NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT Patient Information: The patient is a 28-year-old African-American woman.
Subjective Data:
CC (Chief Complaint): “I have come for a reemployment assessment.”
History of Present Illness (HPI): The patient is a 28-year-old African-American woman who has come for reemployment assessment. She stated that she has found employment at her new company. She does not have any acute concerns. She last had a gynecological exam four months ago at SHGC. She was diagnosed with Polycystic ovary syndrome (POCS) and prescribed well-tolerated medications. The patient has a history of type 2 diabetes that she controls using diet, metformin, and having an active lifestyle. She does not suffer from any side effects.
Medications: The patient is on metformin, drospirenone and ethinyl estradiol, albuterol spray, ibuprofen and acetaminophen.
- Metformin 850 mg per os twice a day. For blood sugar control.
- Drospirenone and ethynyl estradiol per os 3/0.02 mg once a day for PCOS.
- Albuterol inhaler two puffs a day. The last use was 3 months ago.
- Acetaminophen 500-1000 mg per os PRN for headaches.
- Ibuprofen 400 mg per os twice a day for menstrual cramps. Last taken 6 weeks ago.
Allergies: He has no known food or drug allergies.
Past Medical History (PMH):The patient was diagnosed with asthma when one and a half years old. The last asthma exacerbation occurred three months ago. My last asthma hospitalization was in high school. She has never been intubated. Has type 2 diabetes that was diagnosed at the age of 24 years. She has been taking metformin for five months without much side effects. Average blood sugar is 90 mg/dL and is monitored daily in the morning. She also exercises and diets to manage the condition as well as hypertension.
Past Surgical History (PSH): No history of surgery. No history of blood transfusion.
Sexual/Reproductive History: Menarche at 11 years. She is heterosexual. She has never been pregnant whilst her coitarche was at the age of 18 years. She has a new boyfriend
Personal/Social History: The patient does not have children and they were never married. Lives with her mother alongside her sister in a single apartment but planning to move to her own once she starts work. She enjoys reading, attending Bible studies, dancing, and attending church functions. She has a string of social support systems including the church and her family. She doesn’t consume tobacco whilst she used cannabis from ages 15-21 years of age. Does not abuse any other drugs. Uses alcohol in the company of friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, and lunch to supper. Does not take coffee but takes Diet Coke. Has not traveled outside recently and does not keep pets. She does mild exercise at least four times per week.
Health Maintenance: The patient attends the doctor’s appointment. She had a pap smear done four months ago. She had an eye exam 3 months ago. The dental exam was last conducted 150 days ago. She is negative for PPD which was done two years ago. Safety: Has smoke detectors in the home. She wears safety belts in the car. Does not ride the bike. Uses sunscreen in the sun. She has locked her father’s gun in their bedroom.
Immunization History:Her immunization status is up to date with tetanus and HPV vaccines. Childhood vaccines are up to date ad as well as meningococcal vaccine.
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 hypercholesterinemia. Maternal grandparents died from a stroke. Paternal grandmother is alive and 82 years of age whilst grandfather died of cancer at 65 years of age. The latter also had a history of type 2 diabetes alongside the patient’s father who died in an accident. Has an overweight brother and an asthmatic sister. There is a history of alcoholism in her paternal uncle whilst no other diseases exist in the family as well as her.
Mental Health History: She has enhanced her coping mechanism to stress. She has no history of suffering from depression, anxiety, or suicidal thoughts. She is alert to all faculties. She is dressed properly and easily converses and cooperatively offers information. She has a pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and her words are clear.
Review of Systems:
General: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat. Reports no change in sense of smell, sneezing, epistaxis, sinus pain, or pressure. or rhinorrhea. Reports no general mouth issues. Dental concerns are nonexistent. Swallowing, is okay, no sore throat, voice changes, or swollen nodes.
Respiratory:No shortness of breath, cough, orsputum.
Cardiovascular/Peripheral Vascular:No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
Gastrointestinal: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
Genitourinary: No polyuria, dysuria, burning sensation, cloudiness, vaginal discharge or urgency.
Musculoskeletal: No arthralgia, back pain, or myalgia.
Neurological: No headache, dizziness, syncope, paralysis, ataxia. No change in bowel or bladder control.
Psychiatric: No history of depression or anxiety. No delusions or hallucinations.
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. No rash or itching.
Hematologic: No anemia, bleeding, or bruising.
Lymphatics: No enlarged nodes. No history of splenectomy.
Endocrinologic: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
Allergies: No history of asthma, hives, eczema, or rhinitis.
Objective Data:
Head-to-toe assessment:
Vital signs: Blood Pressure: 128/82 mmHg; Pulse: 78 bpm; Respiratory Rate: 15 breaths per minute; Pulse Ox: 99%; Temperature: 99.0 °F; Blood glucose: 90 mg/dL; Height: 170 cm; Weight: 84 Kg; BMI: 29.00
General: The patient is alert and oriented to all facets. She sits upright on the examination table. She has good health, is well groomed, and has good hygiene as well.
HEENT:Head; is rounded, symmetrical, and normocephalic. No depression, or masses on palpation. No palpation tenderness. Eye; eyebrows and lashes are evenly distributed. No swelling of the eyelid, ptosis, discharge, or skin changes. The pupils are equal in size and reactive to light bilaterally. The extraocular muscles are intact bilaterally. No nystagmus. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. No scleral jaundice, or conjunctival pallor. Ears; Pinna are symmetrical and equal in size. No structural deformities. No discharge. Whispered words bilaterally heard. Nose; Symmetrical, straight, and uniform. No discharge. Frontal and maxillary sinuses nontender to palpation. The nasal mucosa is moist and pink, septum midline. Mouth; Oral mucosa moist without ulcerations or lesions. Uvula rises midline on phonation. The gag reflex is intact, Dentation minus evidence of carries or infection. Tonsils have Mallampati score II bilaterally.
Neck:Coordinated head movement. No masses. No cervical spine tenderness. No neck stiffness. No cervical lymphadenopathy. Thyroid smooth minus nodules, no goiter. The trachea is centrally placed with no deviation. No jugular vein distension.
Chest/Lungs:Chest is symmetrical and expands with respiration. No tenderness on palpation. Both sides of the chest are resonant to percussion. No crepitation, or wheezing on auscultation. In office spirometry: FVC 3.91, FEV1/FVC ratio 80.56%.
Heart/Peripheral Vascular: No heaves of lifts. No distended veins on the chest. Pulse has normal strength, is regular, and has a normal rate. Normal S1 and S2 heart sound, 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:The abdomen is protuberant, and symmetric without visible masses, scars, or lesions, and coarse hair from the pubis to the umbilicus. No caput medusae, Moves with respiration. No tenderness guarding, organomegaly, or masses on palpation. Normoactive bowel sounds in all four quadrants on auscultation. Tympanic abdomen on percussion.
Genital/Rectal:No external lesions. Good anal sphincter tone. No urethral discharge. No tenderness or masses.
Musculoskeletal:Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.
Neurological:Sensory: Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterallyDecreased sensation to monofilament in bilateral plantar surfaces.Motor: Cerebella function tests produced normal results. Deep tendon reflexes 2+ and equal bilaterally in upper and lower extremities.
Skin:No erythema, no pallor, or cyanosis. Skin is warm to touch. Normal skin turgor. Pustules on the face are scattered whilst the upper lip has facial hair. The posterior neck has acanthosis nigricans. Nails are free of ridges or abnormalities.
Diagnostic results:
Complete Blood Count: This is a full differential count of all blood cell lineages. It is important to evaluate the patient’s blood cell parameters to rule out conditions such as anemia(Celkan, 2020). It also indicates whether the patient is fighting any infection.
Chest Radiograph: a chest x-ray is a first-line imaging modality in patients presenting for re-employment assessment. The radiograph indicated the presence of any lung pathology of public health concern such as tuberculosis(Uzorka et al., 2019). It investigates for presence of opacification, air bronchograms, and consolidation.
Spirometry: This lung function test assesses lung volumes to monitor the patient’s illness such as asthma(Gallucci et al., 2019). This is important in identifying the patient’s predisposition to occupational asthma and other pneumoconiosis.
Assessment:
- Type 2 diabetes mellitus
This is an endocrine disorder characterized by the inability of the body to regulate glucose levels due to a deficiency or insensitivity to insulin. It is a systemic illness and thus may present in various ways such as polyuria, easy fatiguability, loss of weight, characteristic fruity breath, blurry vision, and paresthesia(Bellary et al., 2021). The patient was diagnosed at 24 years of age and has been managing the condition through lifestyle modifications and oral glycemic control medication metformin. The assessment revealed that the patient’s diabetes is well controlled.
- Polycystic ovary syndrome (PCOS)
PCOS is a condition caused by multiple cysts in the ovary which produce excess sex hormones. The androgens lead to symptoms such as obesity, severe acne, and easy fractures due to bone demineralization(Hoeger et al., 2021). The acne affects the face, trunk, and limbs. The patient may also have amenorrhea or dysmenorrhea. The patient reports improvement in the pustules indicating that the PCOS is progressively being managed.
- Asthma
Asthma is a chronic disease of the lung that is caused by airway hyperresponsiveness, narrowing, and difficulty in breathing. It usually develops early in life but may also present in adulthood(Cevhertas et al., 2020). The patient last used her inhaler 3 months ago and does not complain of any respiratory symptoms proving that her asthma is well managed.
References
Bellary, S., Kyrou, I., Brown, J. E., & Bailey, C. J. (2021). Type 2 diabetes mellitus in older adults: Clinical considerations and management. Nature Reviews Endocrinology, 17(9), 534–548. https://doi.org/10.1038/s41574-021-00512-2
Celkan, T. T. (2020). What does a hemogram say to us? Turk Pediatri Arsivi, 55(2), 103–116. https://doi.org/10.14744/TurkPediatriArs.2019.76301
