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
... [Show More] 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
Title:
Shadow Health Physical Assessment Rubric
Shadow Health Physical Assessment Rubric
Criteria Ratings Pts
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This criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript)
Range
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25.0 pts
Above Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.
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21.0 pts
Average- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.
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10.0 pts
Below Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.
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0.0 pts
Unsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing.
pts
25.0 pts
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