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

Walden University NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment                     

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment                     

The introduction for the Walden University NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment                     

After the introduction, move into the main part of the NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment                     

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6512 Assignment 3 Week 9: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment                     

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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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.

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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 5^th 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 have come for my pre-employment assessment.

History of Present Illness (HPI): The patient is a 28-year-old African American unmarried female that came to the clinic for pre-employment assessment. She is cooperative and offers information. She maintains normal eye contact and has normal speech. The client reports that she recently got a job that requires her to have a health insurance. She denies any acute concern. She reports that she had her gynecological exam four months ago where she was diagnosed with POCS and prescribed medications that she tolerates well. She is also diabetic and manages it with metformin and active lifestyle. She tolerates the medication well.

Medications: The patient currently uses Metformin 850 MG po BID Drospitenone and ethinyl estradiol PO QD. She also has Albuterol spay that she puffs twice and last use was three months ago. She occasionally uses Acetaminophen 500-1000 mg PO prn for headaches and Ibuprofen for menstrual cramps and last taken 6 weeks ago.

Allergies: The client reports allergic reaction to penicillin, which causes rashes. She also reports allergic reaction to dust and cats. She denies food and latex allergies.

Past Medical History (PMH): The client reports that she was diagnosed with asthma when 1 1/2 years old. Her last asthma exacerbation occurred three months ago. Last asthma hospitalization was when in high school. She report that she has never been intubated. The client reported that she has type 2 diabetes that was diagnosed at the age of 24. She has been taking metformin for five months without much side effects. Her average blood sugar is 90 and she monitors it daily in the morning. She also exercises and diets to manage the condition as well as hypertension. She has never undergone any surgery.

Past Surgical History (PSH): She has no history of surgery

Sexual/Reproductive History: She developed menarche at the age of 11. She has sex with men. She has never been pregnant whilst her had first sex at the age of 18. She has a new boyfriend.

Personal/Social History: She graduated with accounting degree and has been hired as an accounting clerk at Smith, Stevens, Steward, Silver & Company. The patient does not have children. She is not married. She lives with her mother alongside 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 considers her social support to include the church, friends and her family. She does not use tobacco. She used cannabis from ages 15-21. She does not abuse any other drugs. She uses alcohol in the company of friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, lunch to supper. She does not take coffee. She takes diet coke. She has not travelled outside recently and does not keep pets. She does mild exercise at least four times per week. She denies being stressed or anxiety.

Health Maintenance: The patient attends to the doctor’s appointment as scheduled. She had a pap smear 4 months ago. She also had an eye exam 3 months ago. The dental exam was last conducted 150 days ago. She is negative for PPD that was done two years ago. Her immunization status is current bar tetanus and HPV vaccines. She swims at YMCA. She reports that she has smoke detectors in the home. She wears safety belts in the car. She does not ride the bike. She uses sunscreen in the sun. She has locked her father’s gun in their bedroom.

Immunization History: Her immunization status is current bar tetanus and HPV vaccines. Childhood vaccines are up to date ad as well as meningococcal vaccine.

Significant Family History: There is 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 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. Alcoholism in paternal uncle. There are no other diseases in the family.

Review of Systems:

General: The client is dressed appropriately for the occasion. She maintains normal eye contact during the assessment. Her speech is of normal rate and tone. She denies, chills, night sweats, headache, fatigue, or weight changes

HEENT: The client denies headache or head injuries. She denies general hearing problems, changes in hearing, ear pain or discharge. She also denies eye pain, itchy eyes, eye redness, or dry eyes. She denies changes in smell, sneezing, runny nose, nose bleeds or sinus pain. Dental visit was five months ago. She denies general mouth problems, changes in sense of taste, dry mouth, mouth pain, gum problems, tongue or jaw problems, and dental problems. She denies difficulty in swallowing, sore throat, voice changes, neck pain, or lymphadenopathy.

Respiratory: She denies any current breathing problems. She chest tightness, wheezing, chest pain, 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, blood stained urine, flank pain, abnormal vaginal discharge, breast lump or breast pain.

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

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

Psychiatric: Has enhanced coping mechanism to stress. Does not suffer depression, anxiety, or suicidal thoughts. She is alert to all faculties. She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear.  Skin/hair/nails: she uses sun-glasses when playing outdoors. She denies slow-healing wounds, with improving acne and some male-pattern hair growth. She denies sores, dandruff, nail fungus, dry skin or rashes.

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: She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear.

HEENT: Normocephalic head, and atraumatic as well. Bilateral eyes with equal hair distribution on lashes and eye brows, lids without lesions. No ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. OEMS intact bilaterally, no nystagmus. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMS intact and pearly gray bilaterally, positive light reflex. Whispered words bilaterally heard.

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 minus evidence of carries or infection. Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.

Neck: Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.

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: 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 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. No CVA tenderness.

Genital/Rectal:

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: Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterally. Cerebella function tests produced normal results. DTRs 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: none. The client has come for preemployment physical examination.

ASSESSMENT: The patient is a 28-year-old African American unmarried female that came to the clinic for pre-employment assessment. She is cooperative and offers information. She maintains normal eye contact and has normal speech. The client reports that she recently got a job that requires her to have a health insurance. She denies any acute concern. She reports that she had her gynecological exam four months ago where she was diagnosed with POCS and prescribed medications that she tolerates well. She is also diabetic and manages it with metformin and active lifestyle. She tolerates the medication well.

The patient currently uses Metformin 850 MG po BID Drospitenone and ethinyl estradiol PO QD. She also has Albuterol spay that she puffs twice and last use was three months ago. She occasionally uses Acetaminophen 500-1000 mg PO prn for headaches and Ibuprofen for menstrual cramps and last taken 6 weeks ago. Physical examination findings are unremarkable. She denies any mental health problems such as anxiety or depression. No diagnostic investigations were ordered during this client’s visit.

Subjective Data Collection: 50 of 50 (100.0%)

NURS_6512_Week_4_Assignment_1_Rubric

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		Excellent	Good	Fair	Poor
Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: ·  Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). ·   Use clinical terminologies to explain the physical characteristics featured in the graphic.		Points Range: 30 (30%) – 35 (35%)The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies.	Points Range: 24 (24%) – 29 (29%)The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies.	Points Range: 18 (18%) – 23 (23%)The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies.	Points Range: 0 (0%) – 17 (17%)The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.
·   Formulate a different diagnosis of three to five possible considerations for the skin graphic.    ·   Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.		Points Range: 45 (45%) – 50 (50%)The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.	Points Range: 39 (39%) – 44 (44%)The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature.	Points Range: 33 (33%) – 38 (38%)The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature.	Points Range: 0 (0%) – 32 (32%)The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.		Points Range: 5 (5%) – 5 (5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.	Points Range: 4 (4%) – 4 (4%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.	Points Range: 3 (3%) – 3 (3%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.	Points Range: 0 (0%) – 2 (2%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation		Points Range: 5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.	Points Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.	Points Range: 3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.	Points Range: 0 (0%) – 2 (2%)Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.		Points Range: 5 (5%) – 5 (5%)Uses correct APA format with no errors.	Points Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.	Points Range: 3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.	Points Range: 0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors.
Total Points: 100

Name: NURS_6512_Week_4_Assignment_1_Rubric

OBJECTIVE DATA:

Physical Exam:

Vital signs: Height: 170 cm, Weight: 84 kg, BMI: 29, Heart Rate: 78, Blood Pressure: 128/82, Respiration Rate: 15, Temperature: 99.0 degrees Fahrenheit, and SpO2: 99 percent

General: The patient looks to be in good health with no indications of concern. Aware and centered in time, place, and person. Very friendly and helpful throughout the interview.

HEENT: Eyes: Anicteric sclera, no lid lag, moist conjunctiva, and mild retinopathy in the right eye. bilaterally PERRLA. Ears, Nose, Mouth & Throat: mucosal membranes of the oropharynx are moist and clear. There are no mucosal ulcerations visible. complete dentition with no indication of gum bleeding. No abnormalities were found, only hard and soft palates.

Neck: without jugular vein distention, soft. Nothing stiff. neither swollen lymph nodes nor lumps.

Chest/Lungs: Auscultation reveals bilateral clarity. a prolonged period of expiration. No rales, rhonchi, or wheezing.

Heart/Peripheral Vascular: Existence of S1 and S2. 2/6 systolic murmur. the regular rhythm of the heartbeat. No rales or gallops were seen.

Abdomen: Bowel sounds were apparent, and the patient had no CVA discomfort and was fat and mushy.

Genital/Rectal: a female who seems typical. No unusually strong or offensive discharge. displays a sacral or right buttock region that is somewhat erythematous and slightly broken.

Musculoskeletal: both upper and lower extremities have a full range of motion. No joint pain or stiffness.

Neurological: Lack of specific neurological impairments. full mental and verbal faculties. minimally intact II through XII cranial nerves. reduced monofilament feeling on both plantar surfaces.

Skin, Hair & Nails: facial hair on the upper lip and a face covered in many pustules. Ankylosis nigricans of the back of the neck. No further anomalies in the hair or nails.

Diagnostic results: The requested laboratory tests include a basic metabolic panel, a thyroid function test, a kidney function test, and a full blood count. Additional tests may include cholesterol testing, pap smears, and screenings for cervix and breast cancer. Imaging modalities, such as computed tomography (CT) and X-rays, are utilized to evaluate the prognosis of polycystic ovary syndrome (PCOS) (Sullivan, 2019).

 

ASSESSMENT:

1. The patient’s physical findings indicate a high BMI, indicating overweight status (Lebiedowska et al., 2020).
2. The monofilament test indicates reduced sensation in the patient’s feet, indicating peripheral neuropathy as a result of diabetes (Liu et al., 2019).
3. Mild retinopathy, indicating early stages of diabetes, was observed in the right eye (McAnany et al., 2019).
4. Acanthosis nigricans, a skin condition, is commonly linked to systemic diseases such as diabetes and obesity, which are caused by insulin resistance (Das et al., 2020).
5. The presence of upper lip facial hair may be linked to her prior PCOS diagnosis (Shah & Lieman, 2022).

The patient’s care plan will be determined based on an additional assessment of her conditions, including overweight, diabetes, PCOS, and asthma.