ADV HEALTH ASSESSMENT

Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

Week 9 SOAP NOTE

Doris Ofodile

Walden University

Nurs 6512

Advanced Health Assessment & Diagnostic Reasoning

Dr Kristin Curcio

July 31st, 2022

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

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): Miss Jones is currently employed by Smith, Steven, Stewart, Silver & Company. Before she begins work, a pre-employment physical must be completed. Despite having a history of type 2 diabetes, in which she is able to control it by taking metformin, dieting, and doing physical activity. For the past 4-5 months, she has been compliant with metformin. By eating yogurt, Metformin has no longer caused any side effects for her. The last time she saw a doctor was for her gynecology appointment four months ago in which the doctor prescribed oral birth control pills to her after she was diagnosed with the polycystic ovarian syndrome. Although, according to her, she is in good health and does not have any acute health issues, or stressful events, and is looking forward to starting her new job.

Medications: Metformin 850mg PO BID, the last dose taken this morning. Fluticasone propionate (Flovent) was 110 milligrams twice daily.( taken last in Albuterol (Proventil) 90mcg 2 puffs every four hours PRN.( taken three months ) Drospirenone/ethinyl estradiol (dosage unknown). It was taken this morning. Tylenol 500 mg PO PRN for headache, medication was taken last week. Ibuprofen 600mg PO TID PRN to alleviate period cramps, was taken six weeks ago. Zantac was taken for GERD (completed) Tetracycline was taken because of acne (completed)

Allergies: Miss Jones is allergic to penicillin which causes an allergic reaction characterized by hives and a rash. She is also allergic to cats and dust which triggers an asthma attack causing her to itch, wheeze and sneeze. She denies allergic reactions to latex and foods.

Past Medical History (PMH): During her second and a half years of life, Miss Jones was diagnosed with asthma. Her medication regimen includes Proventil and Flovent. A diagnosis of diabetes was made at the age of twenty-four. Metformin is the medication she uses to manage her diabetes, but she had trouble complying because she had side effects like gassiness, which was later relieved with yogurt. As a result, she is better able to monitor her blood sugar levels daily, which last read at 90. The patient also reports losing 10 pounds in four months. Also, she reported that she slipped and hit her right foot, resulting in a healed wound.

At the age of 28, she was diagnosed with the polycystic ovarian syndrome which she manages by taking birth control pills. Miss Jone’s menstrual cycle flows for five days and is regular. No Sexually transmitted diseases or pregnancies have been reported. At 38-year-old, she was diagnosed with hypertension; Exercise and diet helped normalize her blood pressure. Blood pressure medication is not needed by the patient. At the age of 28, myopia was diagnosed, and prescription glasses were needed. No recent hospitalization.

Past Surgical History (PSH): No history of surgery.

Sexual/Reproductive History: Miss Jones is a single woman without children. Denies pregnancy and Sexually transmitted diseases. Reports two years without sexual activity.

Personal/Social History: Currently, Miss Jones lives with her mother and sister in a single- family house but announced moving into an apartment with her boyfriend. She does not smoke, vape, or use any illegal drug but drinks occasionally with friends which consist of diet coke and rum. There is currently no sexual activity between her and her boyfriend. She reports that if she becomes sexually active, she will use a condom. Miss Jones enjoys hanging out with her friends by going to bible study. She soon plans on starting a book club. Her exercise regimen includes 30 to 45-minute walks five times a week and weekly swimming sessions with her sister. Miss Jones is a recent graduate working as an accounting clerk at a new job. When it comes to her eating habits she mainly consumes food low in carbs but is not cautious when it comes to her sodium intake. Her breakfast consists of smoothies, yogurt, and eggs on toast, lunch consists of leftover dinner and wheat bread, and dinner consists of chicken or fish, vegetables, rice, and quinoa. Her daily intake of water is typically around 4-5 glasses.

Health Maintenance: When going outside, the patient uses sunscreen. Additionally, she always wears a seatbelt while driving. Four months have passed since her last pap smear in which the results were negative. An optician prescribed reading glasses to the patient three months ago. Ms. Jones reports feeling safe at home.

Immunization History: During her childhood and in college, she received the tetanus shot and other required vaccinations. According to her, she did not receive a flu shot.

Significant Family History: The father died in a car accident when he was 58 years old. He was diagnosed with hypercholesterolemia, hypertension, and type 2 diabetes. There is also a history of hypertension and hypercholesterolemia in her mother of 50 years. Her 27-year-old brother is obese.

Her 14-year-old sister suffers from asthma. At the age of 80, her maternal grandfather died from a heart attack and also had a history of hypercholesterolemia and hypertension. At the age of 73, her maternal grandmother had a stroke and died, Also had a diagnosis of hypertension and hypercholesterolemia. At the age of 65, her paternal grandfather died from complications of colon cancer. A diagnosis of hypertension and type 2 diabetes was made for him. At the age of 82, her paternal grandmother was diagnosed with hypertension and hypercholesterolemia. An uncle of my paternal line, age unknown, is an alcoholic. There is no history of mental illness in the family.

Review of Systems: General: T.J. reports being excessively healthy. Over the past couple of months, she has lost 10 pounds. Her energy and stress levels have improved.

HEENT: Denial of headaches and tenderness of the scalp and report no head injury reported. Denies having pain in the eyes although complains of blurred vision when not wearing corrective lenses. Denies hearing loss and ear pain. Denies losing her smell or having rhinorrhea. Denies having mouth sores or dental problems but attends dental visits. Denies having a sore throat or difficulty swallowing. Denies feeling pain in the neck. Respiratory: Denies breathing difficulties. Denies experiencing asthma or dyspnea. Reports that three months ago, she had her last asthma attack. Cardiovascular/Peripheral Vascular: Denies palpitations, chest pain, or pressure in the chest. Gastrointestinal: The patient reports that her appetite is normal. Denies symptoms such as nausea, vomiting, constipation, and diarrhea. There has been no change in bowel movements. Since a few months ago, there has been no heartburn or symptoms. Genitourinary: Denies having any symptoms of urinary incontinence. Neither hematuria nor flank pain is reported. There are no reports of vaginal discharge or itching. Musculoskeletal: Denies joint and muscle pain. She denies feeling pain in her back, legs, or arms. There were reports of back pain a week ago. The pain has gone away after stretching and using heat and ice packs. Neurological: Neither headaches, dizziness, nor lightheadedness have been reported. There were no syncopal episodes or loss of sensation. Psychiatric: Denies HI and SI. Affirms that she does not have depression and anxiety. Skin/hair/nails: There has been improvement in her facial acne and the discoloration on her neck has faded.

OBJECTIVE DATA:

Physical Exam: Vital signs: Temperature 37.2 C; RR 15; HT 5'7, Pulse Ox 99% WT 90kg, HR 78; BMI 31, BP 128/82; General: Ms. Jones has a good sense of direction and is alert. The patient is seated upright on the examination table. Her grooming and clothing are appropriate for the weather. It does not appear that she is in distress. HEENT: There are no masses or lesions on the scalp, and the hair is distributed evenly. There is no injury to the head and it is normocephalic. A uniform distribution of eyebrows and lashes. The sclera is white and the eyes are clean. There is a bilateral PERRLA and pink conjunctiva. It was noted that the right eye had cotton bodies and retinopathic changes. Hemorrhages were not observed. The Snellen test shows 20/20 vision bilaterally in both eyes with a corrective lens. The mucosa of the mouth is moist and pink. There were no mouth sores or dental problems observed. A midline uvula and gag reflex are present. Moisture and pinkness are present on the tongue. There is no goiter or nodule on the thyroid. The TM is pale gray in color and intact. There are no signs of infection. Heard bilaterally during the whisper test. The nasal mucosa appears to be moist and pink. When palpated, the sinuses of the face are not tender. Neck: Refutes having any neck pain or problems. Chest/Lungs: There are no signs of acute distress. An even and unlabored breathing pattern is present. When auscultated, there are clear breath sounds. No sounds of adventitious breathing were heard. Throughout the lobes, there is a resonance on percussion. Based on spirometry, the FVC was 1.78 L, the FEV1 was 1.549 L, and the FEV1/FVC ratio was 87 - 88%. Heart/Peripheral Vascular: S1 and S2 do not have murmurs, gallops, or clicks. Heart rate appears regular. There is no bruit bilaterally in the carotid artery. A PMI is present at the fifth intercostal space along the clavicular line. Non-displaced PMI with no heaves or lifts. All extremities have 2+ peripheral pulses. All extremities have a capillary refill time of less than 3 seconds. Edema not present

Abdomen: There are no tenderness scars on the abdomen. It is symmetrical and does not appear to have a mass. Hair observed on the pubic area. Protuberant abdomen. In all four quadrants, bowel sounds are normoactive. There is softness in the abdomen. The tympanic sound can be heard on the percussion. There is no tenderness on palpation of the CVA. Organomegaly is not present. The mass was not palpable. Palpable kidneys with no mass after deep operation. On percussion, the liver measures 7cm MCL. The liver is 1 cm below the RCM. Genital/Rectal: On hold for this visit. Musculoskeletal: All ranges of motion observed. Movement is not painful. The muscle In all extremities, strength is 5/5. All regions have DTRs of 2+. Observed neuropathy in the plantar of feet. There was no evidence of deformity.

Neurological: Stereognosis and graphesthesia are normal. All extremities have DTRs of 2+. Hands alternate equally in both directions. Foot plantar neuropathy was observed. Skin: On the face, acne vulgaris is observed. Under the nose, facial hair is observed. At her neck, she was found to have acanthosis nigricans. Nail appears to be normal.

Diagnostic results: ASSESSMENT:

● The following lab tests may be recommended: Broad Thyroid Panel; Essential Nutrients: iron/ferritin, vitamin D, vitamin B12, magnesium; Complete Metabolic Panel and Complete Blood Count. Diabetes mellitus, renal failure, and anemia are some of the conditions that can be detected by blood tests. The best time to order a blood test is after a complete history and physical examination indicate questionable symptoms (Shaked et al., 2019).

● The following metabolic markers are measured: hemoglobin A1c, fasting glucose, insulin, and lipid profile. There are several cardiometabolic disorders included in the metabolic syndrome (MetS), including central obesity, high triglyceride levels, high blood pressure, low HDL cholesterol levels, and hyperglycemia (Li et al., 2018). The results of this test will reveal abnormalities and assist the provider in making health recommendations.

● Inflammatory markers: homocysteine hsCRP, Primary care physicians regularly use inflammation markers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and plasma viscosity (PV) to diagnose and observe inflammatory illnesses such as infections, autoimmune diseases, and malignancies (Watson et al., 2019).

● Testing of the urine for drugs and alcohol (if requested by the employer). Albumin levels are determined by a urine test. A protein called albumin can leak into the urine when kidney function is impaired (Niddk.nih.gov., 2016). In diabetics, urine albumin creatinine ratios (UACRs) detect abnormal protein levels and should be checked annually (Willison et al., 2016).

● Vaccine titer test A decrease in antibodies is revealed by this test. It is imperative to link the assay's results to a clinical interpretation in order to determine an individual's susceptibility to infection (Charlton et al., 2016).

Plan: The patient will be given the results of the lab work and a list of immunizations for him or her to take to work.

Vaccine booster shots are recommended if a decrease in antibodies is detected based on the vaccine titer test. Education: If you experience shortness of breath, chest pain, syncope, nausea/vomiting, or lightheadedness, call 911 or go to the emergency department. Continue to take medications as prescribed. Consult your provider before stopping medication. A morning and night blood pressure check is recommended. Each morning, weigh yourself on the same scale before eating breakfast. Record your daily caloric intake in a journal.