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NSG500 Advanced Health Assessment

Residency Assignment

Focused History and Physical Exam

Students will record a video with soundto demonstrate competency obtaining a focused history and physical exam. Each student will have a “patient” use the information provided in the following case. The patient may be a family member or friend. The patient will sign the video release form prior to taping the exam. Students will then perform a videotaped focused history and physical exam on the patient use the case study below.

The findings from the history and physical exam will be also be written in the form of a SOAP note and submitted to the assignment folder. This information is due at the end of Module 10.

Ms. A is a 40 year old female high school English teacher who presents to her primary care provider for evaluation of a cough. The cough has been present for the past 10 days. At onset, the cough was accompanied by a fever up to 100.3 po. She has coughed up green sputum on occasion, but over the last 2 days, the sputum has become blood-tinged. She has noticed increased shortness of breath with exertion and had difficulty sleeping at night because of the cough. She has tried using over-the-counter medications without relief. She has not traveled anywhere recently. Several of her coworkers are also sick. She has ear pain. She denies sinus congestion or sore throat. She has had no palpitations, constipation, diarrhea, dysuria, or swelling in her extremities. She does admit to a headache, which has been intermittent for the last 5 days, and appears to be relieved somewhat by acetaminophen. 

She has smoked 1 packs of cigarettes per day since the age of 21.

She takes medication for seasonal allergies as needed. In childhood, she had her tonsils and adenoids removed.

Using this information, perform a focused history and physical exam on the “patient. “ Use a family member or friend as your “patient.”  “Your “patient” can simulate or ad lib to any of the information listed. If the student ass a question and answers are not in the case, the “patient” should make up a response. The case should be given to the patient prior to taping.

VideoCriteria

1.            The video will include obtaining the focused health history and physical exam. The video must not exceed 30 continuous minutes. All videos must be tapedin one continuoussession.

2.            The student will not be allowed any prompting materials during the focused history and physical examdemonstration.

3.            The student must actually put hands on the patient and perform/demonstrate thephysical assessment skills.

4.            The student should speak to describe what they are performing during the physical; for example I am observing the patient’s color, breathing pattern.

5.            The student must achieve a passing grade on the physical exam in orderto pass thecourse.

6.            The exam must take place in an appropriate setting and the examiner should be in professionaldress. The location may include a student’s home.

7.            Students are required to supply all video recordingequipment.

8.            A video release form must be signed by the client. A signed release form can be found in the content section of the course. The video will not be graded without a signed releaseform.

9.            During the video recording, the camera must be focused on the examiner, patient, and the area being assessed. The faculty grading the assignment will need to verify physical assessment technique, and if the video camera is too far away from the area being examined, the technique cannot be verified and the student will have to repeat thevideotape.

10.          Students should review their video after completion to ensure that the sound is adequate and that the exam is in full view of the camera.

11.          Any identifiers related to the client being examined must be removed prior to videotaping.

12.          Students may face program dismissal if Physical Assessment videos are made public outside of Wilkes.

Final assessment videos must be submitted by Sunday at 11:59 pm of Module 10 but can be submitted before that final date. If you are unable to perform a satisfactory physical assessment, a failing grade (F) will be assigned as the final grade for the course.

A SOAP note based on the assessment video will also be submitted. See the SOAP note instructions and Grading Rubric in the “Course Resources.”

Instructions for use of Panopto in D2L are located in the Course Resources for the alternative assignment.

 

 

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