COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

Comprehensive Assessment SH Transcript, Sub, Obj & Documentation Transcript Hello, my name is . I will be conducting an interview and later perform a physical exam. Hey. What is your name? Tina Jones Your date of birth? February 17th. How old are you? I’m 28. What brought you into the clinic today? I came in because I’m required to have a recent physical exam for the health insurance at my new job. Do you have any current health problem? I don’t have anything specific going on today. I mean, I still have asthma and diabetes, but both of those are under control. I’m taking good care of my health these days. What is your new job? I’m going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. I’ll be helping a more experienced accountant with her clients, and then eventually I’ll get more responsibility, and build my own client list. I start in two weeks– I’m really excited! That is great. Empathize

Thanks. When was your last physical exam? Let’s see . . . I had two doctor’s appointments earlier this year. About five months ago, I came in here for a check-up, and the nurse practitioner got me on metformin. Then a few weeks later I saw a gynecologist for a pap smear. What did your gynecologist say? She said everything looked good, except that I had PCOS, which the nurse here had said was possible. She started me on birth control, and it seems to be helping things. How often do you take birth control? I take it every morning, with breakfast. What is the name of the birth control pill you took? They’re called Yaz. Has your menstrual cycle improved since taking Yaz? Now that I’m on the pill I’m getting my period every month. That is great. I am glad you are having your period every month. Empathize

Thanks. How long have you had asthma. I’ve had asthma a long time. . . since I was really little. What age were you diagnosed with asthma? My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then. I am sorry about the experience. Empathize

Thanks. How do you manage your asthma? I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler. What are your triggers for asthma? Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though. It is important to stay away from triggers. Educate

Thanks for telling me. What happens when you are around dust? I used to have a reaction when I was in a dusty house for a long time. . . I would get allergies, like sneezing and stuff, and then my asthma would act up. But that hasn’t happened since I got my daily inhaler. What inhaler do you use? The daily inhaler is Flovent, and the rescue inhaler is Proventil. How often do you use flovent? Twice a day. When did you most recently use the flovent inhaler? I use my Flovent inhaler two times a day. When did you last use your inhaler? I used my Flovent inhaler this morning–I have to take it twice a day. My albuterol. . . I’ve maybe used it twice since I came in with those asthma problems. Once three months ago, and before that it had been months, too. How much Albuterol do you use? I have a few friends I’ve known since middle or high school, and we’re all pretty close. Plus I have my friends from church. What is your relationship like with your family? Things are pretty good between all of us–we’re a tight knit family. I think we’re pretty special, the way we all get along. That is great. Empathize

Thanks. Are you involved in church? Yeah. We go to First Baptist, and we do a lot with our church community. We socialize before and after church, and I go to Bible study on Wednesdays, too. Are you feeling stressed?I’m actually feeling really good lately. . . not stressed at all. How do you cope with stress? I’ve realized that I got kind of overwhelmed with everything back when I was having those sleep problems. Just coming in and talking to someone here about it helped a little because I felt like I was doing something. So I’ve been trying to address problems as they come when I can, and that helps. That, plus the stuff I’ve always done–going to church, especially–is all working well for me. That is good to hear. Empathize

Thanks. Are you feeling depressed? No, I’m actually feeling really good these days.

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How do you feel about your life? Well, I’m starting my new job in two weeks, and I’m really excited about that. I’m going to be an Accounting Clerk at this really nice accounting firm. I’m hoping I’ll learn a lot in that position, and within a couple years, I’ll get promoted and be given new responsibilities. I just always want to be learning new things and getting better at my job. Are you feeling anxious? I guess I had anxiety back when I was having those sleep problems. . . I’ve been feeling much better lately, though. Do you have sleeping problems? I’m sleeping a lot better now, which is a relief. Good to hear. Empathize

Thanks. How many hours are you sleeping a night? I’m usually asleep by 11:30, and I wake up at 8, so. . . about 8 or 9 hours a night. That is great. Empathize

Thanks. Have you ever smoked tobacco? No. I think it’s gross. Have you ever used cocaine? No way, I have no interest in that. That stuff can mess you up. Have you ever used heroin? Uh, no. Have you ever used illegal drugs? Well, I used to smoke pot. . . but I don’t do that anymore. What was the last time you smoked pot? I haven’t smoked pot since I was twenty or twenty-one. Do you have any family history of mental illness? No. They’re crazy, but nobody’s diagnosed with anything. Have you had suicidal thoughts? No, I’ve never done that. Any new family medical history report? My mom has some issues, and I think some of my grandparents did, too. How old is your mom? Mom is 50. What medical problems does your mum have? Mom has high cholesterol and blood pressure, I think. She seems to be doing okay though. What medical problems did your father have? He had high blood pressure and cholesterol, and diabetes too…the same kind as me. How old is your brother? He’s almost 27. Does he have any medical issue? (Clarified to Does your younger sister have health problems?.) She’s pretty healthy. She has asthma too, but she almost never has attacks. (Clarified to if my younger sister has health problems.) Does your bother have health issues? (Clarified to Does your brother have medical problems?.) No, I don’t think so. He’s a little big, maybe. (Clarified to if my brother has health issues.) How old is your maternal grandmother? Nana was 73 when she died of a stroke about five years ago. I think she had high blood pressure and cholesterol, too. How old is your maternal grandfather? Poppa died of a heart attack when he was 80. . . he had some blood pressure and cholesterol issues when he was alive, too. Any medical history for your paternal grandmother? She takes some blood pressure pills, and I think she has high cholesterol, but Granny’s doing great for 82. Does your dad’s father have health issues? Grandpa Jones had colon cancer, and that caused all kinds of problems for him. Plus, he had high blood pressure, and…I’m pretty sure he had diabetes. Have you had any recent illness? No. . . the last time I was sick was when I was having those heartburn problems a while ago. Any fever? I haven’t had a fever. Any chills? Nope, no chills. Any acne? I took something for my acne. . . tetracycline, I think, back in high school. Since then I’ve just washed my face, I haven’t used anything special. But my zits have gotten better, and I think it’s because I’m on birth control now. Has your body hair improved? I think I have a little less body hair than I used to. Do your eyes feel itchy? They haven’t been itchy lately at all. Are you having any redness in your eyes? My eyes haven’t been red lately. . . not since I came in with those allergies a while ago. Are your eyes dry?

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My eyes don’t feel dry. Do you have any pain in your eyes? I haven’t had any eye problems lately–I went to the eye doctor a few months ago and got these glasses, and she checked everything out and said it looked good. Are you having any ear problems? My ears feel fine. Any changes in your hearing? My hearing is good. Any ear pain? My ears feel fine. Ear drainage? (Clarified to Do you have drainage from your ears?.) Nothing is coming out of my ears. (Clarified to if I have ear drainage.) Any changes in your sense of smell? No. Any nose bleeds? Nope, my nose isn’t bleeding at all. Any sinus pressure? My sinuses have been fine. Has your sense of taste changed? No, I think my sense of taste is fine. Are you having dry mouth? My mouth hasn’t been dry. ANY pain in your mouth? No, my mouth feels fine. ANY sore throat? No, it’s fine. Any issue with your gums? My gums have been fine. Any issue with your tongue? My tongue feels fine. Any difficulties when swallowing? I can swallow fine. SORE throat? No, it’s fine. Any voice changes? My voice has been fine. Any swollen lymph nodes? My lymph nodes seem fine. Are you having any nausea? No, I haven’t been nauseous at all. Any vomiting? No. ANY pain in the abdomen? I haven’t really had any stomach problems since I came in with them a while ago. Any constipation? I don’t have that problem. Any diarrhea? I haven’t had any problems with diarrhea. Excessive flatulence? I haven’t been having any gas lately. I had a little when I first started metformin, but I found out I could eat yogurt to help it, and it seems to have worked. Flatulence is one of the side effect of metformin Educate

Thanks for telling me. Any food intolerance? I can eat just about anything. Any burning sensation when you urinate? No, it doesn’t burn when I pee. Any blood in your urine? No! That doesn’t sound like it would be good. Are you having any pain right now? I don’t have any pain anywhere. Any vaginal discharge? My discharge is normal, I think. . . I have a little, and it’s kind of clear, sometimes white-ish. Any vaginal itching? No, it feels normal. Do you have any problem with your breasts? No, my breasts feel fine. Any pain in the breasts? No, my breasts feel fine. Are you having any dizziness? I haven’t been getting dizzy at all. Any lightheadedness? No, I don’t really get lightheaded. Any tingling? Nope, no tingling. Any loss of balance? My balance is fine. Any changes in sensation? I haven’t noticed any changes. Any seizures? No, I’ve still never had problems with seizures, fortunately. Do you have memory problems? I think my memory has been fine. Any muscle pain? My muscles have felt great, especially since I started exercising more. Joint pain? My joints always seem fine. Any muscle weakness? No, I haven’t felt weak at all. Any swelling? Nothing is swollen.

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Subjective Data Collection: 50 of 50 (100.0%) Current Health Status Finding: Confirmed reason for visit Finding: Reports needing a pre-employment physical Example : Can I confirm that you are here for a physical? Finding: Reports no current acute health problems Example : Do you have any current health problems? Finding: Asked about last visit to a healthcare provider Finding: Last visit to a healthcare provider was 4 months ago Example : When did you see a healthcare provider? Finding: Reason for last visit was annual gynecological exam Example : Why did you see a healthcare provider? Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler Example : When was your last physical exam? Finding: Asked about current prescription medications Finding: Reports taking diabetes medication Example : Have you been taking medication for your diabetes? Finding: Reports using a daily inhaler Example : Do you use a daily inhaler? Finding: Reports taking prescription birth control pills Example : Are you taking any form of birth control? Finding: Followed up about diabetes medication Finding: Medication is metformin What is the name of your diabetes medication? Finding: Started taking metformin 5 months ago Example : How long have you been taking metformin? Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time Example : Have you noticed any side effects from the metformin? Finding: Followed up on metformin frequency and dose Finding: Reports taking metformin twice daily How many times a day do you take metformin? Finding: Metformin dose is 850 mg Example :This study source was downloaded by 100000784551390 from CourseHero.com on 10-18-2023 22:23:01 GMT -05:00

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What is the dose of your metformin? Finding: Asked about asthma medication Finding: Reports using Flovent inhaler twice daily Example : How often do you use your daily inhaler? Finding: Has a Proventil rescue inhaler Example : Do you have a rescue inhaler? Finding: Last use of Proventil inhaler was three months ago Example : When did you last use your rescue inhaler? Finding: Has used Proventil inhaler twice in the last year Example : How often do you use your rescue inhaler? Finding: Followed up about birth control prescription Finding: Started taking birth control 4 months ago Example : How long ago did you start taking birth control? Finding: Reason for birth control was to manage PCOS symptoms Example : Why did you decide to start taking birth control? Finding: Birth control type is Yaz (drospirenone and ethinyl estradiol) Example : What type of birth control do you use? Finding: Takes birth control pill daily Example : How often do you take your birth control pill? Finding: Takes birth control pill at the same time every day Example : Do you take your pill at the same time every day? Finding: Reports no skipped days Example : Have you missed any days of your birth control pill? Finding: Asked about current non-prescription medications Finding: Reports rare Advil use for cramps Example : Do you take Advil? Finding: Reports no OTC herbal products Example : Do you use any herbal products? Finding: Reports no OTC vitamins Example : Do you take any vitamins? Finding: Reports no OTC supplementsThis study source was downloaded by 100000784551390 from CourseHero.com on 10-18-2023 22:23:01 GMT -05:00

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Example : Do you take any supplements? Finding: Asked about allergies Finding: Confirms allergies Example : Can you confirm your allergies? Finding: Reports no new allergies Example : Have you noticed any new allergies? Finding: Followed up on seasonal allergies Finding: Reports no recent seasonal allergy symptoms Example : Have you been having seasonal allergies? Finding: Reports no current medication for allergies Example : Are you taking any medication for your allergies? Finding: Asked about diabetes Finding: Reports managing diabetes with diet and exercise in addition to medication Example : How are you managing your diabetes? Finding: Asked about blood glucose monitoring Finding: Reports checking blood sugar once a day Example : How often do you monitor your blood glucose? Finding: Checks sugar in the morning Example : When do you check your blood glucose? Finding: Blood sugar number is usually around 90 Example : What is your average blood sugar number? Finding: Reports having adequate supplies

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Objective Data Collection: 70 of 73 (95.9%) HEENT Inspected mouth: Oral mucosa moist. Inspected head and neck---Scattered pustules on face and facial hair on upper lip---Head is normocephalic, atraumatic--Normal scalp hair distribution--Acanthosis nigricans noted on neck Inspected eyebrows and orbital area Right eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema Left eye: equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema Palpated scalp---No masses Palpated sinuses--No frontal sinus tenderness--No maxillary sinus tenderness Palpated jaw---No clicks, full ROM Palpated lymph nodes---No axillary lymphadenopathy--No supraclavicular lymphadenopathy Palpated thyroid---Thyroid smooth without nodules, no goiter Inspected eyelids and conjunctiva Upper eyelids: conjunctiva pink, no lesions, white sclera Lower eyelids: conjunctiva pink, no lesions, white sclera Tested PERRL with penlight------Right pupil: equal, round, reactive to light Left pupil: equal, round, reactive to light Tested eye movements---Normal convergence EOMs intact bilaterally, no nystagmus Tested peripheral vision---Peripheral vision intact in both eyes, all fields Inspected interior eyes with ophthalmoscope---Mild retinopathic changes on right Left fundus with sharp disc margins, no hemorrhages Palpated abdomen – deep RUQ: no masses, guarding or rebound RLQ: no masses, guarding or rebound LUQ: no masses, guarding or rebound: LLQ: no masses, guarding or rebound Palpated organs Liver: palpable 1 cm below right costal margin Spleen: not palpable Right kidney: not palpable, no masses Left kidney: not palpable, no masses

Musculoskeletal Inspected neck---Neck without swelling, masses, or deformity Inspected upper extremities Right shoulder without swelling, masses, or deformity Right arm without swelling, masses, or deformity Right elbow without swelling, masses, or deformity Right wrist and hand without swelling, masses, or deformity Left shoulder without swelling, masses, or deformity Left arm without swelling, masses, or deformity Left elbow without swelling, masses, or deformity Left wrist and hand without swelling, masses, or deformity Fingernails: no ridges or abnormalities in nails, pink nailbeds Inspected hips---Hips without swelling, masses, or deformity Inspected lower extremities Right leg without swelling, masses, or deformity Right knee without swelling, masses, or deformity Right ankle without swelling, masses, deformity, or discoloration Right foot without swelling, masses, or deformity Left leg without swelling, masses, or deformity Left knee without swelling, masses, or deformity Left ankle without swelling, masses, or deformity Left foot without swelling, masses, or deformity Toenails: no ridges or abnormalities in nails, pink nailbeds Tested ROM for upper extremities----Right and left shoulders: full ROM Right and left elbows: full ROM Right and left wrists: full ROM Tested ROM for spine----Rotate left: full ROM Rotate right: full ROM Extension: full ROM Flexion: full ROM

Documentation / Electronic Health Record Vitals--128/82 mm Hg (97.3 MAP) HR 78 SpO2 99% RR 15 Temperature 37.2 c Weight 84 kgs • Height: 170 cm • Weight: 84 kg • BMI: 29.0 • Blood Glucose: 100 • RR: 15 • HR: 78 • BP:128 / 82 • Pulse Ox: 99% • Temperature: 99.0 F

Health History--The patient is a 28-year-old female who presented for a pre-employment physical exam. She provided the health information freely during the interview. Ms. Jones’ speech is clear and coherent

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Ms. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Speech is clear and coherent. She maintains eye contact throughout the interview.

General Survey--Ms. Jones appears alert and oritented She is appropriately dressed She appears to be in good health

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

Reason for Visit---Ms. Jones visited to have a physical exam for the health insurance at her new workplae

“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---Ms. Jones reported that she recently got a job at a new place and she is required to obtain a physical

examination. She does not have any acute cincerns She was diagnosed with PCOS and oral contraceptives were prescribed She had type 2 diabetes and asthma She reports positive lifestyle modifications Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver & Company. She needs to obtain a pre- employment physical prior to initiating employment. Today she denies any acute concerns. Her last healthcare visit was 4 months ago, when she received her annual gynecological exam at Shadow Health General Clinic. Ms. Jones states that the gynecologist diagnosed her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type 2 diabetes, which she is controlling with diet, exercise, and metformin, which she just started 5 months ago. She has no medication side effects at this time. She states that she feels healthy, is taking better care of herself than in the past, and is looking forward to beginning the new job.

Medications---Metformin 850 PO BID Flovent 2 puffs 88 mcg/spray BID Albuterol 90 mcg/spray MDI 2 puffs Q4H Drospirenone PO QD

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

Allergies----Allergic to cats and dust Allergiic to penicillin Denies any food or latex allergy

• Penicillin: rash • Denies food and latex allergies • Allergic to cats and dust. When she is exposed to allergens she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.

Medical History----Diagnosed with asthma at 2 1/2 years DIagnosed with diabetes at age 24 years Last asthma exacerbation 3 months

ago Diagnosed with PCOS four months ago and take Yaz Has a history of hypertension Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats. Her last asthma exacerbation was three months ago, which she resolved with her inhaler. She was last hospitalized for asthma in high school. Never intubated. Type 2 diabetes, diagnosed at age 24. She began metformin 5 months ago and initially had some gastrointestinal side effects which have since dissipated. She monitors her blood sugar once daily in the morning with average readings being around 90. She has a history of hypertension which normalized when she initiated diet and exercise. No surgeries. OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 2 weeks ago. Diagnosed with PCOS four months ago. For the past four months (after initiating Yaz) cycles regular (every 4 weeks) with moderate bleeding lasting 5 days. Has new male relationship, sexual contact not initiated. She plans to use condoms with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.

Neurological Subjective--Reports no dizziness, light-headedness, tingling, loss of coordination or sensation, seizures, or sense of disequilibrium. Objective--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, Hair & Nails Subjective--Reports improved acne due to oral contraceptives. Skin on neck has stopped darkening and facial and body hair has improved. She reports a few moles but no other hair or nail changes. Objective--Scattered pustules on face and facial hair on upper lip, acanthosis nigricans on posterior neck. Nails free of ridges or abnormalities.

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