Week 9 passing score 90

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Week 9 Patient Comprehensive Exam

Walden University

NURS 6512 Advanced Health Assessment

Dr. Vijayarani Suresh

August 2, 2021

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Week 9 Patient Comprehensive Exam

Week 9 Shadow Health Comprehensive SOAP Note Template

Patient Initials: T.J. Age:28 Gender: female

SUBJECTIVE DATA:

Chief Complaint (CC): “I’m here because I need a physical for my new job.”

History of Present Illness (HPI): T.J. is a 28-year-old African American female who is here today for a general physical for a new job as an accounting clerk soon. She is oriented to person, place, and time. She is calm, pleasant, and attentive. T.J. has dressed appropriately for the season and is a good historian.

Medications: Metformin 850mg BID, last dose this morning Flovent Inhaler two puffs twice daily, last used this morning Albuterol Inhaler for rescue hasn’t been used recently. She states approximately three months ago and has only used it twice last year. Drospirenone/Ethinyl estradiol birth control, one pill daily. She started taking these four months ago and was prescribed by her GYN MD. Last dose this morning. Ibuprofen and Tylenol as needed

Allergies: Cats: makes asthma worse. PCN: “Not sure; I have been told this since I was a child.” Denies any food allergies. She denies latex allergy. She states she does have some environmental allergies.

Past Medical History (PMH): The patient has asthma, PCOS, and Type II Diabetes. She states she checks her glucose every morning, and they have been stable. She has had GERD in the past; however, she isn’t currently taking medication. She has only been hospitalized for asthma as a child that she remembers and never for surgery. The patient denies any severe injuries that would impair her. T.J. was seen for heart palpitations that since then have subsided. She has been monitoring her blood pressure as it has fluctuated at times but has now been normal. Last menstrual cycle was approximately two weeks ago. The patient has never been pregnant and is up to date on her immunizations except for the influenza vaccine. She recently had a routine pap smear; however, she needs to be educated on how to do self-breast exams, as she states she has only had a doctor perform this and doesn’t know what to look for. She denies any depressive or anxiety symptoms. She has never had thoughts of harming herself or others, and She denies having a transfusion. The patient states she was seen here a few months ago for a foot injury that since then has subsided. She has back issues at times but is currently feeling well. The

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patient had a recent dental visit and was prescribed new glasses at her recent eye appointment.

Past Surgical History (PSH): none

Sexual/Reproductive History: The patient states she has never been pregnant and is not currently sexually active. She has a new boyfriend and says that she will be having sex with him soon. The patient denies any STDs and thought she had been tested when she was at the GYN a few months back. The patient is currently on birth control and is aware of safe sex precautions. The patient states her menstrual cycle is much improved after being put on birth control. It is once a month and lasts approximately five days each month.

Personal/Social History: T.J. has recently taken a new position as an accounting clerk for Smith, Stevens, Stewart, Silver, and Company. The patient is a college graduate, received her B.A. a few years ago. She will be helping an experienced accountant until she can build her client list. The patient has recently lost ten pounds per self-report and is exercising 4-5 times a week. She has also been swimming with her best friend, Selena. The patient is taking better care of her blood sugars by regulating her diet. She states she is eating fewer carbohydrates and “only a candy bar once in a while.” The patient has been introducing more vegetables and fruit into her diet. The patient limits her caffeine to two diet cokes per day. She denies substance abuse and only has alcohol “when she is out with her friends.” The patient hasn’t used tobacco. She currently still lives with her mother and younger sister but states she will be moving out in the next few months. She controls her stress by exercising and see a therapist when she needs to. She says talking helps a lot with anxiety. She enjoys going to church, bible study, and watching science documentaries.

Health Maintenance: The patient has had all yearly health needs met, except for doing self-breast-exams to provide education for her. Will need

Immunization History: All immunizations are up to date. The patient didn’t receive the influenza vaccine this year.

Significant Family History: Mother is alive and well, has a history of hypertension and high cholesterol, father died approximately two years ago in a car accident. He had hypertension, high cholesterol, and diabetes. Maternal grandmother died at age 73 from a stroke, and maternal grandfather passed away at age 80 from a heart attack. Paternal grandmother is alive, age 82, and has hypertension and high cholesterol. Her paternal grandfather died of colon cancer in his mid-sixties. He also had hypertension and diabetes. Sister, age 14, alive and well, does have asthma that is well controlled. Her brother is 25 and is overweight. Her paternal uncle has alcoholism.

Review of Systems:

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General: The patient denies any fever, chills, or night sweats. She denies any nausea or vomiting. The patient is slightly overweight but overall in good health. HEENT: The patient wears glasses and had a vision exam. She denies getting any

headaches since she was prescribed her new glasses. No double vision, and she hasn’t ever had a head injury. The patient denies eye injuries or surgeries—no changes in smell, no epistaxis, or sinus problems. No ear problems state she “hears just fine.” She has had a recent dental exam, no mouth sores, no gingivitis, no bleeding gums. Breasts: The patient denies noticing any lumps; however, she states she doesn’t know what the patient is looking for, so she doesn’t regularly check. Educated on self-breast exams. No nipple discharge or drainage.

Respiratory: The patient has asthma, has two inhalers for this, only uses her rescue inhaler “couple times per year.” No recent hospitalizations for asthma. No history of pneumonia, hemoptysis, last tuberculosis testing “couple years ago.”

Cardiovascular/Peripheral Vascular: The patient has a history of palpitations; however, it has been resolved. The last EKG was normal sinus rhythm approximately four months ago. She denies shortness of breath unless “running upstairs” or being “around cats.” No chest pain and no edema were noted. She can breathe out of her nose with no issues.

Gastrointestinal: She denies a history of abdomen pain, no constipation, or diarrhea. No changes in bowel habits. The patient does not use any laxatives and states she “drinks plenty of water.” Denies any hematochezia, hematemesis, or hemorrhoids. She had been seen in the clinic for GERD a while back but is currently not having symptoms.

Genitourinary: The patient denies any urgency, frequency, dysuria, polyuria, or incontinence. No history of STDs. She denies a history of UTIs. The patient has never been pregnant, is currently on birth control States The periods are regular and only lasting approximately five days. Last pelvic exam about four months ago with a pap smear.

Musculoskeletal: Denies muscle or joint pain. She states she hurt her back a while back helping her friend move but saw a physical therapist, and it is much better. The patient has had no fractures.

Neurological: Reports no vertigo, no vision disturbances, no numbness or tingling, no loss of coordination, no seizure activity. She denies any balance issues. Endocrine: states diabetes has improved, and her blood sugars daily have been running around 90. She has been watching her diet more and states she has lost 10 pounds. She takes metformin as prescribed.

Psychiatric: Feels less stressed after graduating and getting a new job. She states she is pretty excited about her new employment. She sees a therapist when needed and says that this helps. She has no psychiatric medications prescribed. The patient sleeps eight to nine hours per night.

Skin/hair/nails: The patient denies any rashes or sores that won’t heal. She does use sunscreen daily, especially when exercising. She states her acne is improving after being placed on birth control; however, she sees some male pattern hair growth. No changes in moles and doesn’t have dandruff. She reports no nail fungus or dry skin.

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OBJECTIVE DATA:

Physical Exam: Vital signs: Blood pressure 128/82 pulse 78, respirations 15 pulse ox 99% temp 37.2C General: The patient is a 28-year-old African American female starting a new job as an accounting clerk in approximately two weeks. The patient is alert and oriented x 3, appears well-nourished, and in good spirits.

HEENT: Head normocephalic, atraumatic. No tenderness or bruit was noted in the temporal area. Pupils are reactive to light and accommodation. No orbital edema, no palpated nodules on eyes, the patient wears glasses. The patient denies any vision issues. The vision was 20/20 with screening. Ears are pink and dry, with no pain or drainage from canals. The tympanic membrane is intact and pearly gray. Whisper voice test positive for hearing. No dandruff is noted, and hair is distributed evenly. Did note increased facial area noted above lip and sides of the hairline. Acne and acne scarring were noted. Some papules are scattered on the right side of the face, more prominent than typical acne lesions. The nose is patent, with no drainage noted. The septum is midline. The throat is moist and pink, tonsils present with no edema. No exudate was noted. No lesions were noted, teeth intact. Lips are wet and smooth in texture—gag reflex present. The jaw has good ROM with no clicks.

Neck: Good ROM, no lymph nodes palpated, axillary or supraclavicular. Thyroid smooth without nodules and no goiter present. The neck is supple with no adenopathy, No JDV. Did note skin thickening with verrucous texture around the entire neck.

Chest/Lungs: Appears symmetric, without any rashes or deformity. The chest wall is non-tender to palpitation. Lungs are clear throughout all fields. On percussion, resonance is noted throughout. The spirometer test patient performed had an FVC of 1.78 and FEV1 1.549. Voice muffled throughout when patient stated “99” when prompted. No cough. Fremitus is equal bilaterally in both upper and lower anterior chest walls.

Heart/Peripheral Vascular: No edema noted in extremities. The chest is symmetrical, with no apparent abnormalities noted. PMI is non-displaced, with no heaves or lifts. S1 and S2 audible with no adventitious sounds noted. Heart rate and rhythm are regular. Capillary refill in both fingers and toes is less than 3 seconds. Radial, brachial, femoral-popliteal pulse are +2 bilaterally, Posterior tibial and dorsalis pedis are also +2 bilaterally.

The carotid artery was 2+, and no thrill was noted bilaterally; right and left renal arteries had no bruit, and no bruit was noted at the aorta. Right and left iliac had no bruit, and right and left femoral had no bruit noted.

Abdomen: The abdomen is soft, round, symmetric, and non-tender. No distention was noted. There are visible striae on the belly and hair from the pubis to the umbilicus. The umbilicus is midline with no herniation visualized. Bowel sounds active x 4 quadrants—no aortic bruit or CVA tenderness. Spleen percussion was dull, and liver span measured 7 cm MCL per percussion. No tenderness or masses with light palpation of the abdomen, no masses, guarding, or rebound noted with deep palpation. Able to palpate liver 1cm below the right costal margin. Spleen and kidneys are not palpable and without masses.

Genital/Rectal: Deferred as a patient recently had a pap smear and pelvic exam. No hemorrhoids or bleeding from the rectum was noted.

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Musculoskeletal: Arms and legs are symmetrical, and no edema was noted. No joint swelling, redness, or tenderness was noted. Strength tests on extremities, both proximal and distal, were 5/5.

Neurological: The patient can state her name, date of birth, and the building. She is also able to states the correct date and year. Heel to shin test performed: patient able to make a straight path down the shin without any difficulty. She can close her eyes and touch her nose with both index fingers. The patient can move her hands and arms with regular and rapid smoothness. When testing the patient’s feet, it was noted that she had lost some sensation in her left and right great toes, left forefoot under the great toe, and left small toe. Deep tendon reflexes are 2+ on bilateral triceps, biceps, and bilaterally brachioradialis. Left and right deep tendon reflexes of the knee are 2+ and the right and left Achilles’ reflex is 2+. Graphesthesia is intact in both hands as well as stereognosis is intact. Position sense is entire in toes and fingers.

Skin: Acne/folliculitis noted on the right side of the face, few papules on the left side of the face. There is excessive hair growth above the upper lip and on both sideburn, areas, and in- between pubis and umbilicus—noted skin thickening around the neck with slight verrucous texture (Acanthosis nigricans). Also noted upper back area, small discolored patches. They are primarily hypopigmented areas covering the majority of the upper back.

Diagnostic results: 1) Type II Diabetes: The patient has a diagnosis and is currently on metformin 850mg BID.

Would need HgA1c, fasting glucose, lipid panel, cholesterol. Type II diabetes is most likely to develop if the patient is overweight, has a family history of diabetes, is black, has high blood pressure, and is heavy (Type 2 Diabetes, 2021). The patient, in this case, meets all of these criteria.

2) Asthma: The patient used a Flovent inhaler and has a rescue inhaler as need. Adult-onset asthma is asthma that develops as an adult, usually over the age of 20. If the patient had childhood asthma, is female after the age of 20, is overweight, has relative asthma, around people who smoke or have allergies, they are more susceptible (Adult-onset Asthma: Causes, Symptoms, Treatment and Management, 2021). This patient fits the criteria for this diagnosis as well. Labs to consider for this diagnosis would be CBC, routine FEV1/FVC ratio, peak expiratory flow rate, and chest x-ray.

3) PCOS: The patient has this diagnosis and is currently being treated with birth control medication. Patients with this diagnosis may see the irregular menstrual cycle, too much hair on the face, chin, and parts of the body that men usually have hair, weight gain, darkening of the skin, especially around the neck, and skin tags (Polycystic Ovary Syndrome, 2021). This patient meets all these criteria for this diagnosis. Labs considered for this diagnosis would be serum 17-hydroxyprogesterone, prolactin, androgen hormone, TSH, oral glucose test, fasting lipid panel, and pelvic ultrasound.

ASSESSMENT:

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

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References

Adult-onset Asthma: Causes, Symptoms, Treatment, and Management. (2021). Global Allergy

and Airway Patient Platform. http://gaapp.org

Polycystic Ovary Syndrome. (2021). U.S. Department of Health and Human Services.

http://womenshealth.gov

Type 2 Diabetes. (2021). American Association of Clinical Endocrinology. http://aace.com

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