Feb 23, 2024 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT
DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT
DIGITAL CLINICAL EXPERIENCE COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT
Week 9 Shadow Health Comprehensive SOAP Note Template
SUBJECTIVE DATA:
Chief Complaint (CC): ‘I have come for reemployment assessment.’
History of Present Illness (HPI): The client is a 28-year-old African American that has come to the clinic for a reemployment assessment. She is cooperative and offers information needed for the assessment. Her speech is normal and she maintains eye contact during the assessment. She appears alert and oriented to all facets. She has good health and first-class hygiene. She denied any acute concerns as she has come for preemployment assessment. Her significant illnesses include POCS diagnosed four months ago, type 2 diabetes mellitus, and allergy to penicillin, dust, and cars.
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Medications: The client currently uses several medications. They include Metformin 850 mg BID, Drospitenone and ethinyl estradiol PO QD, Albuterol spray that she puffs twice and last use was three months ago. She also uses acetaminophen 500-1000 mg PO prn for headaches and ibuprofen for menstrual cramps, which she took six weeks ago. She denies any side effects from these medications.
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Allergies: She reports allergic reaction to penicillin, which causes rashes. She also reports allergies to dust and cars. She denies food and latex allergies.
Past Medical History (PMH): The client was diagnosed with asthma when she was one and half years old. She reports that last asthma exacerbation was three months ago. Her last asthma hospitalization was when she was in high school. She has not history of intubation. She has type 2 diabetes mellitus that was diagnosed when she was 24 years. She manages it using metformin, with her blood sugar being an average of 90. She monitors blood sugar daily in the morning. She also manages diabetes using exercise and diets. She is also hypertensive. She has no history of surgery.
Past Surgical History (PSH): She denied any history of surgery
Sexual/Reproductive History: She developed her menarche at the age of 11. She has sex with men. She has no history of pregnancy. She had her first sex at the age of 18. She was diagnosed with POCS four months ago when she went for her gynecological exam.
Personal/Social History: The client just secured an employment. She is not married but has a boyfriend. She lives with her mother and intends to move to her apartment once she starts working. She loves reading, dancing, attending Bible studies, and church functions. She has a strong social support system comprising her family and church.
Health Maintenance: The client does not use tobacco. She used cannabis from ages 15-21 years.
DIGITAL CLINICAL EXPERIENCE COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT
She does not abuse any drugs. She occasionally drinks alcohol when with her friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, lunch, to supper. She takes diet coke. She engages in mild exercise at least four times a week. The client also attends to the doctor’s appointments. Her last pap smear was four months ago. She had eye examinations three months ago. Her dental examination was 150 days ago. She is negative for PPD, which was done two years ago. She has smoke detectors at home and wears safety belts in the care. She does not ride the bike. She uses sunscreen in the sun. She has her father’s gun locked in their bedroom.
Immunization History: Her immunization status is current bar HPV and tetanus vaccines. Childhood vaccines are also up to date as well as meningococcal vaccines.
Significant Family History: There is a history of hypertension in all the grandparents from both sides and both parents. Both parents and maternal grandparents have high cholesterol. Stroke killed maternal grandparents. Paternal grandmother is alive and 82 years of age whilst grandfather died of cancer at 65. The deceased grandfather also had a history of type 2 diabetes alongside the patient’s father who died in an accident. The client has an overweight brother and an asthmatic sister. Alcoholism in paternal uncle whilst no other diseases exist in the family as well as her.
Review of Systems:
General: The client is alert and oriented to all facets. She is cooperative, maintains eye contact, and normal speech during the assessment.
HEENT: The client denies current headache and history of head injury or acute visual changes. She reports no eye pain, itchy eyes, redness, or dry eyes. She wears corrective lenses. Her last visit to the optometrist was 3 months ago. Reports no change of hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain, or pressure, or rhinorrhea. Denies any general mouth issues. She also denies dental concerns. She denies dysphagia, sore throat, voice changes, or swollen nodes.
Respiratory: The client reports normal breath, lack of wheezing, chest pain, dyspnea and cough.
Cardiovascular/Peripheral Vascular: The client reports no palpations, tachycardia, easy bruising or edema.
Gastrointestinal: The client reports no nausea, vomiting, pain constipation, excessive flatulence or diarrhea. She does not have food intolerance.
Genitourinary: She does not have dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching
Musculoskeletal: The client does not have muscle and joint pains whilst muscle weaknesses and swelling does not exist.
Neurological: She denies dizziness, tingling, light-headedness, seizures, loss of coordination or sensation, or sense of disequilibrium.
Psychiatric: Does not suffer depression, anxiety, or suicidal thoughts.
Skin/hair/nails: Reports that the oral contraceptives have led to improved acne. Skin has stopped darkening at the neck region and facial and body hair has improved. She reports few moles but no other hair or nail changes.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Height: 170m cm Weight: 84 bmi: 29.00 Blood glucose: 90 RR: 15 HR: 78 BP: 128/82 Pulse Ox: 99% Temperature: 99.0 F
General: The patient is alert and oriented to all facets. She sits upright on the examination table. She has good health and has first class hygiene as well.
HEENT: Head is normocephalic and atraumatic. The eyes are bilateral eyes with equal hair distribution on lashes and eye brows. Eye lids do not have lesions. There is no ptosis or edema. Conjunctiva appears pink with no lesions and white sclera. PERRLA bilaterally. OEMS intact bilaterally, no nystagmus. Snellen assessment results: 20/20 right eye, 20/20 left eye with corrective lenses. Tympanic membranes intact and pearly gray bilaterally with positive light reflex. The client hears whispered words bilaterally.
Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions. Uvula rises midline on phonation. Gag reflex is intact. Dentation do not show evidence of carries or infection. Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. There is no lymphadenopathy.
Neck:
Chest/Lungs: Chest is symmetric. The lung sounds are clear whilst voice occurs in all areas. Percussion produced resonance throughout. In office spirometry: FVC 3.91, FEV1/FVC ratio 80.56%.
Heart/Peripheral Vascular: Hear rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts or thrills. Bilateral peripheral pulses equal bilaterally, capillary refills less than 3 seconds. No peripheral edema.
Abdomen: Abdomen is protuberant, symmetric without visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly and CVA tenderness.
Genital/Rectal: Not assessed
Musculoskeletal: Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. There is no pain with movement.
Neurological: Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterally. Cerebella function tests produced normal results. Deep tendon reflexes 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.
Skin: Pustules on the face are scattered whilst the upper lip ha facial hair. The posterior neck has acanthosis nigricans. Nails are free of ridges or abnormalities.
Diagnostic results: non
ASSESSMENT: The client is a 28-year-old African American that has come to the clinic for her preemployment assessment. She is dressed appropriately for the occasion, alert, and oriented to all facets. The client is cooperative, responsive to questions, and does not demonstrate any abnormal manners. Her speech is normal in terms of volume and tone. She has enhanced coping mechanisms to stress. Her significant medical history includes asthma, hypertension, and diabetes mellitus, which are well controlled. She does not abuse any drugs or substances. She engages in healthy lifestyles and behaviors. Her physical assessment findings are within the normal range.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
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 old respectively, alive and well. Her paternal grandfather died at the age of 80 years due to a heart attack while her paternal grandmother is 78 years and is hypertensive. Her maternal grandfather is 77 years with a history of type 2 diabetes and high cholesterol while her maternal grandmother died at the age of 70 years due to a stroke. No family history of malignancies, mental illness, asthma, sickle cell, or diabetes.
ROS:
GENERAL: Reports fatigue and occasional fever. Denies weight loss, night sweats, and chills.
HEENT: Reports headaches, nasal congestion, post nasal drip, and sneezing. No blurring of vision, visual loss, hearing loss, tinnitus, nose bleeds, ear pain, mouth sores, or sore throat.
SKIN: no skin lesion or rashes. No abnormal pigmentation.
CARDIOVASCULAR: Negative for palpitations, chest pain, paroxysmal nocturnal dyspnea, and peripheral limb edema.
RESPIRATORY: Occasional non-productive cough. No difficulty in breathing, dyspnea, or orthopnea.
GASTROINTESTINAL: Reports loss of appetite and occasional nausea and vomiting. Denies change in bowel habits, abdominal pain, or distention.
GENITOURINARY: No frequency, dysuria, nocturia, and polyuria. No vaginal itchiness or abnormal vaginal discharge.
NEUROLOGICAL: Reports headache. Denies dizziness, lightheadedness, numbness, tingling, loss of sensation, syncope, and convulsion.
MUSCULOSKELETAL: No muscle pain, joint pains, muscle weakness, or muscle swelling.
HEMATOLOGIC: No anemia, easy bruising, or bleeding.
LYMPHATICS: Normal lymph nodes
PSYCHIATRIC: Denies anxiety, depression, suicidal ideations, or hallucinations.
ENDOCRINOLOGIC: Denies heat or cold intolerance, polyphagia, and polydipsia.
ALLERGIES: Reports no allergies.
O.
Physical exam:
VITAL SIGNS: BP 125/78 mmHg, HR 88 b/min, Temp 99. 8 F, RR 20 b/min, saturation 95% on room air, Height 168 cm, weight 76 Kg. Pain level 5/10
GENERAL: A middle-aged African-American female, well kempt, not in any form of respiratory distress but slight discomfort. Maintains eye contact, coherent speech, and a stable mood. Well-hydrated and nourished. No palmar or conjunctival pallor, jaundice, central or peripheral cyanosis, cervical or inguinal lymphadenopathy, and peripheral limb edema.
HEENT: Normocephalic and atraumatic head. Non-tender scalp. Bilateral eyes with pink conjunctiva and white sclera. Pupils equally and bilaterally reacting to light, no ptosis or lid edema. Normal extraocular movements. Bilateral ears present, no impaction or skin lesions, tympanic membrane pearly grey bilaterally, and positive white reflex. Both nares are present and are discharging mucus, midline nasal septum, and pink and soft nasal mucosa. Tender maxillary and frontal sinus. Moist and pink oral mucosa, no oral lesions or ulceration. Normal dentition and teeth alignment.
NECK: Soft neck. The trachea is central. Full range of motion, non-tender, no cervical lymphadenopathy, and no thyroid enlargement.
CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse in the 5th intercostal space in the midclavicular line. S1 and S2 head, no murmurs, thrills, gallops, rubs, or heaves.
RESPIRATORY: Symmetrical chest that moves with respiration. No scars or skin lesions. Equal chest expansion and equal tactile fremitus bilaterally. Equal air entry, vesicular breath sounds, no wheezes, and crackles, and equal vocal fremitus in all lung zones.
NEUROLOGICAL: GCS 15/15, oriented to time, place, and person, intact short-term and long-term memory, good concentration, and a clear coherent speech. Cranial nerves 1 to 12 intact. Normotonic across all joints, normal bulk, and power 5/5 across all muscle groups in upper and lower extremities, deep tendon reflexes 2+ and equal bilaterally in upper and lower limbs. Intact monofilament sensation across all dermatomes, good bowel, and bladder function. No spinal tenderness, normal gait, coordination, graphesthesia, and stereognosis. Normal finger nose, heel to the shin, and rapid alternating movements tests.
Diagnostic results:
J.K.L appears to have an inflammatory/infectious condition. Consequently, complete blood count and inflammatory markers particularly CRP and ESR are paramount. Similarly, bacterial or fungal cultures obtained endoscopically or by direct sinus aspiration are required to identify the possible pathogen. Additionally, a skin prick test is essential to exclude allergic rhinitis. Imaging modalities principally Sinus CT and MRI are recommended to evaluate for rhinosinusitis and intraorbital or intracranial involvement.
A.
Differential Diagnoses
Acute Sinusitis- refers to the inflammation of sinuses lasting less than 4 weeks (DeBoer & Kwon, 2022). The condition is more common in females and particularly during early fall to early spring (DeBoer & Kwon, 2022). It is most commonly caused by viral infection following a common cold although bacteria and fungi are not uncommon etiologies. J.K.L presents with clinical features that are typical of acute sinusitis including fatigue, fever, headache, facial pain, and pressure worse on bending (DeBoer & Kwon, 2022). Maxillary sinuses and frontal sinuses appear to be the affected sinuses in her as evidenced by pain around the forehead and tenderness of the maxillary and frontal sinuses (DeBoer & Kwon, 2022).
Rhinitis- Refers to the inflammation of the nasal mucosa. J.K.L presents with clinical manifestations suggestive of rhinitis including sneezing, nasal congestion, postnasal drip, and rhinorrhea (Liva et al., 2021). Similarly, she reports a “head cold” three weeks ago. Rhinitis is mostly caused by an upper respiratory infection or type 1 hypersensitivity reaction (Liva et al., 2021). However, an upper respiratory tract infection is likely the cause in her case.
Cluster headache- Cluster headache is a type of primary headache that is usually unilateral retro-orbital and characterized by sharp and stabbing pain (Goadsby et al., 2018). Cluster headache may present with symptoms of lacrimation, nasal congestion, rhinorrhea, ptosis, or miosis (Goadsby et al., 2018). However, it is unlikely the diagnosis in her as cluster headache usually lasts for a brief period. Similarly, cluster headaches mostly awake the patient at night.
Migraine headache- Migraine headache is another type of primary headache that may be preceded with or without aura. It is usually pulsating and moderate to severe (Pescador Ruschel & O, 2022). It is common in young women. However, it is unlikely the diagnosis as migraines last 4 to 72 hours if untreated and are typically associated with nausea, vomiting, photophobia, and phonophobia (Pescador Ruschel & O, 2022).
Rebound headache– Commonly referred to as medication overuse headache. Rebound headache predominantly occurs in individuals with primary headaches who overuse analgesia (Micieli & Robblee, 2018). Rebound headaches are more common in females and individuals less than 50 years. Drugs precipitating this headache include barbiturates, acetaminophen, opioids, ergotamine, and triptans (Micieli & Robblee, 2018). However, this is an unlikely diagnosis in J.K.L as a diagnosis of primary headache hasn’t been established.
References
DeBoer, D. L., & Kwon, E. (2022). Acute Sinusitis. https://pubmed.ncbi.nlm.nih.gov/31613481/
Goadsby, P., Wei, D.-T., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology, 21(5), 3. https://doi.org/10.4103/aian.aian_349_17
Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine, 10(14), 3183. https://doi.org/10.3390/jcm10143183
Micieli, A., & Robblee, J. (2018). Medication-overuse headache. Journal de l’Association Medicale Canadienne [Canadian Medical Association Journal], 190(10), E296–E296. https://doi.org/10.1503/cmaj.171101
Pescador Ruschel, M., & O, D. J. (2022). Migraine Headache. https://pubmed.ncbi.nlm.nih.gov/32809622/
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:
90mcg proventil PRN for wheezing.
P.O 200 mg ibuprofen every 8 hours PRN when she has menstrual cramps.
1 tablet of drospirenone pill taken every day.
P.O 850 mg metformin two times daily.
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 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 i
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