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The University of Texas at Arlington College of Nursing N5418 Advanced Health Assessment and Diagnostic Reasoning Fall 2010 CLASS SCHEDULE DATE Thursday September 2, 2010 TIME 4:00-9:00pm TOPIC Orientation to course, & Web CT Soap Note Documentation Diagnostic Reasoning Process Meet Your Advisor Practice Soap Note DUE via Web-Ct by 10pm Thursday September 9, 2010 PREP FOR CLASS ***WEEK ONE PREPARATION; SOAP 1 AND SOAP II MODULES Please to the How to be successful in Health Assessment sheet located at the end of the schedule. It reviews post-test, Assigned Readings, Web-Ct Activities, and supplemental readings. This includes but is not limited to: Read and Complete the power point module on web ct on the topic for each topic for today Complete the Required reading Daines Chapter I: Clinical Reasoning Complete the Post-test. Review as needed. If you did not do well, Review the supplemental readings if needed: Mosby’ Guide to Physical Examination: Seidel and Ball: Chapter I: The history and interviewing process Chapter 3: Exam Techniques and Equipment Chapter 26: Recording Information HELPFUL HINTS your Syllabus to class Your Practice soap note is due on Thursday September 9, 2010
Exam I Thursday October14, 2010 Exam I will be online- The exam will be from Thursday October 21, 2010 4:00-9:00 Geriatric functional assessment Mini Mental Status Exam Mini lecture, demo and practice: Neuro Msk & Sports Exam Episodic Demo and Practice Practice from Head to toe Prep Modules for MSK, Sports Physical, Neuro Thursday November 4 2010 Thursday November 18, 2010 4:00-9:00 or possibly during this day Comprehensive check offs- Please schedule with your advisor- they maybe this evening or at another time this week Mini lecture, demo and Practice: Breast GU GYN Graded episodic Psychiatric Assessment via web/ct Prep Modules for GYN, Breast, GU
Endocrine Thyroid enlargement, heat or cold intolerance, excessive sweating, excessive thirst or hunger, skin striae. Psychiatric Depression, mood changes, nervousness, tension, irritability, difficulty concentrating, memory loss. PHYSICAL EXAMINATION General. 25 year old African American female, alert, cooperative, well groomed, communicates well, makes eye contact. T 98.6 F, P 70, R 16 VS---BP sitting, supine, and standing Wt-54.5 kg, Ht-5'4" Mental Status. Awake and oriented x 3 to person, place, and time. Speech clear, enunciated words; comprehends directions. Skin, Hair, and Nails. Soft, moist, turgor with instant recoil, no lesions, tenderness, or edema noted; nails beds pink without clubbing, uniform thickness; nails smooth, capillary refill > 3 sec. Hair thick, no patches of hair missing. Multiple nevi on bilateral arms and chest. Head. Head erect and midline, scalp pink, no lesions or tenderness noted, symmetrical facial features. Temporal arteries soft, non-tender, no bruits. Eyes. Brows, lids, and lashes evenly distributed; no tearing; conjunctivae pink without discharge; Pupils react equally to light and accommodation. Extra-ocular movements intact, no eye drooping; no lid lag, no strabismus, visual field well defined. Corneal reflex equal bilaterally, red reflex present, Retina pink, no hemorrhages or exudates noted bilaterally; visual acuity checked with near vision chart and Snellen eye chart. Ears. Auricles in proper alignment, without lesions, masses, or tenderness; canals with small amount dry cerumen. Tympanic membranes gray, translucent; no perforations. Weber: equal lateralization present. Rinne: air conduction> bone conduction bilaterally, Repeats whispered words bilaterally. Nose and Sinuses. No flaring of nares, no deviation in septum, nares patent bilaterally, mucosa pink and moist. No discharge. No frontal or maxillary sinus tenderness with palpation.