NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Walden University NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
The introduction for the Walden University NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
How to Write the Body for NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
After the introduction, move into the main part of the NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for NURS 6512 Assignment 3: 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 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Patient particulars
Age: 48years
Sex: male
Race: American
Subjective Data
Chief complaint: I cannot feel my toes on the left foot. I have a tingling sensation in my right heel.
History of presenting illness: G.G is a 48years old male presenting with an inability to feel his toes on the left foot and a tingling sensation on the right foot. These symptoms are of gradual onset over four months. These symptoms proceed with pain in the feet that was sharp and aching. The pain increases in intensity on walking, touch, and cold season. The pain does not radiate, is worse at night, and resting relieves the pain. Other associating symptoms are the weakness of the limbs, burning sensation, muscle spasms of the lower limbs, and reports of loss of memory. The patient denies joint pain and stiffness.
Current medication:
- metformin 850MG PO BD for diabetes mellitus,
- Tylenol 1g PO PRN for pain and
- HCTZ 50mg PO for hypertension
Allergies: the patient denies food and drug allergies
Past medical history: the patient has diabetes mellitus and hypertension. However, he does not go for regular checks in the hospital. He is not compliant with his treatment. He denies hospital admission, blood transfusion, and surgical procedure.
Social history: the patient is married and has two children. He works as a call center manager. He enjoys reading
novels. He takes alcohol every day and smokes tobacco. He takes fast food and does not engage in physical exercise. He does not use his phone while driving. He uses a safety belt while driving and has smoke detectors in his house.
Family history: he is the last born in a family of three. His father passed on at the age of 60years old due to a heart attack. His 70years old mother is obese and has coronary heart disease and osteoarthritis. His elder brother has hypertension and diabetes mellitus. His sister had her left limb amputated up to the ankle joint due to a diabetic foot. His grandparents passed on due to old age. He denies a family history of cancer and psychiatric diseases.
Review Of Systems
General: the patient denies fatigue, malaise, fever, and weight loss.
HEENT: The patient denies headache, throat pain, nasal discharge, loss of hearing, visual loss, and blurring of vision.
Respiratory system: the patient denies coughing, running nose, wheezing, sputum production, chest pain, tachypnea, and shortness of breath.
Cardiovascular system: the patient denies chest pain, syncope, dyspnea, and orthopnea.
Gastrointestinal system: the patient denies abdominal pain, diarrhea, vomiting, heartburn, and reflux.
Genitourinary system: the patient denies dysuria, hematuria, urgency, and incontinence.
Neurological system: the patient presents with paralysis, ataxia, numbness, and tingling in the extremities. However, he denies change in bowel or bladder control.
Musculoskeletal system: the patient denies back pain, joint pain, or stiffness.
Hematologic system: the patient denies anemia, bleeding tendencies, or bruising.
Lymphatic system: the patient denies enlarged nodes and spleen enlargement.
Psychiatric: the patient denies depression, insomnia, anxiety, and hallucinations.
Endocrine system: the patient denies sweating, heat intolerance, polyuria, and polydipsia.
Allergies: the patient denies asthma, hives, eczema, and rhinitis.
Objective Data
Physical examination: the patient is alert and oriented. He has cold and clammy hands and feet. However, he has no pallor, jaundice, cyanosis, edema, or dehydration.
Vitals: blood pressure is at 178/89mmHg, PR 88beats per minute, RR 16 cycles per minute, height 161 cm, weight 110kg, BMI 42.44kg/m2.
Neurological examination: the patient assumes an upright gait and posture. However, he has tremors in the fingers. He cannot perceive pinpricks and gross light touch. He has diminished tendon reflexes. However, the cranial nerves are intact.
Skin: the patient has dry and crusty skin. The skin folds have wrinkles and dark sports. There are erythematous and tender lesions around the joints.
Musculoskeletal system: the patient has muscle wasting on the upper and lower limbs. The bulk, tone, and power are reduced. However, there is no bone deformity or joint swelling.
Cardiovascular system: the heartbeat is at the 5th ICS MCL with S1 and S2. There are no murmurs, rubs, or JVD. The peripheral pulse is present at a regular rate and rhythm. The capillary refill is less than 3sec in all four extremities.
Respiratory system: the chest wall is symmetrical with no scars or mass. The breathing is quiet and unlabored. There is a resonant percussion note over the chest. The breath sounds are clear to auscultation in the upper and lower lobes. There are no rhonchi, stridor, or crackles.
Gastrointestinal system: the abdomen is soft, round, and non-tender with normal-active bowel sounds in all the four quadrants. There are no abdominal bruits and tenderness to light and deep palpation. The liver span is 1cm below the costal margin. There is a tympanic percussion note throughout. The spleen and bilateral kidneys are not palpable.
Diagnostic Tests
- Lipid profile to rule out hyperlipidemia
- HbA1c and fasting blood sugar to check the blood glucose control
- Liver function tests
- Erythrocyte sedimentation rate to rule out autoimmune reactions
- Thyroid function test to rule out hyperthyroidism
- Nerve conduction study findings
- MRI plexus to rule out tumors
Assessment
The patient presents with numbness and tingling of the lower limb. Other associating symptoms are pain, muscle spasms, weakness of the limbs, and burning sensation. He has hypertension and diabetes mellitus and does not comply with medication. He leads a sedentary lifestyle, takes alcohol, and smokes tobacco. On examination, he has reduced muscle tone, bulk, power, and reflexes. The skin is cold and clammy with wrinkles and dark spots. Therefore, my differential diagnoses are diabetic neuropathy, transient ischemic attack, and alcoholic neuropathy.
Differential Diagnoses
- Diabetic neuropathy
- Transient ischemic attack
- Alcoholic neuropathy
Diabetic neuropathy is a complication of diabetes mellitus common in patients above 40years old. The complication is a result of poor drug compliance and inadequate treatment. The patient presents with numbness, tingling sensation, muscle cramping, dryness of the skin, loss of sensation of skin pricks, absent tendon reflex, and painful paresthesia (Zakin, et al, 2019). In diabetes mellitus, the patient has reduced absorption of the complex vitamins due to their autonomic effects on the gastrointestinal system. This contributes to the numbness of extremities. Additionally, poor glycemic control causes damage to the nerves hence the patient loses sensation and causes muscle weakness and spasms. This is the actual diagnosis because the patient has diabetes mellitus and does not comply with treatment.
The transient ischemic attack is a neurological dysfunction caused by the brain and the spinal cord without infarction. It causes changes in behavior, memory, gait, speech, and movement. The risk factors are previous surgery, seizure, illicit drugs, metabolic diseases, and cardiovascular diseases (Amarenco, P. 2020). The presenting signs and symptoms are a reduced level of consciousness, muscle weakness, numbness, tingling sensation, loss of memory, and staggering gait. This patient has diabetes mellitus and similar symptoms of a stroke. Finger glucose test for hypoglycemia, cardiac enzymes, and head CT scan will help rule out TIA.
The toxic effects of alcohol cause damage to the autonomic and peripheral nerves. The autonomic effects on the gastrointestinal system cause mal-absorption of the complex vitamins (Sadowski, A., & Houck, R. C. 2018). This leads to thiamine deficiency that eventually induces neuropathy. The presenting signs and symptoms are weakness and muscle wasting, gait dysfunction, tremors, hypothermia, orthostatic hypotension, and paresthesia. However, it is not the actual diagnosis because the patient has no hypothermia, orthostatic hypotension, gait dysfunction, and tremors.
References
Amarenco, P. (2020). Transient ischemic attack. New England Journal of Medicine, 382(20), 1933-1941. DOI: 10.1056/NEJMcp1908837
Sadowski, A., & Houck, R. C. (2018). Alcoholic neuropathy. PMID: 29763031
Zakin, E., Abrams, R., & Simpson, D. M. (2019, October). Diabetic neuropathy. In Seminars in neurology (Vol. 39, No. 05, pp. 560-569). Thieme Medical Publishers. DOI: 10.1055/s-0039-1688978
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Sample Answer 2 for NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
SUBJECTIVE DATA:
Chief Complaint (CC): Pre-employment physical
History of Present Illness (HPI): J.T is a 28 years old African American female patient who reported to the clinic for a pre-employment physical. She reports that the last time she visited a healthcare professional was 4 months ago for an annual gynecological exam. She was diagnosed with polycystic ovarian syndrome and initiated on oral contraceptives which she claims to tolerate appropriately. However, her last general physical examination was done 5 months ago, when she started taking daily inhalers and metformin for her diabetes type 2. She denies any current acute health problem and claims that she feels healthy as she takes better care of herself currently. She looks forward to starting her new job.
Medications: Metformin, 850 mg orally twice daily, fluticasone propionate inhaler, 110 mcg 2 puffs twice daily, and Drospirenone and Ethinyl estradiol orally twice daily. The last time she took all these drugs was this morning. Albuterol 90 mcg/spray MDI 2 puffs when necessary, with last use 3 months ago. Acetaminophen 500-1000 mg orally when necessary for headache and Ibuprofen 600 mg orally three times a day when necessary for her menstrual cramps. She last used these two medications 6 weeks ago.
Allergies: Confirms penicillin allergy which presents with rashes. Report’s dust and cat allergies which present with swollen and itchy eyes, running nose, and worsened asthma symptoms. Denies latex and food allergies.
Past Medical History (PMH): Diagnosed with asthma when she was 2 years and a half which she manages using an albuterol inhaler in the presence of cats. She used the inhaler 3 months ago as a result of her last asthma exacerbation. Her last hospitalization as a result of asthma was when she was in high school. She has never been intubated. Diagnosed with diabetes type 2 at the age of 24 years, but started taking metformin 5 months ago, with gastrointestinal side effects which resolved recently. Average blood sugar levels of 90, which she monitors every morning. Confirms a history of hypertension which she manages with diet and exercise.
Past Surgical History (PSH): Denies surgical history.
Sexual/Reproductive History: Experienced her first menses at the age of 11 years, and sexual encounter at the age of 18 years, with men. Denies ever being pregnant with her last menses 2 weeks ago. She got the PCOS diagnosis 4 months ago. Her menstrual cycle normalized four months ago after initiating Yaz. She is in a new relationship with a man but is not yet having sex, but when they start, claims to use a condom. HIV/AIDS and STIs test negative, four months ago.
Personal/Social History: Denies being married with no children. She used to live alone from age 19 but moved in with her sister and mother in a single-family house which she plans to leave and move to her apartment in a month. She starts her new job at Smith, Stevens, Stewart, Silver, & Company in 2 weeks. She loves reading, volunteering in church, dancing, attending Bible study, and spending time with friends. Claims to receive strong support from the church and family members, which helps her cope with stress. Denies tobacco, cocaine, heroin, and methamphetamine use. Used cannabis from age 15 to 21 years. Confirms alcohol use 2 to 3 times per month when out with friends, with no more than 3 drinks each episode. Denies taking coffer, and confirms maintaining a healthy diet. Takes 1 to 2 diet sodas daily. No pets. Denies recent foreign travel. Exercises regularly, 4 to 5 times every week comprising of swimming, yoga, and walking.
Health Maintenance: Last Pap smear 4 months ago. Eye examination- 3 months ago. Negative test results for PDD 2 years ago.
Safety: Smoke detectors are well installed at home, and does not ride a bike wear seatbelt in the car. Applies sunscreens. Locked guns that belonged to her father in the parents’ room.
Immunization History: Received tetanus booster last year. Influenza injection not up to date. She has not received the human papillomavirus vaccine. Received a meningococcal vaccine when she was in college. Her childhood vaccines are up to date.
Significant Family History: Mother managing hypertension and elevated cholesterol at the age of 50 years. Her father died in a car accident last year at the age of 58 years, with a history of diabetes type 2, high cholesterol, and hypertension. Brother is overweight and 25 years old. Sister is asthmatic and 14 years old. Maternal grandmother passed on at the age of 73 years from stroke, with a history of hypertension, and high cholesterol levels. Maternal grandfather passed on at the age of 78 years from stroke, with a history of hypertension, and high cholesterol levels. Paternal grandmother is still alive, with a history of hypertension at age 82 years. Paternal grandfather passed on at age 65 years from colon cancer, with a history of diabetes type 2. Paternal uncle is an alcoholic. Denies family history of mental illness, sudden death, sickle cell anemia, kidney problems, thyroid problems, and other cancers.
Review of Systems:
General: The patient is alert and well oriented. Clear and coherent speech. Maintains good eye contact all through the interview. Does not appear distressed. Seated upright, well-nourished, good hygiene, and appropriately dressed. No fatigue, night sweats, chills, or fever. Recent changes in weight and diet.
HEENT: Head: No headache, or signs of head injury. Eyes: No itchiness, excessive tearing, pain, or discharge. Ears: No hearing problems, pain, or drainage. Nose: No congestions, running nose, epistaxis, or inflammation of the nasal mucosa. Mouth/Throat: No bleeding gums, toothache, ulcerations, sore throat, or swallowing difficulties.
SKIN: No rashes, lumps, adenopathy, bruising, eczema, or skin lesions.
CARDIOVASCULAR: No history of cyanosis or hurt murmurs.
RESPIRATORY: No cough, shortness of breath, wheezing, or sneezing.
GASTROINTESTINAL: No diarrhea, vomiting, abdominal pain or discomfort, jaundice, constipation, or changes in bowel movement.
GENITOURINARY: No changes in urine frequency, dysuria, polyuria, or pyuria. No abnormal discharge or painful sex.
NEUROLOGICAL: No syncope, ataxia, dizziness, headache, or paresthesia.
MUSCULOSKELETAL: No joint or muscle pain.
HEMATOLOGIC: Denies bruising easily, difficulties in stopping bleeds, or lumps under the neck or arm, or anemia.
LYMPHATICS: Denies any history of lymphadenopathy or splenectomy.
ENDOCRINOLOGIC: No disturbances in growth, polyphagia, history of thyroid disease, or excessive fluid intake.
PSYCHIATRIC: Denies mental health problems.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Ht: 170 cm; Wt: 84 kg; BMI: 29.0 ;BG: 100; RR: 15; HR: 78; BP:128 / 82; Pulse Ox: 99%; T: 99.0 F
General: The patient is alert and well oriented. Clear and coherent speech. Maintains good eye contact all through the interview. Does not appear distressed. Seated upright, well-nourished, good hygiene, and appropriately dressed. No fatigue, night sweats, chills, or fever. Lost 10 pounds recently as a result of increased exercise and changes in diet.
HEENT: Atraumatic and normocephalic head. Bilateral eyebrows with hair distributed equally on the eyebrows and lashes. No edema or ptosis, lids with no lesions. Pink conjunctiva, white sclera, and no lesions. Bilateral PERRLA. Bilateral EOMs, with no nystagmus. Mild changes on the retinopathy of the right eye. No hemorrhages, Left fundus with sharp margins of the disc. Snellen: right eye 20/20, left eye 20/20 with corrective lenses. Positive light reflex and intact TMs and pearly gray bilaterally. Whispered words were heard equally in both years. Maxillary and frontal sinuses non-tender on palpation. Pink and moist nasal mucosa, midline septum. Moist oral mucosa with no lesions or ulcerations, uvula rises midline on phonation. Intact gag reflex. No evidence of infections or caries. Tonsils 2+ bilaterally. Smooth thyroid with no nodules, or goiter. No signs of lymphadenopathy.
Respiratory: Symmetric chest with respiration, clear auscultation with no wheezing or cough. Constant resonant to percussion. In-office spirometry: FEV/FVC ratio 80.56%, FVC 3.91 L
Cardiovascular: Regular heart rate. S1, S2 present with no gallop, rubs, or murmurs. Equal bilateral carotids with no bruit. PMI at midclavicular line, 5th intercostal space, no thrills, lifts, or heaves. Peripheral pulses bilaterally equal, capillary refill < 3 seconds. No edema on the periphery.
Abdominal: Abdomen protuberant, symmetric, no visible masses, scars, or lesions, coarse hair from the pubis to the umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly. No CVA tenderness.
Musculoskeletal: Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity, and with a full range of motion. No pain with movement.
Neurological: Normal graphesthesia, stereognosis, and rapid alternating movements bilaterally. Tests of cerebellar function normal. DTRs 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.
Skin: Scattered pustules on the face and facial hair on the upper lip, acanthosis nigricans on the posterior neck. Nails free of ridges or abnormalities.
Diagnostic results: Administer drug and alcohol tests. Physical ability test comprising of cardiovascular health, flexibility, mental fortitude under physical strain, muscle tension, and balance (Fischer, Sinden, & MacPhee, 2017). OSHA-specific screening and surveillance physicals were also administered. Psychological evaluation was also administered with the utilization of self-response questionnaires (Han, Kim, Lee, & Lim, 2019). Other routine tests that were ordered include lipid profile test, FBS, cholesterol test, liver function test, and chest X-ray, as a result of her current diagnosed conditions (Drain, & Reilly, 2019).
ASSESSMENT: The patient displays a previous history of hypertension, with current-controlled blood pressure within normal limits. She also has a history of asthma, which she manages appropriately with her inhaler. She is overweight but is on diet control and exercise which helps in managing her hypertension (Gaafar, 2021). She has diabetes which she monitors very well every morning and manages by taking medication. Physical test results reveal excellent strength and flexibility, with a full range of movement. She is able to lift a moderate amount of weight with perfect endurance, with muscle tension for a woman of her age (Gumieniak, Gledhill, & Jamnik, 2018). She displays no mental disabilities with no signs of substance use disorder. Her medical examination results are excellent for her new job. She is fit to start working any day from now.
References
Fischer, S. L., Sinden, K. E., & MacPhee, R. S. (2017). Identifying the critical physical demanding tasks of paramedic work: Towards the development of a physical employment standard. Applied Ergonomics, 65, 233-239. https://doi.org/10.1016/j.apergo.2017.06.021
Gumieniak, R. J., Gledhill, N., & Jamnik, V. K. (2018). Physical employment standard for Canadian wildland firefighters: examining test-retest reliability and the impact of familiarisation and physical fitness training. Ergonomics, 61(10), 1324-1333. https://doi.org/10.1080/00140139.2018.1464213
Han, K., Kim, Y. H., Lee, H. Y., & Lim, S. (2019). Pre-employment health lifestyle profiles and actual turnover among newly graduated nurses: A descriptive and prospective longitudinal study. International journal of nursing studies, 98, 1-8. https://doi.org/10.1016/j.ijnurstu.2019.05.014
Gaafar, A., & Gaafar, A. (2021). Routine pre-employment echocardiography assessment in young adults: cost and benefits. The Egyptian Heart Journal, 73(1), 1-8. https://doi.org/10.1186/s43044-020-00131-8
Drain, J. R., & Reilly, T. J. (2019). Physical employment standards, physical training, and musculoskeletal injury in physically demanding occupations. Work, 63(4), 495-508. DOI: 10.3233/WOR-192963
Sample Answer 3 for NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Episodic/Focused SOAP Note
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 5th 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 for NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
SUBJECTIVE DATA:
Chief Complaint (CC): ‘I have come for reemployment assessment.’
History of Present Illness (HPI): The client is a 28-year-old African American that has come to the clinic for a reemployment assessment. She is cooperative and offers information needed for the assessment. Her speech is normal and she maintains eye contact during the assessment. She appears alert and oriented to all facets. She has good health and first-class hygiene. She denied any acute concerns as she has come for preemployment assessment. Her significant illnesses include POCS diagnosed four months ago, type 2 diabetes mellitus, and allergy to penicillin, dust, and cars.
Medications: The client currently uses several medications. They include Metformin 850 mg BID, Drospitenone and ethinyl estradiol PO QD, Albuterol spray that she puffs twice and last use was three months ago. She also uses acetaminophen 500-1000 mg PO prn for headaches and ibuprofen for menstrual cramps, which she took six weeks ago. She denies any side effects from these medications.
Allergies: She reports allergic reaction to penicillin, which causes rashes. She also reports allergies to dust and cars. She denies food and latex allergies.
Past Medical History (PMH): The client was diagnosed with asthma when she was one and half years old. She reports that last asthma exacerbation was three months ago. Her last asthma hospitalization was when she was in high school. She has not history of intubation. She has type 2 diabetes mellitus that was diagnosed when she was 24 years. She manages it using metformin, with her blood sugar being an average of 90. She monitors blood sugar daily in the morning. She also manages diabetes using exercise and diets. She is also hypertensive. She has no history of surgery.
Past Surgical History (PSH): She denied any history of surgery
Sexual/Reproductive History: She developed her menarche at the age of 11. She has sex with men. She has no history of pregnancy. She had her first sex at the age of 18. She was diagnosed with POCS four months ago when she went for her gynecological exam.
Personal/Social History: The client just secured an employment. She is not married but has a boyfriend. She lives with her mother and intends to move to her apartment once she starts working. She loves reading, dancing, attending Bible studies, and church functions. She has a strong social support system comprising her family and church.
Health Maintenance: The client does not use tobacco. She used cannabis from ages 15-21 years. She does not abuse any drugs. She occasionally drinks alcohol when with her friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, lunch, to supper. She takes diet coke. She engages in mild exercise at least four times a week. The client also attends to the doctor’s appointments. Her last pap smear was four months ago. She had eye examinations three months ago. Her dental examination was 150 days ago. She is negative for PPD, which was done two years ago. She has smoke detectors at home and wears safety belts in the care. She does not ride the bike. She uses sunscreen in the sun. She has her father’s gun locked in their bedroom.
Immunization History: Her immunization status is current bar HPV and tetanus vaccines. Childhood vaccines are also up to date as well as meningococcal vaccines.
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 high cholesterol. Stroke killed maternal grandparents. Paternal grandmother is alive and 82 years of age whilst grandfather died of cancer at 65. The deceased grandfather also had a history of type 2 diabetes alongside the patient’s father who died in an accident. The client has an overweight brother and an asthmatic sister. Alcoholism in paternal uncle whilst no other diseases exist in the family as well as her.
Review of Systems:
General: The client is alert and oriented to all facets. She is cooperative, maintains eye contact, and normal speech during the assessment.
HEENT: The client denies current headache and history of head injury or acute visual changes. She reports no eye pain, itchy eyes, redness, or dry eyes. She wears corrective lenses. Her last visit to the optometrist was 3 months ago. Reports no change of hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain, or pressure, or rhinorrhea. Denies any general mouth issues. She also denies dental concerns. She denies dysphagia, sore throat, voice changes, or swollen nodes.
Respiratory: The client reports normal breath, lack of wheezing, chest pain, dyspnea and cough.
Cardiovascular/Peripheral Vascular: The client reports no palpations, tachycardia, easy bruising or edema.
Gastrointestinal: The client reports no nausea, vomiting, pain constipation, excessive flatulence or diarrhea. She does not have food intolerance.
Genitourinary: She does not have dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching
Musculoskeletal: The client does not have muscle and joint pains whilst muscle weaknesses and swelling does not exist.
Neurological: She denies dizziness, tingling, light-headedness, seizures, loss of coordination or sensation, or sense of disequilibrium.
Psychiatric: Does not suffer depression, anxiety, or suicidal thoughts.
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.
OBJECTIVE DATA:
Physical Exam:
Vital signs: Height: 170m cm Weight: 84 bmi: 29.00 Blood glucose: 90 RR: 15 HR: 78 BP: 128/82 Pulse Ox: 99% Temperature: 99.0 F
General: The patient is alert and oriented to all facets. She sits upright on the examination table. She has good health and has first class hygiene as well.
HEENT: Head is normocephalic and atraumatic. The eyes are bilateral eyes with equal hair distribution on lashes and eye brows. Eye lids do not have lesions. There is no ptosis or edema. Conjunctiva appears pink with no lesions and white sclera. PERRLA bilaterally. OEMS intact bilaterally, no nystagmus. Snellen assessment results: 20/20 right eye, 20/20 left eye with corrective lenses. Tympanic membranes intact and pearly gray bilaterally with positive light reflex. The client hears whispered words bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions. Uvula rises midline on phonation. Gag reflex is intact. Dentation do not show evidence of carries or infection. Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. There is no lymphadenopathy.
Neck:
Chest/Lungs: Chest is symmetric. The lung sounds are clear whilst voice occurs in all areas. Percussion produced resonance throughout. In office spirometry: FVC 3.91, FEV1/FVC ratio 80.56%.
Heart/Peripheral Vascular: Hear rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts or thrills. Bilateral peripheral pulses equal bilaterally, capillary refills less than 3 seconds. No peripheral edema.
Abdomen: Abdomen is protuberant, symmetric without visible masses, scars, or lesions, coarse hair from pubis to umbilicus. Bowel sounds are normoactive in all four quadrants. Tympanic throughout to percussion. No tenderness or guarding to palpation. No organomegaly and CVA tenderness.
Genital/Rectal: Not assessed
Musculoskeletal: Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. There is no pain with movement.
Neurological: Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterally. Cerebella function tests produced normal results. Deep tendon reflexes 2+ and equal bilaterally in upper and lower extremities. Decreased sensation to monofilament in bilateral plantar surfaces.
Skin: Pustules on the face are scattered whilst the upper lip ha facial hair. The posterior neck has acanthosis nigricans. Nails are free of ridges or abnormalities.
Diagnostic results: none
ASSESSMENT: The client is a 28-year-old African American that has come to the clinic for her preemployment assessment. She is dressed appropriately for the occasion, alert, and oriented to all facets. The client is cooperative, responsive to questions, and does not demonstrate any abnormal manners. Her speech is normal in terms of volume and tone. She has enhanced coping mechanisms to stress. Her significant medical history includes asthma, hypertension, and diabetes mellitus, which are well controlled. She does not abuse any drugs or substances. She engages in healthy lifestyles and behaviors. Her physical assessment findings are within the normal range.