Description
Please fill out the SOAP note template in the attached files based on the scenario. Please provide at least 1 scholarly reference with DOI for each diagnosis (last five years, 2019). Write in bullet format same way as you did in the previous SOAP note. I have already chosen the diagnosis, and I wrote them in the template. You just need to add the justification with citations.
Unformatted Attachment Preview
12/29/23, 1:39 AM
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
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Week 5 – Focused Exam: Cough Results | Turned In
Advanced Health Assessment and Diagnostic Reasoning – NP – November 2023, nurs6512-garkfankexr4i4fxd1r758nzalvp9xpgbz3jtsta:canvas-lms-202430
Return to Assignment (/assignments/917200/)
Your Results
Reopen (/assignment_attempts/15813134/reope
Lab Pass (/assignment_attempts/15813134/lab_pass.
Overview
Objective Data Collection: 12.9 of 13 (99.23%)
Transcript
Subjective Data Collection
Correct
Incorrect
Objective Data Collection
Partially correct
Missed
Education & Empathy
Documentation
Program Competency Progress
Video Tutorial
Inspected eyes and orbital area
Orbital Area (1/4 point)
1 of 1 poi
Sclera (1/4 point)
No visible abnormal findings
White
Ptosis
Jaundice
Eyelid edema
Injection
Lesion
Icterus
Allergic shiners
Conjunctiva (1/4 point)
Conjunctival Discharge (1/4 point)
Moist and pink
No discharge
Pale
Clear, watery discharge
Dry appearance
Purulent discharge
Erythema
Edema
Inspected nasal cavities
Color (1/4 point)
1 of 1 poi
Discharge (1/4 point)
Pink
No discharge
Erythemic
Clear discharge
Bluish
Bloody discharge
Purulent discharge
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| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Turbinate Patency (1/4 point)
Observations (1/4 point)
Patent
No additional visible abnormal finding
Decreased patency
Foreign body present
Not patent
Polyp
Septum perforated
Septum deviated
Lesion
Inspected ears
Right: Auditory Canal Color (No point)
Right: Tympanic Membrane Color (1/10
Pink
Pearly gray
Erythemic
Erythemic
Pallor
Opaque
Yellow
Not visible because of cerumen
Right: Tympanic Membrane Appearance (1/10 point)
Right: Cone Of Light (1/10 point)
No visible abnormal findings
5:00
Fluid observed
Cone of light distorted
Visible scars
Bulging
Perforation
Retraction
Right: Discharge (1/10 point)
Left: Auditory Canal Color (1/10 point)
No discharge
Pink
Cerumen
Erythemic
Clear discharge
Pallor
Bloody discharge
Purulent discharge
Left: Tympanic Membrane Color (1/10 point)
Left: Tympanic Membrane Appearance
Pearly gray
No visible abnormal findings
Erythemic
Fluid observed
Opaque
Visible scars
Yellow
Bulging
Not visible because of cerumen
Perforation
Retraction
Left: Cone Of Light (1/10 point)
Left: Discharge (1/10 point)
7:00
No discharge
Cone of light distorted
Cerumen
Clear discharge
Bloody discharge
Purulent discharge
Inspected mouth and throat
Oral Mucosa (1/5 point)
Tonsils (1/5 point)
Moist and pink
No visible abnormal findings
Dry appearance
Edema
Erythema
Erythema
Posterior Oropharynx Color (1/5 point)
Pink
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Posterior Oropharynx Texture (1/5 poin
No abnormal findings
2/5
12/29/23, 1:39 AM
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Erythemic
Cobblestoning
Exudate
Post Nasal Drip (1/5 point)
No discharge
Clear discharge
Purulent discharge
Inspected neck
Symmetry (1/2 point)
Appearance (1/2 point)
Symmetric
No visible abnormal findings
Asymmetric
Swelling
Visible pulsation
Visible mass
Discoloration
Inspected chest
Symmetry (1/2 point)
Appearance (1/2 point)
Symmetric
No visible abnormal findings
Asymmetric
Rash or lesion
AP diameter abnormal Intercostal retr
Excessive use of accessory muscles
Pectus excavatum
Skin growths (freckles or moles)
Evidence of skin trauma (scar, lacera
Palpated sinuses
Frontal (1/2 point)
Maxillary (1/2 point)
None reported
None reported
Tenderness reported
Tenderness reported
Palpated lymph nodes
Cervical (1/3 point)
Supraclavicular (1/3 point)
No palpable nodes
No palpable nodes
Palpable nodes on right side
Palpable nodes on right side
Palpable nodes on left side
Palpable nodes on left side
Axillary (1/3 point)
No palpable nodes
Palpable nodes on right side
Palpable nodes on left side
Palpated fremitus
Symmetry (1/2 point)
Vibration (1/2 point)
Equal bilaterally
Expected fremitus
Unequal bilaterally
Decreased fremitus
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12/29/23, 1:39 AM
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Auscultated breath sounds
Breath Sounds (1/3 point)
Adventitious Sounds (1/3 point)
Present in all areas
No adventitious sounds
Diminished in some areas
Wheezing
Absent in some areas
Fine crackles
Stridor
Rhonchi
Rales
Location (1/3 point)
All areas clear
Adventitious sounds in anterior right upper lobe
Adventitious sounds in anterior right middle lobe
Adventitious sounds in anterior right lower lobe
Adventitious sounds in anterior left upper lobe
Adventitious sounds in anterior left lower lobe
Adventitious sounds in posterior right upper lobe
Adventitious sounds in posterior right lower lobe
Adventitious sounds in posterior left upper lobe
Adventitious sounds in posterior left lower lobe
Auscultated for bronchophony
Bronchophony (1/1 point)
Positive
Negative
Auscultated heart sounds
Heart Sounds (1/2 point)
Extra Heart Sounds (1/2 point)
S1 and S2 audible
No extra sounds
S1, S2, and S3 audible
Gallops
S1, S2, and S4 audible
Murmur
S1, S2, S3, and S4 audible
Friction rub
Valve clicks
Percussed chest wall
Observations (1/2 point)
Location (1/2 point)
All areas resonant
No areas of dullness
Some areas dull, some resonant
Dullness, anterior right upper lobe
Some areas hyperresonant, some resonant
Dullness, anterior right middle lobe
Dullness, anterior right lower lobe
Dullness, anterior left upper lobe
Dullness, anterior left lower lobe
Dullness, posterior right upper lobe
Dullness, posterior right lower lobe
Dullness, posterior left upper lobe
Dullness, posterior left lower lobe
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12/29/23, 1:39 AM
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
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12/29/23, 1:33 AM
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Customer Support will be closed on the December 31st and January 1st as it falls on a Sunday and Monday. We will reopen these channels on January 2nd
CST. You can continue to raise issues through the support hub, and we will respond to these queries when we’re back on the 2nd. Feel free to visit our Shad
Health Support Center for assistance during this time. Click here for more information (https://service.elsevier.com/app/home/supporthub/shadow-health/)
Week 5 – Focused Exam: Cough Results | Turned In
Advanced Health Assessment and Diagnostic Reasoning – NP – November 2023, nurs6512-garkfankexr4i4fxd1r758nzalvp9xpgbz3jtsta:canvas-lms-202430
Return to Assignment (/assignments/917200/)
Your Results
Reopen (/assignment_attempts/15813134/reope
Lab Pass (/assignment_attempts/15813134/lab_pass.
Overview
Subjective Data Collection: 21 of 21 (100.0%)
Transcript
Subjective Data Collection
Hover To Reveal…
Indicates an item that
you found.
Hover over the Patient Data items
below to reveal important
information, including Pro Tips
and Example Questions.
Indicates an item that
is available to be found.
Objective Data Collection
Education & Empathy
Documentation
Program Competency Progress
Video Tutorial
Category
Scored Items
Patient Data
Not Scored
Experts selected these topics as essential
A combination of open and closed questio
components of a strong, thorough interview
with this patient.
will yield better patient data. The following
details are facts of the patient’s case.
Chief Complaint
Established chief complaint
Reports cough
Asked about onset of cough
Reports cough started 5 days ago
History of Present Illness
Asked about frequency and duration of
cough
Asked about character of cough
Reports coughing every few minutes
Reports cough is wet
Reports clear sputum
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12/29/23, 1:33 AM
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Asked about aggravating factors for cough
Reports cough is worse at night
Reports exposure to secondhand smoke
Denies knowing what makes the cough worse
Asked about relieving factors for cough
Denies resting relieves co
Denies drinking water relie
Asked about nasal symptoms
Reports current runny nos
Denies sneezing
Reports frequent runny no
Followed up on nasal discharge
Reports nasal discharge i
Reports nasal discharge i
Asked about ear symptoms
Reports pain in right ear
Followed up on ear pain
Reports ear pain started y
Reports ear pain is a 3 ou
Denies ear discharge
Asked about throat symptoms
Reports sore throat
Reports “a little” pain with
Asked about allergies
Denies seasonal allergies
Denies food allergies
Denies medication allergie
Denies allergies to animal
Denies latex allergy
Asked about contact with illnesses
Denies being around anyo
Asked about home medications
Confirmed home medicati
Home Medications
Reports taking a daily vita
Reports taking cough med
Followed up on cough medicine
Reports cough medicine w
Reports taking one spoon
Reports mother gave him
Reports cough medicine p
Past Medical History
Asked about relevant medical history
Denies asthma diagnosis
Reports immunizations as
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12/29/23, 1:33 AM
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
Reports past pneumonia and frequent coughs
Denies past hospitalizations
Social Determinants of Health
Asked about exposure to secondhand smoke
Reports father smokes cig
Reports father sometimes
Social History
Asked about living conditions
Reports living in a house w
Reports feeling safe at ho
Reports park with playgro
Review of Systems
Asked about constitutional health
Denies fever
Denies chills
Reports feeling “kind of tir
Denies night sweats
Denies weight loss
Denies appetite loss
Asked about review of systems for HEENT
Denies ear popping or cra
Reports history of frequen
Denies ear surgery or ear
Denies headaches
Denies nosebleeds
Denies vision problems
Denies dizziness
Denies watery eyes
Denies eye redness
Denies eye pain
Denies sinus pain
Denies hearing problems
Asked about review of systems for respiratory
Denies difficulty breathing
Denies chest tightness
Denies chest pain
Denies history of inhaler u
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
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12/29/23, 1:33 AM
| Shadow Health® │ Digital Clinical Experiences™ from Elsevier
About Shadow Health (https://evolve.elsevier.com/education/simulations/shadow-health/)
Terms and Conditions (https://www.elsevier.com/legal/elsevier-website-terms-and-conditions)
Privacy Policy (https://www.elsevier.com/legal/privacy-policy)
Support and Contact (https://service.elsevier.com/app/home/supporthub/shadow-health/) Patents (/static/patents)
s://www.elsevier.com/)
(https://w
Cookies are used by this site. Cookie settings | Your Privacy Choices.
Copyright © 2023 Elsevier Inc., its licensors, and contributors. All rights are reserved, including those for text and data mining, AI training, and
similar technologies.
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Name:
Section:
Week 5
Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation
SUBJECTIVE DATA: Include what the patient tells you, but organize the information.
Chief Complaint (CC):
History of Present Illness (HPI):
Medications:
Allergies:
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History:
Personal/Social History:
Immunization History:
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.
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
© 2021 Walden University
Psychiatric:
Neurological:
Lymphatics:
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.
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.
HEENT:
Respiratory: Always include this in your PE.
Cardiology: Always include the heart in your PE.
Lymphatics:
Psychiatric:
Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the
differential diagnoses.)
ASSESSMENT:
Primary diagnosis:
1. Acute Viral Rhinitis.
Differential diagnosis:
1. Acute sinitus.
2. Influenza
3. Ear infection
© 2021 Walden University
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