 7:19 AM MDT
Your avatar
Palpated right femoral pulse: No thrill, 2+
Exam Action
10/06/20 7:19 AM MDT
Your avatar
Palpated left femoral pulse: No thrill, 2+
Exam Action
10/06/20 7:19 AM MDT
Your avatar
Palpated right popliteal pulse: No thrill, 1+
Exam Action
10/06/20 7:20 AM MDT
Your avatar
Palpated left popliteal pulse: No thrill, 1+
Exam Action
10/06/20 7:20 AM MDT
Your avatar
Palpated right tibial pulse: No thrill, 1+
Exam Action
10/06/20 7:22 AM MDT
Your avatar
Palpated right tibial pulse: No thrill, 1+
Exam Action
10/06/20 7:23 AM MDT
Your avatar
Palpated left tibial pulse: No thrill, 1+
Exam Action
10/06/20 7:23 AM MDT
Your avatar
Palpated right dorsalis pedis pulse: No thrill, 1+
Exam Action
10/06/20 7:23 AM MDT
Your avatar
Palpated left dorsalis pedis pulse: No thrill, 1+
Exam Action
10/06/20 7:23 AM MDT
Your avatar
Palpated right upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
Exam Action
10/06/20 7:25 AM MDT
Your avatar
Palpated left upper quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
Exam Action
10/06/20 7:26 AM MDT
Your avatar
Palpated left lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension
Exam Action
10/06/20 7:26 AM MDT
Your avatar
Palpated right lower quadrant with light pressure: No tenderness reported; no masses, guarding, or distension.NURS6512 Week 7 – Focused Exam: Chest Pain Brian Foster Results
Exam Action
10/06/20 7:26 AM MDT
Your avatar
Percussed right upper quadrant
Exam Action
10/06/20 7:27 AM MDT
Your avatar
Percussed left upper quadrant
Exam Action
10/06/20 7:27 AM MDT
Your avatar
Percussed right lower quadrant
Exam Action
10/06/20 7:27 AM MDT
Your avatar
Percussed left lower quadrant
Exam Action
10/06/20 7:27 AM MDT
Your avatar
Percussed spleen
Exam Action
10/06/20 7:27 AM MDT
Your avatar
Percussed for liver span: 7 cm in the mid-clavicular line
Exam Action
10/06/20 7:28 AM MDT
Your avatar
Performed EKG
Exam Action
10/06/20 7:28 AM MDT
Your avatar
Thank you Mr. Foster. I’m done with physical evaluation
Educate
10/06/20 7:30 AM MDT
Brian Foster
Good to know. Thank you.
Your avatar
Houston Foster how old are you ? (No matching questions found.)
Question
10/07/20 4:13 AM MDT
Your avatar
Mr.Foster how old are you ?
Question
10/07/20 4:13 AM MDT
Brian Foster
I’m 58 going on 30.
Your avatar
Early happy birthday
Empathize
10/07/20 4:14 AM MDT
Brian Foster
Thanks. I appreciate that. Shadow Health Digital Clinical Experience Focused Exam Essay Paper
Your avatar
Is it physical activity activates the pain ?
Question
10/07/20 4:53 AM MDT
Brian Foster
Well I used to ride my bike a lot but it got stolen a couple years ago. I guess I haven’t had much regular exercise since then. I want to get a new bike if the doctor says it is OK to exercise with this chest pain I’ve been having.
Your avatar
Sorry to hear that
Empathize
10/07/20 4:53 AM MDT
Brian Foster
Thanks. I appreciate that.
Your avatar
What aggravates your pain ?
Question
10/07/20 4:54 AM MDT
Brian Foster
Well, I think it’s when I’m doing something physical most of the time. The first time it happened, my chest started hurting after I was doing some yard work. The second time happened when the elevator broke at work so I had to take the stairs. My office is on the 5th floor.
Your avatar
Do you like red meat ?
Question
10/07/20 5:59 AM MDT
Brian Foster
Yes, yes I do.
Your avatar
Do you like vegetables and fruits ?
Educate
10/07/20 5:59 AM MDT Shadow Health Digital Clinical Experience Focused Exam Essay Paper
