Assessment of the Heart, Lungs, and Peripheral Vascular System
This week, you will evaluate abnormal findings in the Chest and Lungs. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system.
Assignment 1: Digital Clinical Experience: In this DCE Assignment, you will conduct a focused exam related to chest pain using the simulation tool, Shadow Health. Consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
In a Focus note, include General Assessment, Heart, Lungs and Affected System. Use Scholarly references, Peer-reviewed articles, Research Articles, Professional Organization Recommendations and Walden’s Library or your current textbook. When documenting your Focus note, refer to SOAP note Template, this will ensure you include all required information. Review Rubric before submission.
Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.
Objective Documentation in Provider Notes –
Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.
You only need to examine the systems that are pertinent to the CC, HPI, and History.
Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned
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