NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

NURS 6512 Assignment 3 Week 9 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment

SUBJECTIVE DATA:

Chief Complaint (CC): Pre-employment physical

History of Present Illness (HPI): J.T is a 28 years old African American female patient who reported to the clinic for a pre-employment physical. She reports that the last time she visited a healthcare professional was 4 months ago for an annual gynecological exam. She was diagnosed with polycystic ovarian syndrome and initiated on oral contraceptives which she claims to tolerate appropriately. However, her last general physical examination was done 5 months ago, when she started taking daily inhalers and metformin for her diabetes type 2. She denies any current acute health problem and claims that she feels healthy as she takes better care of herself currently. She looks forward to starting her new job.

Medications: Metformin, 850 mg orally twice daily, fluticasone propionate inhaler, 110 mcg 2 puffs twice daily, and Drospirenone and Ethinyl estradiol orally twice daily. The last time she took all these drugs was this morning. Albuterol 90 mcg/spray MDI 2 puffs when necessary, with last use 3 months ago. Acetaminophen 500-1000 mg orally when necessary for headache and Ibuprofen 600 mg orally three times a day when necessary for her menstrual cramps. She last used these two medications 6 weeks ago.

Allergies: Confirms penicillin allergy which presents with rashes. Report’s dust and cat allergies which present with swollen and itchy eyes, running nose, and worsened asthma symptoms. Denies latex and food allergies.

Past Medical History (PMH): Diagnosed with asthma when she was 2 years and a half which she manages using an albuterol inhaler in the presence of cats. She used the inhaler 3 months ago as a result of her last asthma exacerbation. Her last hospitalization as a result of asthma was when she was in high school. She has never been intubated. Diagnosed with diabetes type 2 at the age of 24 years, but started taking metformin 5 months ago, with gastrointestinal side effects which resolved recently. Average blood sugar levels of 90, which she monitors every morning. Confirms a history of hypertension which she manages with diet and exercise.

Past Surgical History (PSH): Denies surgical history.

Sexual/Reproductive History: Experienced her first menses at the age of 11 years, and sexual encounter at the age of 18 years, with men. Denies ever being pregnant with her last menses 2 weeks ago. She got the PCOS diagnosis 4 months ago. Her menstrual cycle normalized four months ago after initiating Yaz. She is in a new relationship with a man but is not yet having sex, but when they start, claims to use a condom. HIV/AIDS and STIs test negative, four months ago.

Personal/Social History: Denies being married with no children. She used to live alone from age 19 but moved in with her sister and mother in a single-family house which she plans to leave and move to her apartment in a month. She starts her new job at Smith, Stevens, Stewart, Silver, & Company in 2 weeks. She loves reading, volunteering in church, dancing, attending Bible study, and spending time with friends. Claims to receive strong support from the church and family members, which helps her cope with stress. Denies tobacco, cocaine, heroin, and methamphetamine use. Used cannabis from age 15 to 21 years. Confirms alcohol use 2 to 3 times per month when out with friends, with no more than 3 drinks each episode. Denies taking coffer, and confirms maintaining a healthy diet. Takes 1 to 2 diet sodas daily. No pets. Denies recent foreign travel. Exercises regularly, 4 to 5 times every week comprising of swimming, yoga, and walking.

Health Maintenance: Last Pap smear 4 months ago. Eye examination- 3 months ago. Negative test results for PDD 2 years ago.

Safety: Smoke detectors are well installed at home, and does not ride a bike wear seatbelt in the car. Applies sunscreens. Locked guns that belonged to her father in the parents’ room.

Immunization History: Received tetanus booster last year. Influenza injection not up to date. She has not received the human papillomavirus vaccine. Received a meningococcal vaccine when she was in college. Her childhood vaccines are up to date.

Significant Family History: Mother managing hypertension and elevated cholesterol at the age of 50 years. Her father died in a car accident last year at the age of 58 years, with a history of diabetes type 2, high cholesterol, and hypertension. Brother is overweight and 25 years old. Sister is asthmatic and 14 years old. Maternal grandmother passed on at the age of 73 years from stroke, with a history of hypertension, and high cholesterol levels. Maternal grandfather passed on at the age of 78 years from stroke, with a history of hypertension, and high cholesterol levels. Paternal grandmother is still alive, with a history of hypertension at age 82 years. Paternal grandfather passed on at age 65 years from colon cancer, with a history of diabetes type 2. Paternal uncle is an alcoholic. Denies family history of mental illness, sudden death, sickle cell anemia, kidney problems, thyroid problems, and other cancers.

Review of Systems:

General: The patient is alert and well oriented. Clear and coherent speech. Maintains good eye contact all through the interview. Does not appear distressed. Seated upright, well-nourished, good hygiene, and appropriately dressed. No fatigue, night sweats, chills, or fever. Recent changes in weight and diet.

HEENT: Head: No headache, or signs of head injury. Eyes: No itchiness, excessive tearing, pain, or discharge. Ears: No hearing problems, pain, or drainage. Nose: No congestions, running nose, epistaxis, or inflammation of the nasal mucosa. Mouth/Throat: No bleeding gums, toothache, ulcerations, sore throat, or swallowing difficulties.

SKIN: No rashes, lumps, adenopathy, bruising, eczema, or skin lesions.

CARDIOVASCULAR: No history of cyanosis or hurt murmurs.

RESPIRATORY: No cough, shortness of breath, wheezing, or sneezing.

GASTROINTESTINAL: No diarrhea, vomiting, abdominal pain or discomfort, jaundice, constipation, or changes in bowel movement.

GENITOURINARY: No changes in urine frequency, dysuria, polyuria, or pyuria. No abnormal discharge or painful sex.

NEUROLOGICAL: No syncope, ataxia, dizziness, headache, or paresthesia.

MUSCULOSKELETAL: No joint or muscle pain.

HEMATOLOGIC: Denies bruising easily, difficulties in stopping bleeds, or lumps under the neck or arm, or anemia.

LYMPHATICS: Denies any history of lymphadenopathy or splenectomy.

ENDOCRINOLOGIC: No disturbances in growth, polyphagia, history of thyroid disease, or excessive fluid intake.

PSYCHIATRIC: Denies mental health problems.

OBJECTIVE DATA:

Physical Exam:

Vital signs: Ht: 170 cm; Wt: 84 kg; BMI: 29.0 ;BG: 100; RR: 15; HR: 78; BP:128 / 82; Pulse Ox: 99%; T: 99.0 F

General: The patient is alert and well oriented. Clear and coherent speech. Maintains good eye contact all through the interview. Does not appear distressed. Seated upright, well-nourished, good hygiene, and appropriately dressed. No fatigue, night sweats, chills, or fever. Lost 10 pounds recently as a result of increased exercise and changes in diet.

HEENT: Atraumatic and normocephalic head. Bilateral eyebrows with hair distributed equally on the eyebrows and lashes. No edema or ptosis, lids with no lesions. Pink conjunctiva, white sclera, and no lesions. Bilateral PERRLA. Bilateral EOMs, with no nystagmus. Mild changes on the retinopathy of the right eye. No hemorrhages, Left fundus with sharp margins of the disc. Snellen: right eye 20/20, left eye 20/20 with corrective lenses. Positive light reflex and intact TMs and pearly gray bilaterally. Whispered words were heard equally in both years. Maxillary and frontal sinuses non-tender on palpation. Pink and moist nasal mucosa, midline septum. Moist oral mucosa with no lesions or ulcerations, uvula rises midline on phonation. Intact gag reflex. No evidence of infections or caries. Tonsils 2+ bilaterally. Smooth thyroid with no nodules, or goiter. No signs of lymphadenopathy.

Respiratory: Symmetric chest with respiration, clear auscultation with no wheezing or cough. Constant resonant to percussion. In-office spirometry: FEV/FVC ratio 80.56%, FVC 3.91 L

Cardiovascular: Regular heart rate. S1, S2 present with no gallop, rubs, or murmurs. Equal bilateral carotids with no bruit. PMI at midclavicular line, 5^th intercostal space, no thrills, lifts, or heaves. Peripheral pulses bilaterally equal, capillary refill < 3 seconds. No edema on the periphery.

Abdominal: Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from the pubis to the umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.

Musculoskeletal: Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity, and with a full range of motion. No pain with movement.

Neurological: Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.

Skin: Scattered pustules on the face and facial hair on the upper lip, acanthosis nigricans on the posterior neck. Nails free of ridges or abnormalities.

Diagnostic results: Administer drug and alcohol tests. Physical ability test comprising of cardiovascular health, flexibility, mental fortitude under physical strain, muscle tension, and balance (Fischer, Sinden, & MacPhee, 2017). OSHA-specific screening and surveillance physicals were also administered. Psychological evaluation was also administered with the utilization of self-response questionnaires (Han, Kim, Lee, & Lim, 2019). Other routine tests that were ordered include lipid profile test, FBS, cholesterol test, liver function test, and chest X-ray, as a result of her current diagnosed conditions (Drain, & Reilly, 2019).

ASSESSMENT: The patient displays a previous history of hypertension, with current-controlled blood pressure within normal limits. She also has a history of asthma, which she manages appropriately with her inhaler. She is overweight but is on diet control and exercise which helps in managing her hypertension (Gaafar, 2021). She has diabetes which she monitors very well every morning and manages by taking medication. Physical test results reveal excellent strength and flexibility, with a full range of movement. She is able to lift a moderate amount of weight with perfect endurance, with muscle tension for a woman of her age (Gumieniak, Gledhill, & Jamnik, 2018). She displays no mental disabilities with no signs of substance use disorder. Her medical examination results are excellent for her new job. She is fit to start working any day from now.

 

 

References

Fischer, S. L., Sinden, K. E., & MacPhee, R. S. (2017). Identifying the critical physical demanding tasks of paramedic work: Towards the development of a physical employment standard. Applied Ergonomics, 65, 233-239. https://doi.org/10.1016/j.apergo.2017.06.021

Gumieniak, R. J., Gledhill, N., & Jamnik, V. K. (2018). Physical employment standard for Canadian wildland firefighters: examining test-retest reliability and the impact of familiarisation and physical fitness training. Ergonomics, 61(10), 1324-1333. https://doi.org/10.1080/00140139.2018.1464213

Han, K., Kim, Y. H., Lee, H. Y., & Lim, S. (2019). Pre-employment health lifestyle profiles and actual turnover among newly graduated nurses: A descriptive and prospective longitudinal study. International journal of nursing studies, 98, 1-8. https://doi.org/10.1016/j.ijnurstu.2019.05.014

Gaafar, A., & Gaafar, A. (2021). Routine pre-employment echocardiography assessment in young adults: cost and benefits. The Egyptian Heart Journal, 73(1), 1-8. https://doi.org/10.1186/s43044-020-00131-8

Drain, J. R., & Reilly, T. J. (2019). Physical employment standards, physical training, and musculoskeletal injury in physically demanding occupations. Work, 63(4), 495-508. DOI: 10.3233/WOR-192963

SUBJECTIVE DATA:

Chief Complaint (CC):

“I came in because I’m required to have a recent physical exam for the health insurance at my new job.’’

History of Present Illness (HPI):  

Patient is a 28-year-old African American female who came to the facility for a routine physical examination in preparation for her new position at Smith, Stevens, Silver & Company. Patient reports having no acute health problems. The patient takes a well-tolerated birth control medication called drospirenone at the exact same time every day. During the yearly gynecological exam a few months ago, the patient received a PCOS diagnosis and was prescribed drospirenone/ethinyl estradiol.

In addition, the patient takes metformin for her diabetes and uses an inhaler for her asthma. In order to improve her vision, the patient saw an eye doctor and received prescription glasses. Also, the patient regularly checks her blood sugar levels and states that the medication metformin is helping in the management of her diabetes and to due to this condition she engages in exercise and has made dietary changes to further help her.

 Medications:

1. 90mcg proventil PRN for wheezing.
2. P.O 200 mg ibuprofen every 8 hours PRN when she has menstrual cramps.
3. 1 tablet of drospirenone pill taken every day.
4. P.O 850 mg metformin two times daily.
5. 88mcg flovent twice daily.

Allergies:

Penicillin

Cats

Patient not allergic to any food.

Patient not allergic to latex.

 Past Medical History (PMH):

Asthma

Type 2 diabetes

Hypertension

PCOS

Past Surgical History (PSH):

Patient has not had a previous surgical procedure.

Sexual/Reproductive History:

Patient had her last menstrual period 2 weeks ago.

Patient is on a birth control pill known as drospirenone

Patient first engaged in sexual intercourse when she was 18 years old.

Patient sexual preference is to males.

Personal/Social History:

Patient lives with her mother and sister.

Patient consumes alcohol on occasion with her friends.

Patient is about to be employed at Smith, Stevens, Silver & Company.

Patient does not use tobacco.

Health Maintenance:

Patient got a pap smear a few months ago.

3 months ago patient underwent an eye exam.

Patient adheres to her prescribed medication.

Patient has made changes to her diet and lifestyle to help manage her diabetes condition

Immunization History:

Patient received a tetanus booster.

Patient has received all expected immunizations.

Significant Family History:

Paternal grandfather: passed away.

Paternal grandmother: hypertensive and with high cholesterol.

Maternal grandfather: died.

Maternal grandmother: 82 and healthy.

Father: died due to a car accident.

Mother: hypertensive and with high cholesterol.

Brother: overweight.

Sister: asthmatic.

 Review of Systems:

General:

She has intentionally lost weight.

She has not been recently ill.

She is not fatigued.

HEENT:

She has not had a head injury.

She has not had eye pain.

She has not had ear pain.

She has not had nose problems.

She has not had throat problems.

Respiratory:

She has not had recent breathing problems.

Cardiovascular/Peripheral Vascular:

She has not had palpitations.

She has not had edema.

She has not had chest pain.

Gastrointestinal:

She is not vomiting.

She has not felt nausea.

She is not constipating.

Genitourinary:

She is urinating less at night than before.

She does not have blood in the urine.

She does not feel pain while urinating

 

Musculoskeletal:

She is not having pain in the muscles.

She is not having pain at the joints.

She is not swelling in the limbs.

Neurological:

She does not get periods when she is dizzy.

She has not had seizures.

She has not experienced loss of coordination.

Psychiatric:

She is not anxious.

She is not depressed.

She is not stressed.

She has no difficulty falling asleep.

 Skin/hair/nails:

She has some male-pattern hair growth,

She has no dry skin.

Her acne is improving.

She has no rashes.

 

OBJECTIVE DATA:

Physical Exam:

Vital signs:

B.P-128/82mmHg

SPo2-99%

H.R- 78 bpm

R.R-15

Temp.-37.2 C

Weight- 90kg

Height- 5’7”

General:

Patient is alert and oriented. Patient is well groomed. Patient is sitted upright without signs of distress. Patient has appropriate hygiene.

HEENT:

Scattered pustules observed on the face and facial hair noted on upper lip.

Eyes have normal reaction to light.

Visual acuity is at 20/20 while using corrective lenses.

Tympanic membrane is pearly grey.

The nasal mucosa is moist and pink

Nasal mucosa moist.

Oral mucosa is without lesions and moist.

Neck:

Smooth thyroid with no presence of nodules.

No lymphadenopathy detected.

No goiter present.

Chest/Lungs:

No deformities on the chest walls.

Chest wall is resonant on percussion.

The chest wall is symmetric.

In the lungs no adventitious sounds heard

Heart/Peripheral Vascular:

S1 and S2 sounds heard.

No abnormal heart sounds detected.

Capillary refill is less than 3 seconds.

No edema noted in legs.

Abdomen:

Abdomen is protuberant and symmetric.

Bowel sounds heard to be normoactive.

Abdomen quadrants tympanic on percussion.

Abdomen is non-tender.

No visible masses.

 

Musculoskeletal:

Extremities are without swelling or masses.

Extremities have full range of motion.

Extremities strength at 5/5.

Hip has full range of motion.

Neurological:

Patient has decreased sensation in the right and left foot.

Position sense is intact in the toes and fingers.

Heel to shin coordination is smooth and accurate.

Rapid alternating hand movements is smooth.

Skin:

Presence of hair on the upper lip.

Dark discoloration noted on the neck.

Pustules noted scattered on the face.

Fingernails lack clubbing.

Diagnostic results:

Skin biopsy.

Autonomic testing.

Thyroid function.

Nerve conduction studies (NCS).

ASSESSMENT:

Differential Diagnosis

1. Diabetic neuropathy- this is a possible diagnosis as patient on examination has decreased sensation in the left and right feet. Patient also has diabetes thus it would have complicated and led to this condition. The disease occurs due to prolonged high blood sugar levels that leads to nerve damage (Ziegler, et al., 2021).

2.Guillain Barre’ syndrome- this is a condition that causes numbness, tingling and weakness in the

limbs. It could be a possible diagnosis as patient is presenting with some numbness in the feet. However, it progresses rapidly which has not occurred in this patient (Shahrizaila, et al., 2021).

3.Hypothyroidism- a condition that occurs due to low thyroid hormone levels that could lead to peripheral neuropathy symptoms. It could be a possible condition as the patient presents with decreased sensation in the feet in which this disorder presents with such a clinical manifestation (Wilson, et al., 2021).

References

Shahrizaila, N., Lehmann, H. C., & Kuwabara, S. (2021). Guillain-Barré syndrome. The   lancet, 397(10280), 1214-1228

Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: Diagnosis and   treatment. American family physician, 103(10), 605-613.

Ziegler, D., Keller, J., Maier, C., & Pannek, J. (2021). Diabetic neuropathy. Experimental and      Clinical Endocrinology & Diabetes, 129, S70-S81.

Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.

Photo Credit: Getty Images/Hero Images

To Prepare

• Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
• Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
• Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
• Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
• Also, your Week 9 Assignment 3 should be in the Complete SOAP Note format. Refer to Chapter 2 of the Sullivan text and the Week 4 Complete Physical Exam template and use the template below for your submission.

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

Patient Information:

Initials: J.K.L

Age: 40 years

Sex: Female

Race: African American

Source: Patient

S.

CC: “I have a headache around my forehead.”

HPI: J.K.L is a 40-year-old African American female who presents with a complaint of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It is non-radiating. The headache is constant and varies in severity ranging from 2/10 at its best to 8/10 at its worst. It is usually worse in the morning and while bending. Acetaminophen reduces the severity of the headache to 4/10 and occasionally 2/10.

It is associated with fever, postnasal drip, nasal congestion, sneezing, and occasional non-productive cough. She takes Sudafed HCL 120 mg every 12 hours to obtain some relief. The symptoms have significantly impaired her concentration at work and made her feel very tired. Finally, she reports a head cold three weeks ago.

Current Medications: Pseudoephedrine 120 mg BID for nasal congestion and acetaminophen for headaches.

Allergies: She has no known food and drug allergies.

Past Medical History: During her last visit to the primary care physician 2 months ago, she was noted to be prehypertensive and was advised on lifestyle modifications. No prior hospitalization. No previous surgeries or blood transfusions.

Social History: She is married with two children both alive and well. She works as a secretary Her husband is a college teacher. She neither drinks alcohol nor smokes tobacco. She does not use marijuana or other illicit drugs. She strictly adheres to dietary advice from her nutritionist and she exercises regularly. Denies caffeine intake.

Family History: Father alive aged 60 years and with hypertension while her mother is 58 years old alive and well. Her brother and sister are 35 and 20 years o