Week 3: Shadow Health Neurological
Physical Assessment Assignment
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Pre Brief
Two days after a minor, low-speed car accident in which Tina was a passenger, she
noticed daily bilateral headaches along with neck stiffness. She reports that it hurts to
move her neck, and she believes her neck might be swollen. She did not lose
consciousness in the accident and denies changes in level of consciousness since that
time. She states that she gets a headache every day that lasts approximately 1-2 hours.
She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. This
case study will allow you the opportunity to examine the patient's optic nerve via use of
the ophthalmoscope as well as assess her visual acuity. You will need to document
your findings using appropriate medical terminology. Be sure to assess for foot
neuropathy using the monofilament test.
Reason for visit: Patient presents complaining of headache.
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Rubric
Shadow Health P
Title:
Shadow Health Physical Assessment Rubric
Shadow Health Physical Assessment Rubric
Criteria Ratings Pts
Edit criterion Edit ratingDelete Edit Edit Edit 25.0
descriptionDel rating ratingDelete ratingDelete ratingDelete pts
ete criterion 25.0 pts rating rating rating 25.0 pts
row Above Average- 21.0 pts 10.0 pts 0.0 pts --
, Shadow Health Physical Assessment Rubric
Criteria Ratings Pts
DCE Score Average-
greater than or DCE Score Below
equal to 93; greater than Average-
This criterion Comprehensive or equal to DCE Score
is linked to a introduction with 86-92; Unsatisfactory-
greater than
Learning DCE Score
expectations of Adequate or equal to
OutcomeSubje exam less than or
introduction; 80-85;
ctive Data, equal to 79;
verbalized; some Incomplete
Organization, questions Introduction
questions introduction;
Communicatio worded in a missing;
worded in a many
n, and questions
non-judgmental non- questions
Summary worded in a
way; judgmental worded in a
(DCE Score or professional judgmental
way; judgmental
transcript) way; little
language professional way; some
professional
exercised; language professional
language;
questions well- mostly language
questions
organized; exercised; exercised;
unorganized;
appropriate questions questions
closing
Range closing with generally somewhat
missing.
threshold: pts summary of organized; organized;
findings somewhat incomplete
verbalized to complete closing.
patient. closing.
Edit criterion Edit Edit Edit Edit 20.0
descriptionDel ratingDelete ratingDelete ratingDelete ratingDelet pts
ete criterion rating rating rating e rating 20.0 pts
row 20.0 pts 16.0 pts 8.0 pts 0.0 pts --
This criterion Above Average- Below Unsatisfact
is linked to a Average- Physical Average- ory- No
Learning Physical assessment Physical physical
OutcomeObjec assessment documentation assessment assessmen
tive Data, documentation lacks sufficient documentation t
Physical includes all details lacks sufficient documenta
Examination, relevant body pertaining to details tion or no
Interpretation systems; all one or two pertaining to treatment
of Findings, pertinent relevant body three or more plan.
Assessment, normal and systems; or relevant body
and abnormal identifies ≥ systems; or
Documentatio findings 50% of the identifies <
n identified; pertinent 49% of the
documentation normal and pertinent
reflects abnormal normal and
professional findings; or abnormal
Physical Assessment Assignment
Submit Assignment
Pre Brief
Two days after a minor, low-speed car accident in which Tina was a passenger, she
noticed daily bilateral headaches along with neck stiffness. She reports that it hurts to
move her neck, and she believes her neck might be swollen. She did not lose
consciousness in the accident and denies changes in level of consciousness since that
time. She states that she gets a headache every day that lasts approximately 1-2 hours.
She occasionally takes 650 mg of over the counter Tylenol with relief of the pain. This
case study will allow you the opportunity to examine the patient's optic nerve via use of
the ophthalmoscope as well as assess her visual acuity. You will need to document
your findings using appropriate medical terminology. Be sure to assess for foot
neuropathy using the monofilament test.
Reason for visit: Patient presents complaining of headache.
? W5lvwx7msC0Tg online_upload
Upload a file, or choose a file you've already uploaded.
File: Add Another File
Click here to find a file you've already uploaded
CancelSubmit Assignment
Rubric
Shadow Health P
Title:
Shadow Health Physical Assessment Rubric
Shadow Health Physical Assessment Rubric
Criteria Ratings Pts
Edit criterion Edit ratingDelete Edit Edit Edit 25.0
descriptionDel rating ratingDelete ratingDelete ratingDelete pts
ete criterion 25.0 pts rating rating rating 25.0 pts
row Above Average- 21.0 pts 10.0 pts 0.0 pts --
, Shadow Health Physical Assessment Rubric
Criteria Ratings Pts
DCE Score Average-
greater than or DCE Score Below
equal to 93; greater than Average-
This criterion Comprehensive or equal to DCE Score
is linked to a introduction with 86-92; Unsatisfactory-
greater than
Learning DCE Score
expectations of Adequate or equal to
OutcomeSubje exam less than or
introduction; 80-85;
ctive Data, equal to 79;
verbalized; some Incomplete
Organization, questions Introduction
questions introduction;
Communicatio worded in a missing;
worded in a many
n, and questions
non-judgmental non- questions
Summary worded in a
way; judgmental worded in a
(DCE Score or professional judgmental
way; judgmental
transcript) way; little
language professional way; some
professional
exercised; language professional
language;
questions well- mostly language
questions
organized; exercised; exercised;
unorganized;
appropriate questions questions
closing
Range closing with generally somewhat
missing.
threshold: pts summary of organized; organized;
findings somewhat incomplete
verbalized to complete closing.
patient. closing.
Edit criterion Edit Edit Edit Edit 20.0
descriptionDel ratingDelete ratingDelete ratingDelete ratingDelet pts
ete criterion rating rating rating e rating 20.0 pts
row 20.0 pts 16.0 pts 8.0 pts 0.0 pts --
This criterion Above Average- Below Unsatisfact
is linked to a Average- Physical Average- ory- No
Learning Physical assessment Physical physical
OutcomeObjec assessment documentation assessment assessmen
tive Data, documentation lacks sufficient documentation t
Physical includes all details lacks sufficient documenta
Examination, relevant body pertaining to details tion or no
Interpretation systems; all one or two pertaining to treatment
of Findings, pertinent relevant body three or more plan.
Assessment, normal and systems; or relevant body
and abnormal identifies ≥ systems; or
Documentatio findings 50% of the identifies <
n identified; pertinent 49% of the
documentation normal and pertinent
reflects abnormal normal and
professional findings; or abnormal
