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

Week 9

Shadow Health Comprehensive SOAP Note Template

 

Patient Initials: __T.J_____                     Age: ___28____                           Gender: ___Female____

 

 

SUBJECTIVE DATA: ‘I have come for my pre-employment assessment’

 

Chief Complaint (CC): Tina Jones is a 28-year-old African American that came to the unit for her pre-employment physical examination.

 

History of Present Illness (HPI): Tina Jones has come today for her pre-employment physical assessment. According to her, she has been employed at Smith, Stevens, Stewart, Silver & Company, and is required to undertake the assessment before reporting at her new workplace. Jones no acute health problems currently. She reports that her last visit to a healthcare provider was four months ago for annual gynecological exam. Her last general physical examination as five months ago where she was prescribed daily inhaler and metformin twice a day. She currently uses daily inhaler (Proventil rescue inhaler, twice daily) and diabetes medication (Metformin 850 mg twice daily). She is also taking birth control pills prescribed for polycystic ovarian syndrome diagnosed during her last gynecological visit. Her diabetes is controlled with metformin, exercise and diet.  

 

Medications: Jones noted that she is currently on the following medications

  • Fluticasone propionate, 110 mcg 2 puffs BID (last use: this morning)
  • Metformin, 850 mg PO BID (last use: this morning)
  • Drospirenone and ethinyl estradiol PO QD (last use: this morning)
  • Albuterol 90 mcg/spray MDI 2 puffs Q4H prn (last use: three months ago)
  • Acetaminophen 500-1000 mg PO prn (headaches)
  • Ibuprofen 600 mg PO TID prn (menstrual cramps: last taken 6 weeks ago)

 

Allergies: Jones denies no new allergies as well as seasonal allergies. She reports that she is allergic to penicillin, dust and cats. The associated allergic symptoms include rhinorrhea, exacerbated asthma symptoms, and swollen eyes. She does not have food or latex allergy.

 

Past Medical History (PMH): Jones reports that her last health visit was 4 months ago when she underwent her annual gynecological exam. She was diagnosed with polycystic ovarian syndrome, which she has been treating with oral contraceptives. She has a history of asthma and diabetes. She was diagnosed with diabetes when she was 24 years. She controls diabetes with metformin, dietary modifications, and exercise. Her blood glucose levels are currently controlled. She performs daily self-monitoring of blood glucose, with her blood glucose levels being around 90. She has adequate supplies for blood glucose monitoring. She was diagnosed with asthma at the age of two and half years and has been using albuterol inhaler to manage and prevent it. She denies recent asthma exacerbations or current asthma symptoms. Last asthma exacerbation was three months ago. She has a history of hospitalization due to asthma when she was in high school. She also has a history of hypertension, which resolved following her dietary modifications and engaging in physical activity. She has a history of optometrist visit (3 months ago) where she was prescribed eyeglasses to improve vision.

 

Past Surgical History (PSH): She reported that she has no history of surgery.

 

Sexual/Reproductive History: Her menarche was when she was 11 years. Her first sexual encounter was when she was 18 years. Identifies herself as heterosexual. Her menarche pattern is every four weeks, which last five days, with medium flow. Her last menstrual period was 2 weeks ago. She was diagnosed with polycystic ovarian syndrome four months ago and has been on treatment. Her menstrual period lasts about five days. She reports that she is currently in a new month-old relationship. She intends to use condoms with any sexual activity. Tested negative for HIV/AIDS and STIs four months ago. She has never been married nor pregnant.

 

Personal/Social History: Jones currently lives with her sister and mother and intends to live alone in a month’s time close to her workplace. She is a graduate with accounting degree. She secured a job with Smith, Stevens, Steward, Silver & Company to start in 2 weeks’ time as an accounting clerk. She has strong support system comprising her friends, family, and church. She spends her time with friends, reading, attending bible study, volunteering in her church and dancing. No history of tobacco use. Cannabis use from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin.

Health Maintenance: Jones utilizes health screening services. Her last gynecological exam was four months ago where she was diagnosed with polycystic ovarian syndrome. Her dental examination was done last five months ago. She reports that their home has smoke detectors. She drinks 2-3 alcohol drinks per month and 2 or 3 single drinks (rum and diet coke) when out with friends. Her typical diet comprises of fruit smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt. Lunch comprises of dinner leftovers or tuna or chicken sandwich on wheat bread. Her typical dinner is vegetables with a protein and brown rice or quinoa. Her snack is carrot sticks or an apple. She limits intake of caffeine due to sleep and heart problems. She does not drink coffee. She drinks about 2 diet cokes per day. She engages in mild to moderate exercises by walking four or five times a week, lasting 30-40 minutes. She also swims weakly at YMCA. She reports improved ability to cope with stress after passing graduating and passing CPA exam. She sleeps 8-9 hours a night.

 

Immunization History: Jones reports that she believes that all her immunizations are current.

 

Significant Family History: The following are Jones’ significant family histories

  1. Her father died of car accident. He had a history of high cholesterol, type 2 diabetes, and hypertension
  2. Her brother, Michael is overweight
  3. Her sister, Britney is asthmatic
  4. Her deceased maternal grandmother had hypertension, stroke, and high cholesterol
  5. Her deceased maternal grandfather had hypertension, high cholesterol, and stroke
  6. Her paternal grandmother has hypertension
  7. Her deceased paternal grandfather had colon cancer and type 2 diabetes
  8. Her paternal uncle is alcoholic
  9. There is no history of kidney disease, thyroid problems or any other cancers in the family

 

Review of Systems:

 

General: Jones denies chills, fatigue, recent illness, or night sweats She reports recent weight loss of about 10 pounds due to diet and increased exercise

          HEENT: Jones denies headache, head injuries, changes in hearing, ear pain or discharge. She denies eye pain, discharge, itchiness, redness, or dry eyes. She uses corrective lenses. She denies changes in smell, sneezing, nosebleeds, sinus pain, sinus pressure, or rhinorrhea. Her dental visit was five months ago. She denies changes in senses of taste, dry mouth, mouth pain, sores, tongue, or gum problems. She denies dysphagia, sore throat, chronic throat problems, neck pain, lymphadenopathy, or swollen glands.

          Respiratory: Denies current breathing problems, wheezing, chest tightness, pain when breathing, or cough.

          Cardiovascular/Peripheral Vascular: She denies palpitations, irregular heartbeat, easy bruising, edema, or circulation problems.

          Gastrointestinal: She denies nausea, vomiting, stomach pain, constipation, diarrhea, or flatulence.  

          Genitourinary: She denies dysuria, nocturia, polyuria, frequency, blood in urine, flank pain, vaginal itchiness, or abnormal discharge. She denies breast lumps or pain

          Musculoskeletal: She denies muscle or joint pain, muscle weakness, or swelling.

          Neurological: She denies dizziness, vision disturbance, numbness, tingling, loss of coordination, seizures, or balance problems.  

          Psychiatric: She denies history of mental problems

          Skin/hair/nails: Reports using sunscreen when exercising outdoors, no recent slow healing wounds, improving acne, and some male-hair like pattern. Denies no changes in moles, dandruffs, sores, nail fungus, or dry skin.

 

 

OBJECTIVE DATA:

 

Physical Exam:

Vital signs: Respiration- 15

Temp- 37.2 C

Heartrate – 78

SpO2- 99%

  • Height: 170 cm
  • Weight: 84 kg
  • BMI: 29.0
  • Blood Glucose: 100
  • RR: 15
  • HR: 78
  • BP:128 / 82
  • Pulse Ox: 99%
  • Temperature: 99.0 F

General: Jones is alert oriented, seated upright on examination table, and is in no distress. She is well-nourished, developed, and dressed appropriately with good hygiene.

HEENT: Head is normocephalic, atraumatic. Eyes bilateral with equal hair distribution on lashes and eyebrows. No lesions on lids, no edema or ptosis. Pink conjunctiva, white sclera, PERRLA bilaterally, intact extraocular eye movements, and no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard 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 intact. Dentition without evidence of caries or infection.

Neck: Thyroid smooth without nodules, no goiter. No lymphadenopathy.

Chest/Lungs: Lung sounds clear and voice is present in all areas. Spanish symmetrically. Chest anterior and posterior normal upon inspection. fremitus equal bilaterally. Chest is symmetric with respiration, clear to auscultation bilaterally without cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.

Heart/Peripheral Vascular: Pirated 2 + with no thrill or bruit bilaterally. PMI non-discplaced. S1 and S2 only regular rhythm. No bruit in aorta or any other arteries. Capillary refill is less than 3 seconds in fingers and toes no edema is present. Heart 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 refill less than 3 seconds. No peripheral edema.

Abdomen: bowel sounds are normal in all quadrants. moves bowels regularly. Abdomen is soft with no Masses. liver is one centimeter below the right costal margin. Quadrants are tympanic and spleen is Not dull in sound. Kidney is not palpable no masses are present

 

Abdomen protuberant, symmetric, no 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. No CVA tenderness.

Genital/Rectal:

Musculoskeletal: Range of motion in all areas of full or muscle strength or 5 out of 5 no CVA tenderness. DTR 2+. Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.

 

Neurological: for the feet especially left foot area. Patient is able to sense position of body fingers and toes. Graphesthesia normal sense. Patient is oriented to time person and place. Heel to Shin normal. 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: Acne is present on the face. Skin is normal. Norwegians or abnormalities in the nails. Old scar is present on the left shin.

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

 

Diagnostic results: None

 

ASSESSMENT: Jones is a 28-year-old female that has come today for her pre-employment assessment. She appears well dressed and responsive. She is diabetic and asthmatic, which are controlled. She uses corrective lenses. She has normal sleeping cycle. She engages in active physical activity and has dietary modifications for diabetes control. She monitors her blood glucose levels on a daily basis. She also monitors her peak flow to track asthma and uses albuterol inhaler to manage its symptoms. She denies any current acute health problems.  

 

PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.

 

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment NURS 6512N-32

History of Present Illness (HPI): Ms. Tina Jones is currently employed with Smith, Stevens, Stewart, Silver, and Company. Ms. Jones must have a pre-employment physical before she may begin working. During the interview, she maintains that she has no pressing concerns. Ms. Jones got her yearly gynecological exam at the Shadow Health General Clinic four months ago. She was later diagnosed with POCS, and her gynecologist advised her to use oral contraceptives. She claims to be putting up with the contraception. The patient also admits to having type 2 diabetes, which she manages through exercise, a good diet, and the prescription metformin, which she was prescribed around five months ago. She denies having experienced any bad drug interactions. The patient claims to be healthy because she takes better care of her body than she did previously and because she is excited about her new job.

Medication: The patient is on Flucotisone propionate 110 mcg twice day, with the last puff administered in the morning. In addition, the patient takes Metformin 859 mg PO twice a day, the last dose in the AM. In addition, the patient takes drospirenone and ethinyl estradiol orally (PO) four times each day, with the last dose taken in the morning. Ms. Jones also uses albuterol spray for her asthma; her most recent use was three months ago. Tina also takes Ibuprofen 600 three times every day to ease period symptoms. Her prescription hadn’t been taken in six weeks.

She has a penicillin allergy, which causes rashes. She, on the other hand, denies having food or latex allergies. She admits to having allergies to dust and pets. When the patient is exposed to her allergens, she gets a runny nose, puffy, itchy eyes, and her asthma symptoms worsen.

Tina’s asthma was diagnosed when she was 21/2 years old, according to her medical history (PMH). She uses the albuterol inhaler when she is around allergies, such as cats. She used the same inhaler three months later when her asthma flared up again. Her asthma required hospitalization most recently when she was a senior in high school. She claims she was never intubated. When she was 24, she was diagnosed with type 2 diabetes. She started taking metformin five months ago to help with her asthma. She initially had gastrointestinal issues, but they have since subsided. The patient takes daily morning blood sugar readings, with an average value of 90. Her hypertension was controlled through diet and exercise. She had never had surgery before.

Read Also: Week 8: Assessment of the Musculoskeletal System

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: 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

Week 9: Shadow Health Comprehensive SOAP Note Template

SUBJECTIVE DATA:

Chief Complaint (CC): “I came here because I am required to have a recent physical exam for the health insurance at my new job”

Past Surgical History (PSH): Denies any surgical history

 

Sexual/Reproductive History: She had menarche at the age of 11. She had her maiden sex at the age of 18. She identifies as heterosexual and only has sex with men. She denies ever being pregnant with her last monthly periods occurring a fortnight ago. She was also diagnosed with PCOS during her last physical exam, which occurred 4 months ago. After starting on the prescription drug Yaz, her cycles have become regular accompanied with bleeding that is moderate and which lasts five days. She has started a new relationship with a man but they have not had sex yet. She has plans to protect herself when she starts having sex. She does not have any sexually transmitted infections or HIV/AIDS with the last test occurring four months ago.

You are admitting a 19-year old female college student to the hospital for fevers.  Using the patient information provided, choose a culture unfamiliar to you and describe what would be important to remember while you interview this patient. Discuss the health care support systems available in your community for someone of this culture. If no support systems are available in your community, identify a national resource.

Stanley Ogbo

Posted Date

Feb 18, 2022, 3:02 AM

Unread

Replies to Stanley Ogbo

 

Child Developmental Assessment

 

 

Stanley Ogbo

College Name, Grand Canyon University

Course Number: NRS-434VN

Topic 4 DQ 1

Dr. Lily Polsky

16 February 2022.

 

Culture is defined as the way of life of a people. It is also seen as the customs, arts, social institutions, and achievements of a particular nation, people, or other social group. It is important for nurses to consider the cultural beliefs of their patients while rendering care. The cultural needs of patients should be determined immediately the walk through the door. The nurse should be very observant to check if the patient makes eye contact and communicate well during the interview. It is essential we build a trusting relationship with the patient throughout their hospital stay. The nurse should exercise cultural competency which involves the respect of all beliefs, values, and decision-making power of the patient within a different group cultural group than the nurse.

The Arab American culture

The Arab American has a unique culture, and the nurse should remember that when first treating a patient, they should refrain from any excess eye and physical contact (Attum, Haffiz, Malik, 2020). Maintaining privacy is essential and modesty is important. The family should be included in the treatment planning. This female needs to be seen by female health care providers. It is required in this culture that the patient be assessed by medical professional that are of the same gender as the patient (Falkner, 2018). Respecting the cultural diet is paramount. It is the nurses` responsibility to make the patient feel safe and respected (Falkner, 2018).

Health care support system

The language telephone line should be used for patient during the interview if she feels more comfortable using her preferred language. The language line at the facility where I work has just has video option that the nurse can utilize if the patient gives the consent. Spiritual care should be provided. This because prayer and religion are valued among the Arab Americans (Attum, Haffiz, Malik, 2020). The support system is Arab American Family Services which offer support in the areas of public benefits, immigration, domestic violence, mental health, elderly services, and they sponsor outreach programs to build healthier families and communities (AAFS, 2020)

 

 

References

Arab American Family Services (2020). Support for Arab American Families: About Us. Retrieved from http://arabamericanfamilyservices.org/about-us/

Attum, B., Hafiz, S., Malik, A. (2020). Cultural Competence in the Care of Muslim Patients and Their Families. Retrieved from: htts://www.ncbi.nlm.gov/books/NBK499933/

Falkner, A. (2018). Cultural awareness. In Grand Canyon University Ed.). Health promotion: Health & wellness across the continuum. Retrieved from https://lc.gcumedia.com/nrs429vn/health-promotion-health-and-wellness-across-the-continuum/v1.1/#/chapter/3