Shadow Health Focused exams For: Health History, HEENT, Respiratory, Cardiovascular, Abdominal, Musculoskeletal, Neurological, Skin, Hair, and Nails, Cough, Chest Pain, Abdominal Pain

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Shadow Health Focused exams For: Health History, HEENT, Respiratory, Cardiovascular, Abdominal, Musculoskeletal, Neurological, Skin, Hair, and Nails, Cough, Chest Pain, Abdominal Pain I. First Day of ... Class Presentation – Introduction to Tina Jones II. Weekly Assignment Introductions a. Health History b. HEENT c. Respiratory d. Cardiovascular e. Abdominal f. Musculoskelet al g. Neurological h. Skin, Hair, and Nails i. Focused Exam: Cough j. Focused Exam: Chest Pain k. Focused Exam: Abdominal Pain l. Comprehensive Assessment . Greeting your patient Asking open ended questions – reason for visit Providing clarification Asking specific questions and providing context – ER medication e. Asking additional open-ended questions – current status and medical history g. Asking specific questions – past medical history Providing patient education a. Health History b. HEENT c. Respiratory d. Cardiovascular e. Abdominal f. Musculoskeletal g. Neurological h. Skin, Hair, and Nails i. Focused Exam: Cough j. Focused Exam: Chest Pain k. Focused Exam: Abdominal Pain l. Comprehensive Assessment “Tina has a couple different things to pick up on during the HEENT exam. First, she has some complaints of worsening vision over the last few years. Vision 20/20 in left eye, 20/40 in right eye. Mild retinopathic changes in the right eye. Acanthosis nigricans noted on neck. Respiratory Pertinent Clinical Information: “Tina reports asthma and inhaler use, difficulty breathing around cats resolved with inhaler use. Expiratory wheezing, prolonged expiration (LLL, RLL, LML, RML). Muffled voice sounds throughout. No current respiratory distress. Cardiovascular Pertinent Clinical Information: “In this assessment, you will find that Tina has decreased peripheral pulses and mild edema ( 1) in her right foot. She has no murmurs, gallops, or bruits. Abdominal Pertinent Clinical Information: “Tina has lost 10 pounds this month, is eating more, drinking more, and voiding more. She discontinued taking her metformin on her own about 3 years ago. Protruberant abdomen with striae and normal BS. Musculoskeletal Pertinent Clinical Information: “Tina’s right ankle: 1 pitting edema, no masses, deformity, or discoloration. 2.5cm round wound noted on the ball of her foot. Right leg is without swelling or deformity. Right ankle is found to have limited range of motion and decreased strength. Neurological Pertinent Clinical Information: “Tina is alert and oriented x3, memory is good, denies numbness, tingling, recent mood changes, or history of depression or mental illness. On exam it is uncovered that Tina does have decreased sensation in both her left and right foot. Neuropathy like this is often seen in diabetic patients – especially in the extremities. Skin, Hair, and Nails Pertinent Clinical Information: “Tina has a 2.5 cm round wound on her right foot. There is edema present, along with discharge. The area is warm to the touch. Focused Exam: Cough Danny Rivera is an 8 year old boy who presents to the nurses office at his school with a cough. He describes the cough as “gurgly and watery”. Focused Exam: Chest Pain Brian Foster is a 58 year old man who is 3 days post-operative after a successful prostatectomy due to benign prostatic hypertrophy. He is complaining of 6/10 chest pain that began approximately 15 minutes ago. He describes his pain is a “squeezing pressure” in his chest that is constant and increasing in severity. Focused Exam: Abdominal Pain Esther Park is a 78 year old Korean American woman who presents to the Emergency Department with persistent, generalized abdominal pain she rates at a 6/10. The reports that the pain started almost one week ago, and has gotten progressively worse. The describes the pain as dull and crampy Comprehensive Assessment Tina Jones presents for a pre-employment physical. Today, she denies any acute concerns. She is feeling healthy, is taking better care of herself, and is looking forward to beginning her new job. There are no abnormal findings to uncover in this assessment .....................................CONTINUED............................... [Show More]

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