NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

Walden University NURS 6512 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 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 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

Whether one passes or fails an academic assignment such as the Walden University NURS 6512 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 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

The introduction for the Walden University NURS 6512 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 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

After the introduction, move into the main part of the NURS 6512 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 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 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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Sample Answer for NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

Patient Initials: Tina Jones Age: 28 Gender: Female 

SUBJECTIVE DATA: 

Chief Complaint (CC) for NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT patient: “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) for NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT patient: Tina Jones comes into the clinic for a general physical exam. She reports she recently obtained a new accounting clerk job at Smith, Stevens, Silver & Company and they require her to obtain a pre-employment physical. She denies any acute concerns at this visit. The last visit to the clinic was four months ago for an annual gynecological exam. At that time, she was diagnosed with polycystic ovarian syndrome (PCOS) for which she was prescribed the oral contraceptive drospirenone and ethinyl estradiol (Yaz). She states she takes the pill daily, at the same time each day. Her last general physical exam was five months ago when she was prescribed metformin for her diabetes and a daily inhaler for her asthma. Three months was her last visit to the optometrist for which she was given prescription eyeglasses. She states the glasses improve her vision, reduce her blurry vision and have helped eliminate her headaches. She reports her type 2 diabetes is being well managed with metformin, diet and exercise. She regularly monitors her blood glucose levels, checking once a day in the morning. She also has been keeping records of her asthma by monitoring her peak flow. The rescue inhaler was last used three months ago with a total of two uses in the past year 

Medications: Metformin: Started five months ago. 850 mg twice daily. Reports eating probiotic yogurt helps with side effects. Fluticasone propionate: 88 mcg/spray, two puffs twice daily. Albuterol: 90mcg/spray MDI, two puffs every four hours as needed. Drospirenone and ethinyl estradiol: one pill every day. Ibuprofen: 600 mg as needed for menstrual cramps 

Allergies: Ms. Jones has a penicillin allergy with a reaction of rash. She is allergic to cats and dust. These allergens aggravate her asthma symptoms, so she tries to avoid them. She denies any food allergies 

Past Medical History (PMH): Patient has history of diabetes which was diagnosed at age 24 and is on metformin, compliant with her blood glucose check. Patient was diagnosed with asthma at the age of 2.5 

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. No sexual intercourse with the new boyfriend yet. No sexual transmitted diseases as per the last text done 4 months ago. 

Personal/Social History: Ms Jones reported drinking about 6 drinks/day. Patient denies any illegal use of drugs. Just graduated from college with a BA. 

Health Maintenance: Patients diabetes is well controlled, does exercise daily, eats fine. Though feels exhausted at the end of the day. 

Immunization History: Up to date with childhood immunization record. 

Significant Family History: There is a family history of diabetes – father and paternal uncle. Family also has history of hypertension with grandmother and father. 

Review of Systems  

General: Ms. Jones is sitting comfortably on the examination table, in no acute distress. No current complaints or recent illness. She appears well-nourished and dresses appropriately. Reports recent weight loss. Vitals: Height 170 cm, Weight 84 kg, BMI 29, BP 128/82, HR 78, RR 15, O2 99%, Temp 37.2C 

HEENT: Ms. Jones reports no headaches, vision changes, eye pain or itchy eyes. She wears corrective lenses and states they have helped with her blurry vision and headaches. Denies changes in hearing or ear pain. Denies a runny nose or sneezing. Last dental visit was five months ago with no concerns. 

Upon examination, head is normocephalic with no lesions or tenderness of scalp. Hair is normal texture and distributed evenly. Sclera white, conjunctiva pink, PERRLA, EOMs intact. Left disc round with sharp margins. Mild retinopathic changes on the right. Vision 20/20 bilateral with corrective lenses. Nasal cavities pink, no discharge. Ear canal pink, tympanic membrane pearly gray, no drainage. Whispers heard bilaterally. Mucous membranes pink and moist, tonsils 2+ bilaterally. Gag reflex present, swallows without difficulty. Sinus’ palpated with no tenderness noted. No clicks on jaw palpation, full ROM. Thyroid palpable, no nodules, no goiter. Axillary and cervical lymph nodes palpated, no lymphadenopathy 

Respiratory: Ms. Jones reports no shortness of breath or trouble breathing. No wheezing, runny nose or a cough. Last use of her rescue inhaler was three months ago and two times total over the past year. Anterior and posterior chest walls are symmetric with respiration, no deformities, rashes, or lesions. Breath sounds present and equal bilaterally, no adventitious sounds noted. Chest resonant on percussion. Palpated fremitus equal bilaterally. Normal bronchophony results. Spirometry: FVC 3.9L, FEV1 3.15L, FEV1/FVC ratio 80.56%. 

Cardiovascular/Peripheral Vascular: Ms. Jones reports no chest pain, palpitations, or swelling of hands and feet. Heart rate is regular, S1, S2, no murmurs, gallops or rubs. Bilateral carotids 2+, no thrill, no bruits. PMI nondisplaced, no heaves or lifts. Peripheral pulses 2+, equal bilaterally. No peripheral edema. Capillary refill <3 seconds. 

Gastrointestinal. Reports no nausea, vomiting, constipation, diarrhea, pain or heartburn. Upon inspection, abdomen protuberant and symmetric. Coarse hair growth noted from pubis to umbilicus. Bowel sounds normoactive and present in all four quadrants. Abdomen tympanic on percussion. Liver span 7 cm MCL, palpable 1 cm below right costal margin. Abdomen soft with no tenderness, guarding or masses with palpation. 

Musculoskeletal: MS. Jones reports no muscle pain or weakness. Her gait is smooth with equal stride. Full ROM of TMJ with no crepitus. Upper and lower extremities symmetric without lesions or swelling. Full ROM and 5/5 strength in extremities, spine, and hips. Deep tendon reflexes 2+, upper and lower. 

Neurological: Reports no dizziness, tingling, or loss of sensation. Awake and alert. Oriented to person, place, and time. Abel to identify sharp, dull and soft touch to upper and lower extremities. Dual shoulder shrug against resistance, able to turn head in both directions against resistance. Position sense in fingers and toes are normal. Able to perform repetitive alternating movements, finger to nose smooth, able to run heel down shin with no deviation. Stereognosis and graphesthesia normal bilaterally. Monofilament test shows decreased sensation in both right and left great toes and forefoot.  

Skin/hair/nails: Ms Jones confirmed there is an improvement on the acne on her face since she started the oral contraceptive. Her skin is pink, warm, with no tenting. Pustules noted on bilateral Ms Jones hair is well groomed and evenly distributed. 

Psychiatric: Ms. Jones denies any concerns with mental health. patient does have slight anxiety due her poor sleep problems, only lasted for a couple weeks. 

Genitourinary: Patient denies any problem with urinating, denies blood in urine 

OBJECTIVE DATA :  

Physical Exam: Denies any fatigue, although reports loss of 10lbs in weight since 4 months. No fever and night sweats 

Vital signs: BP= 128/82 T= 37.2 HR= 78 R= 15 SPO2= 99% 

General: Ms Jones, is quite alert and oriented X3, in no obvious distress. 

HEENT: Head is norm cephalic and atraumatic, Normal hair distribution. No ptosis or edema noted., Palpated scalp, no masses noted, no frontal sinus tenderness noted. Lymph nodes palpated-No lymphadenopathy noted. Tested eye Movements-Normal convergence noted Interior eyes inspected with Ophthalmoscope-Mild retinopathy changes noted on the right. Inspected Neck- No swelling masses or deformity noted 

Neck: Acanthosis noted on the neck 

Chest/Lungs: Breath sounds positive. Respiration is clear to auscultation. Resonant to percussion. 

Heart/Peripheral Vascular: s1 and S2 heart sounds heard with no murmurs. Carotid arteries- equal bilaterally with no bruits PMI- 5th intercostal space   

Abdomen: Palpated abdomen- No masses, tenderness or abdominal guarding noted. Palpated kidney- no masses and not palpaple sleen-Not palpalble and no masses seen Liver- Palpable 1cm bellow right coatal margin 

Genital/Rectal: 

Musculoskeletal: Upper extrimities- no deformity, swelling or masses noted. Inspected lower extremity- No masses, abnormality or deformity noted. Fingernails -No ridges or abnormalities noted. Upper and lower extremities- Full ROM noted on both 

Neurological: Normal Graphestesia, Stereognosis and rapid alternating movements noted billateraly. Cerebral function test is normal. Deep tendon reflexes DTRs +2 and equal bilateraly in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces 

Skin: Ms Jones hair is well groomed and evenly distributed. No laceration noted on the skin. No nail deformities, scattered pustules on face. 

Diagnostic results: No diagnostic procedures carried out at this time as the patient only came for pre-employment 

ASSESSMENT: Ms. Jones came in today for her pre-employment test as requested for her new job which she will begin in 2 weeks. She has history of diabetes which is well controlled and on metformin, flovent for asthma and birth control pill. Ms. Jones now understands how best to monitor her blood glucose and knows how best to manage her stress level. She is on a birth control pill which is helping to indirectly control the acne 

Deep tendon reflexes DTRs +2 and equal bilaterally in upper and lower extremities. 

PLAN: This section is not required for the assignments including NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT in this course (NURS 6512), but will be required for future courses.

Also Read:

LAB ASSIGNMENT: ASSESSING THE GENITALIA AND RECTUM

Sample Answer 2 for NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

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/

Sample Answer 3 for 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.

1. Metformin 850 mg per os twice a day. For blood sugar control.
2. Drospirenone and ethynyl estradiol per os 3/0.02 mg once a day for PCOS.
3. Albuterol inhaler two puffs a day. The last use was 3 months ago.
4. Acetaminophen 500-1000 mg per os PRN for headaches.
5. 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:

1. 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.

2. 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.  

3. 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

Cevhertas, L., Ogulur, I., Maurer, D. J., Burla, D., Ding, M., Jansen, K., Koch, J., Liu, C., Ma, S., Mitamura, Y., Peng, Y., Radzikowska, U., Rinaldi, A. O., Satitsuksanoa, P., Globinska, A., Van De Veen, W., Sokolowska, M., Baerenfaller, K., Gao, Y., … Akdis, C. A. (2020). Advances and recent developments in asthma in 2020. Allergy, 75(12), 3124–3146. https://doi.org/10.1111/all.14607

Gallucci, M., Carbonara, P., Pacilli, A. M. G., Di Palmo, E., Ricci, G., & Nava, S. (2019). Use of Symptoms Scores, Spirometry, and Other Pulmonary Function Testing for Asthma Monitoring. Frontiers in Pediatrics, 7, 54. https://doi.org/10.3389/fped.2019.00054

Hoeger, K. M., Dokras, A., & Piltonen, T. (2021). Update on PCOS: Consequences, Challenges, and Guiding Treatment. The Journal of Clinical Endocrinology & Metabolism, 106(3), e1071–e1083. https://doi.org/10.1210/clinem/dgaa839

Uzorka, J. W., Wallinga, J., Kroft, L. J. M., Ottenhoff, T. H. M., & Arend, S. M. (2019). Radiological Signs of Latent Tuberculosis on Chest Radiography: A Systematic Review and Meta-Analysis. Open Forum Infectious Diseases, 6(7), ofz313. https://doi.org/10.1093/ofid/ofz313