Assignment 2: Digital Clinical Experience: Focused Exam: Cough

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

To Prepare

• Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
• Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
• Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
• Access and log in to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
• 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?

Focused Exam: Cough Assignment:

Complete the following in Shadow Health:

• Respiratory Concept Lab (Required)
• Episodic/Focused Note for Focused Exam: Cough
• HEENT (Recommended but not required)

 

Submission and Grading Information

• Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
• Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard for your faculty review. 
• (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.)

You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass

• Complete your documentation using the documentation template in your resources and submit it to your Assignment submission link below.

 

 

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance, “headache”, NOT “bad headache for 3 days”.

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. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was a “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used, and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMH: include immunization status (note date of last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), and any other pertinent data. Always add some health promo questions here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. The reason for the death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General:Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness, or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat Denies hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough, or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding, or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: 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. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format i.e. General: Head: EENT: etc. 

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines.

P.  

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

                                                                                      References

You are required to include at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

 

 

 

 

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