Feb 23, 2024 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32
Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32 Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32 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. Struggling to Meet Your Deadline? Get your assignment on Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32 done on time by medical experts. Don’t wait – ORDER NOW! Meet my deadline 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, 5th 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 have come to the unit because I am needed to have a recent physical examination report for the healthcare insurance for my newly acquired job.’ History of Present Illness (HPI): Ms. J is a 28-year-old client that came to the unit for a physical examination report, as her new employer needs it for healthcare insurance. Ms. J reports during the encounter that she has secured an employment at Smith, Stevens, Stewart, Silver & Company. The company requires her to undergo a pre-physical examination before Ms. J begins working with them. Ms. J denied any acute concern during this visit to the hospital. She reports that she visited the hospital for physical examinations four months ago when she had gone for her yearly gynecological examination at the Shadow Health General Clinic. Ms. J reported that she was diagnosed with polycystic ovarian syndrome during this visit and was prescribed to use oral contraceptives, which she has been tolerating them well. Ms. J further reported that she has type 2 diabetes mellitus, which she currently controls with metformin, diet, and exercise. She was diagnosed with diabetes five months ago and reports no side effects with metformin. The self-reported health and wellbeing of Ms. J is that she is healthy and engaging in healthy behaviors and lifestyles, as a way of promoting her health. She is excited and looking forward to starting her job with the new organization. Medications: Ms. J is currently using and has used a number of medications. They include the following: Metformin 850 mg PO BID (she lastly used it this morning) Fluticasone propionate 110 mcg 2 puffs BID (she lastly used it this morning) Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (lastly used three months ago) Drospirenone and ethinly estradiol PO QD (lastly used this morning) Acetaminophen 500-1000 mg PO prn (headaches) Ibuprofen 600 mg PO TID prn (for menstrual cramps, lastly taken 6 weeks ago) Allergies: Ms. J reported history of drug allergy. She is allergic to penicillin, as it causes rash. She denies any history of food or latex allergies. She however reports that she is allergic to dust and cats. She reports that her exposure to dust or cats causes her running nose, swollen eyes, itchiness, and increase in the symptoms of asthma. Past Medical History (PMH): Ms. J has significant medical histories. She has history of asthma that Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32 she was diagnosed with at the age of two and half years. She reports that she managers asthma symptoms using albuterol inhaler whenever she is exposed to allergens that include dust and cats. She reports that her last experience of asthma exacerbation was three months ago. She has a history of hospital admission due to asthma when she was in high school. As noted initially, Ms. J has type 2 diabetes mellitus. She was diagnosed with it when she was 24 years old. She currently manages the diabetes using metformin, which she started taking five months ago. She reports that she experienced gastrointestinal side effects at the beginning due to metformin but has dissipated since then. She reports that she monitors her blood glucose levels on a daily basis with the average reading being in the range of 90. Ms. J also has a history of hypertension. She reports that she normalized the elevated blood pressure by engaging in regular physical activity and dietary modifications. Past Surgical History (PSH): Ms. J denied any history of surgeries. Sexual/Reproductive History: Ms. J reported that her menarche was when she was 11 years old. Her first sexual encounter was when she was 18 years old. She identified that she has sex with men, hence, heterosexual. She denied any history of pregnancy or pregnancy loss. She noted that her last menstrual period was two weeks ago. She has a diagnosis of polycystic ovarian syndrome that was reached in the last four months during her annual gynecological visit. Ms. J reported experiencing moderate menstrual bleeding that last five days since she started using Yaz. Ms. J also reported that she is in a new relationship with a male that she has not engaged in any sexual relationship or contact. She expressed her intention to start using condoms with her boyfriend. She reported further that she tested negative for STIs and HIV/AIDS four months ago when she came for her annual gynecological visit. There was no history of sexually transmitted infections. Personal/Social History: She denied any history of marriage and children. She has been living alone since the age of 19. She however lives currently with her sister and mother and is planning to relocate to live on her own in a month’s time. Ms. J reported that she is expected to report in her new place of work in two weeks’ time. She denied any recent travel to foreign countries. She does not have pets. She denied any history of psychiatric problems such as anxiety, suicidal thoughts, attempts, or plans, and depression. She appeared alert and oriented to self, others, time, events, and place. She also appeared well groomed for the occasion, engaged easily in the conversation, cooperative with pleasant mood. She did not demonstrate any abnormal behaviors such as tics, tremors, or facial fasciculation. The speech was or normal volume, rate, fluency, and clarity. Health Maintenance: Ms. J reported using health promotion services. Her last pap smear screening was four months ago during her annual gynecological visit. She reported that she went for eye examination three months ago. She also reported that her last dental examination was five months ago. She took a tuberculosis test two years ago, which turned negative. Information about safety practices was obtained during the assessment. She reported that she has some detectors in their home, wears seatbelt whenever driving, and do not ride a bicycle. She reported using sunscreen. She has history of handling her father’s gun that is always locked in his room. Ms. J engages in mild to moderate physical activity at least four to five times on a weekly basis. The physical activity comprises of swimming, walking or yoga. She acknowledged that engaging in physical activity has helped her manage stress and improve her sleeping difficulties. When asked about her hobbies, Ms. J reported that she enjoys spending her time with friends, attending Bible study sessions, reading, and volunteering in her local church. She also reported that she enjoys dancing. She reported being an active member in her church. She attributed it to the influence of her family. She identified her family to be her source of social support. She also identified that church and her family helps her in coping with stressful situations. She denied history of tobacco use. She reported history of cannabis use since when she was 15. She stopped using it at age of 21. She denied use of methamphetamines, cocaine, and heroin. She reported occasional use of alcohol when she is with friends. The frequency of alcohol use was reported to be 2-3 times in a monthly basis. When asked about her dietary habits, Ms. J reported that her breakfast often comprises of fruit smoothie with sugar-free yoghurt. Her lunch comprises of sandwich on low-fat pita or wheat bread or vegetables with brown rice. Her dinner comprises of a protein and roasted vegetables, with carrot or apple snack. Ms. J denied use of coffee but acknowledged that she drinks 1-2 sodas on a daily basis. Immunization History: Her immunization history showed that she received Tetanus booster jab within the last year, with her influenza vaccination not being current. She reported that she has not received human papillomavirus vaccine. She noted that she believes that her childhood vaccinations are up to date. She received meningococcal vaccine when she was in college. Significant Family History: Ms. J has significant family histories. They include the following: Mother: diagnosed with hypertension and elevated level of cholesterol. She is currently aged 50 years Father: He is deceased through a car accident one year ago at the age of 58 years. He had hypertension, type 2 diabetes, and cholesterol. Bother: aged 25 years and is overweight Sister: she aged 14 years old and has asthma Maternal grandmother: she died at the age of 73 years due to stroke. She had a history of high cholesterol and hypertension. Paternal grandmother: Still alive, aged 82 years, and living with hypertension Paternal grandfather: died at the age of 65 years due to colon cancer and a history of type 2 diabetes mellitus Paternal uncle: suffers from alcoholism Ms. J denied other cancers, mental illnesses, kidney disease, thyroid disorders, sickle cell anemia, and sudden death in the family. Review of Systems: General: Ms. J appears well groomed for the occasion. There are no signs of weight loss. She denied fatigue, weakness or recent illness. She also denies pain. She however reports that she feels that she has lost some weight due to her adoption of healthier lifestyles. HEENT: Ms. J denies headaches. She uses corrective lenses. She denies changes in her vision since undergoing eye examination four months ago. She denies hearing loss, tinnitus or loss of body balance. She reports history of ear infection during her childhood period. She denies changes in taste or sense of smell. She also denied difficulty in swallowing. She reports that she underwent dental examination five months ago. Respiratory: Ms. J reports history of asthma with its exacerbations experienced three months ago. She denies shortness of breath, wheezing, dyspnea, or coughing. Cardiovascular/Peripheral Vascular: Ms. J denies palpitations, chest pains, arrhythmia or edema. She has history of hypertension. Gastrointestinal: Ms. J denies any abdominal tenderness, swelling, pain, or changes in bowel movements. She also denies bloating, diarrhea, and stool stained with blood. Genitourinary: Ms. J denies any changes in frequency and urgency of urinary bladder, dysuria, or passage of blood stained urine. She also denies changes in the smell or color of urine. She also denies any history of urinary tract infections. Musculoskeletal: Ms. J reports history of right foot injury after she slipped off a stepping stool. She experienced gait problems after the injury. She denies any current gait problems. She also denies muscle weakness, pain and limited range of motions. Neurological: Ms. J is alert and oriented to others, place, time, events, and space. She has clear, coherent speech. Her level of judgment is intact. She denies tingling sensations, numbing or decline in the level of sensation. Psychiatric: She denies any history of psychiatric problems such as depression, anxiety, and suicidal thoughts, plans, or intentions. Skin/hair/nails: Ms. J reports that acne has improved as well as the excessive growth of hair in the body since she used Yaz. She denies brittle nails or hair as well as changes in moles. OBJECTIVE DATA: Physical Exam: Vital signs: Temp 37.2 C, HR 78, RR 15, BP 128.82, SPO2 99% room air, denies pain, height 170 cm, weight 84 kg, BMI 29, Random blood glucose 100 mg/dl General: Ms. J appears appropriately dressed for the occasion. She denies fever, fatigue, and pain. HEENT: The head is normocephalic with absence of evidence of trauma. She has bilateral eyes with equitable distribution of hair on the eyebrows and eyelashes. There is the absence of lesions, edema, or ptosis in the eyes. The conjunctiva appears pink without lesions. The sclera appears white with bilateral PERRLA. Extra-ocular muscles are intact with absence of nystagmus. There is the presence of mild changes in retinopathy on the right eye. The left fundus has sharp disc margins with no signs of hemorrhage. Snellen score is 20/20 for both eyes when the patient is using corrective lenses. There is the presence of positive light reflect. She hears whispered words bilaterally. The maxillary and frontal sinuses are not tender on palpation. The nasal mucosa appears pink with midline septum. The oral mucosa appears moist with the absence of lesions or ulcerations. There is midline rising of the uvula on phonation. The gag reflexes are intact. The dentition is normal with absence of signs of infection or dental caries. The thyroids are normal with absence of goiter or nodules. There is the absence of lymphadenopathy. Neck: Absence of prominent veins raised jugular vein pressur
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