NURS 6512 Comprehensive (Head-to-Toe) Physical
Walden University NURS 6512 Comprehensive (Head-to-Toe) Physical-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University NURS 6512 Comprehensive (Head-to-Toe) Physical 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 Comprehensive (Head-to-Toe) Physical
Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Comprehensive (Head-to-Toe) Physical 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 Comprehensive (Head-to-Toe) Physical
The introduction for the Walden University NURS 6512 Comprehensive (Head-to-Toe) Physical 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 Comprehensive (Head-to-Toe) Physical
After the introduction, move into the main part of the NURS 6512 Comprehensive (Head-to-Toe) Physical 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 Comprehensive (Head-to-Toe) Physical
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 Comprehensive (Head-to-Toe) Physical
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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Ms. Jones reports that she recently obtained employment at Smith, Stevens, Stewart, Silver and 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 diagnose her with polycystic ovarian syndrome and prescribed oral contraceptives at that visit, which she is tolerating well. She has type two 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 talking better care of herself than in the past and is looking forward to beginning new job.
. 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 six weeks ago).
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 intubeted. 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 a day 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 four weeks) with moderate bleeding lasting five days. Has new male relationship, sexual contact not initiated. She plans to use condom with sexual activity. Tested negative for HIV/AIDS and STIs four months ago.
Throughout this course, you were encouraged to practice conducting various physical assessments on multiple areas of the body, ranging from the head to the toes. Each of these assessments, however, was conducted independently of one another. For this DCE Assignment, you connect the knowledge and skills you gained from each individual assessment to perform a comprehensive head-to-toe physical examination in your Digital Clinical Experience.
Photo Credit: Getty Images/Hero Images
To Prepare
• Review this week’s Learning Resources, and download and review the Physical Examination Objective Data Checklist as well as the Student Checklists and Key Points documents related to neurologic system and mental status.
• Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation with the Shadow Health platform. Review the examples also provided.
• Review the DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
• Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
• Review the Week 9 DCE Comprehensive Physical Assessment Rubric provided in the Assignment submission area for details on completing the Assessment in Shadow Health.
• Also, your Week 9 Assignment 3 should be in the Complete SOAP Note format. Refer to Chapter 2 of the Sullivan text and the Week 4 Complete Physical Exam template and use the template below for your submission.
Week 9 Shadow Health Comprehensive SOAP Note Documentation Template
Note: There are 2 parts to this assignment – the lab pass and the documentation. You must achieve a total score of 80% in order to pass this assignment. Carefully review the rubric and video presentation in order to fully understand the requirements of this assignment.
DCE Comprehensive Physical Assessment:
Complete the following in Shadow Health:
• Episodic/Focused Note for Comprehensive Physical Assessment of Tina Jones (180 minutes)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 9 Day 7 deadline.
Submission and Grading Information
By Day 7 of Week 9
• Complete your Comprehensive (Head-to-Toe) Physical Assessment DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
• Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding Assignment in Blackboard for your faculty review.
• (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
• Review the Week 9 DCE Health History Assessment Rubric, provided in the Assignment submission area, for details on completing the Assignment.
• Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
• Complete the Code of Conduct Acknowledgement.
• Note: You must pass this assignment with a minimum score of 80% in order to pass the class. Once submitted, there are not any opportunities to revise or repeat this assignment.
Grading Criteria
To access your rubric:
Week 9 Assignment 3 DCE Rubric
Submit Your Assignment by Day 7 of Week 9
To submit your Lab Pass:
Week 9 Lab Pass
To sumit this required part of the Assignment:
Week 9 Documentation Notes for Assignment 3
To Submit your Student Acknowledgement:
Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.
________________________________________
What’s Coming Up in Week 10?
Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images
Next week, you will examine how to assess problems with the breasts, genitalia, rectum, and prostate while making the patient feel safe, listened to, and cared about using a non-invasive approach. Once again, you will use a SOAP note format to complete your Lab Assignment for this week.
Week 10 Required Media
Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images
Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Discussion. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Lab Assignment on time.
Next Week
To go to the next week:
Week 10
Week 9: Assessment of Cognition and the Neurologic System
A 63-year-old woman comes to your office because she’s been forgetting things…a young mother comes in concerned because her baby fails to make eye contact and is unresponsive to touch…a teenager comes in and a parent complains that the teen obsessively washes his hands.
An array of neurological conditions could be causing the above symptoms. When assessing the neurologic system, it is vital to formulate an accurate diagnosis as early as possible to prevent continued damage and deterioration of a patient’s quality of life.
This week, you will explore methods for assessing the cognition and the neurologic system.
Learning Objectives
Students will:
• Evaluate abnormal neurological symptoms
• Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for cognition and the neurologic system
• Assess health conditions based on a head-to-toe physical examination
________________________________________
Also Read:
NURS 6512 Assignment Assessing The Genitalia And Rectum
NURS 6512 Assignment Ethical Concerns
NURS 6512 Week 9 Assessment Of Cognition And The Neurologic System
NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children
Discussion: NURS 6512 Assessing the Ears, Nose, and Throat
Discussion: NURS 6512 Effective Communication
Assignment: NURS 6512 Assessment Tools and Diagnostic Tests in Adults and Children
NURS 6512 The Ethics Behind Assessment
NURS 6512 Cognition and the Neurologic System
NURS 6512 Assessment of the Musculoskeletal System
NURS 6512 Assignment Cardiovascular Disease (CVD)
NURS 6512 Abdomen and Gastrointestinal System
NURS 6512 Functional, Cultural and Diversity Awareness in Health
NURS 6512 Building a Comprehensive Health History
NURS 6512 TJ Pregnant Lesbian Essay
NURS 6512 Health History of Tina Jones
NURS 6512 Discussion Week 1 Main Post
NURS 6512 Assignment 2 Focused Exam
NURS 6512 Practice Assessment Skin, Hair, and Nails Examination
NURS 6512 Digital Clinical Experience
NURS 6512 Tools and Diagnostic Tests in Adults and Children
NURS 6512 Episodic/Focused SOAP Note Template
NURS 6512 Discussion Episodic/Focused SOAP Note
NURS 6512 Discussion Adolescent Patients
NURS 6512 Effective communication is required needed in any patient-healthcare provider interaction
NURS 6512 Primary care is a critical aspect of patient care
NURS 6512 Cultural beliefs played a key role in patient health
NURS 6512 Research the health-illness continuum and its relevance to patient care
NURS 6512 discuss the relevance of the continuum to patient care
NURS 6512 Cultural and linguistic competence
NURS 6512 Health assessment of the skin, hair and nails
NURS 6512 The abdomen and the gastrointestinal system Assignment
NURS 6512 Congestive Heart Failure
NURS 6512 Acute Lateral Ankle Sprain
NURS 6512 Bilateral Ankle Pain
NURS 6512 Discussion Categories to Differentiate Knee Pain
NURS 6512 Assessing The Neurologic System
NURS 6512 Comprehensive Physical Assessment
NURS 6512 ethical dilemmas Assessment
NURS 6512 History of Present Illness (HPI)
NURS 6512 provision of quality and effective healthcare services to the diverse population
Learning Resources
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
• Chapter 7, “Mental Status”
This chapter revolves around the mental status evaluation of an individual’s overall cognitive state. The chapter includes a list of mental abnormalities and their symptoms.
• ·Chapter 23, “Neurologic System”
The authors of this chapter explore the anatomy and physiology of the neurologic system. The authors also describe neurological examinations and potential findings.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 4, “Affective Changes”
This chapter outlines how to identify the potential cause of affective changes in a patient. The authors provide a suggested approach to the evaluation of this type of change, and they include specific tools that can be used as part of the diagnosis.
Chapter 9, “Confusion in Older Adults”
This chapter focuses on causes of confusion in older adults, with an emphasis on dementia. The authors include suggested questions for taking a focused history as well as what to look for in a physical examination.
Chapter 13, “Dizziness”
Dizziness can be a symptom of many underlying conditions. This chapter outlines the questions to ask a patient in taking a focused history and different tests to use in a physical examination.
Chapter 19, “Headache”
The focus of this chapter is the identification of the causes of headaches. The first step is to ensure that the headache is not a life-threatening condition. The authors give suggestions for taking a thorough history and performing a physical exam.
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Chapter 31, “Sleep Problems”
In this chapter, the authors highlight the main causes of sleep problems. They also provide possible questions to use in taking the patient’s history, things to look for when performing a physical exam, and possible laboratory and diagnostic studies that might be useful in making the diagnosis.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
• Chapter 2, “The Comprehensive History and Physical Exam” (“Cranial Nerves and Their Function” and “Grading Reflexes”) (Previously read in Weeks 1, 2, 3, and 5)
Note: Download the Physical Examination Objective Data Checklist to use as you complete the Comprehensive (Head-to-Toe) Physical Assessment assignment.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Physical examination objective data checklist. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Mosby’s Guide to Physical Examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Elsevier. Reprinted by permission of Elsevier via the Copyright Clearance Center.
Note: Download and review the Student Checklists and Key Points to use during your practice neurological examination.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Neurologic system: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Mental status: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Bearden , S. T., & Nay, L. B. (2011). Utility of EEG in differential diagnosis of adults with unexplained acute alteration of mental status. American Journal of Electroneurodiagnostic Technology, 51(2), 92–104.
This article reviews the use of electrocenographs (EEG) to assist in differential diagnoses. The authors provide differential diagnostic scenarios in which the EEG was useful.
Athilingam, P ., Visovsky, C., & Elliott, A. F. (2015). Cognitive screening in persons with chronic diseases in primary care: Challenges and recommendations for practice. American Journal of Alzheimer’s Disease & Other Dementias, 30(6), 547–558. doi:10.1177/1533317515577127
Sinclair , A. J., Gadsby, R., Hillson, R., Forbes, A., & Bayer, A. J. (2013). Brief report: Use of the Mini-Cog as a screening tool for cognitive impairment in diabetes in primary care. Diabetes Research and Clinical Practice, 100(1), e23–e25. doi:10.1016/j.diabres.2013.01.001
Roalf, D. R., Moberg, P. J., Xei, S. X., Wolk, D. A., Moelter, S. T., & Arnold, S. E. (2013). Comparative accuracies of two common screening instruments for classification of Alzheimer’s disease, mild cognitive impairment, and healthy aging. Alzheimer’s & Dementia, 9(5), 529–537. doi:10.1016/j.jalz.2012.10.001. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036230/
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: DCE (Shadow Health) Documentation Template for Comprehensive (Head-to-Toe) Physical Assessment (Word document)
Use this template to complete your Assignment 3 for this week.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
• Chapter 14, “The Neurologic Examination” (pp. 683–765)
This chapter provides an overview of the nervous system. The authors also explain the basics of neurological exams.
• Chapter 15, “Mental Status, Psychiatric, and Social Evaluations” (pp. 766–786)
In this chapter, the authors provide a list of common psychiatric syndromes. The authors also explain the mental, psychiatric, and social evaluation process.
Mahlknecht, P., Hotter, A., Hussl, A., Esterhammer, R., Schockey, M., & Seppi, K. (2010). Significance of MRI in diagnosis and differential diagnosis of Parkinson’s disease. Neurodegenerative Diseases, 7(5), 300–318.
Required Media (click to expand/reduce)
Neurologic System – Week 9 (16m)
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 7 and 23 that relate to the assessment of cognition and the neurologic system. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Content
Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
• Grid View
• List View
Excellent Good Fair Poor
Student DCE score
(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)
Note: DCE Score – Do not round up on the DCE score. Points Range: 56 (56%) – 60 (60%)
DCE score>93 Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92 Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85 Points Range: 0 (0%) – 45 (45%)
DCE Score <79
No DCE completed.
Documentation in Provider Notes Area
Subjective documentation of the comprehensive exam in Provider Notes is detailed, organized, and includes documentation of identifying data, general survey, reason for visit/chief complaint, history of present illness, medications, allergies, medical history, health maintenance, family history, social history, mental health history, and review of systems.
The review of systems is clearly defined by each body system (skin, eyes, cardiac, etc.) and all conditions or illnesses asked of the patient are documented along with the patient response. Points Range: 16 (16%) – 20 (20%)
Documentation is detailed and organized with all pertinent information noted in professional language.
Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details, some organization and some pertinent information noted in professional language.
Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.
Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). Points Range: 0 (0%) – 5 (5%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.
No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).
or
No documentation provided.
Objective Documentation in Provider Notes – this is to be completed in Shadow Health
Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.
Diagnostic result- Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned
Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). Points Range: 16 (16%) – 20 (20%)
Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.
Each system assessed is clearly documented with measurable details of the exam. Points Range: 11 (11%) – 15 (15%)
Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.
Each system assessed is somewhat clearly documented with measurable details of the exam. Points Range: 6 (6%) – 10 (10%)
Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.
Each system assessed is minimally or is not clearly documented with measurable details of the exam. Points Range: 0 (0%) – 5 (5%)
Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.
None of the systems are assessed, no documentation of details of the exam.
or
No documentation provided.
Total Points: 100
Name: NURS_6512_Week_9_DCE_Assignment_3_Rubric
Description: Note: To complete the Shadow Health assignments it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Week 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Do not copy any sample documentation as this is plagiarism. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score. You must pass this assignment with a total cumulative score of 79.5% or greater in order to pass this course.
Sample Answer for NURS 6512 Comprehensive (Head-to-Toe) Physical
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 2 for NURS 6512 Comprehensive (Head-to-Toe) Physical
SUBJECTIVE DATA:
Chief Complaint (CC): “I have come for my pre-employment assessment.”
History of Present Illness (HPI): The patient is a 28-year-old African American unmarried female that came to the clinic for pre-employment assessment. She is cooperative and offers information. She maintains normal eye contact and has normal speech. The client reports that she recently got a job that requires her to have a health insurance. She denies any acute concern. She reports that she had her gynecological exam four months ago where she was diagnosed with POCS and prescribed medications that she tolerates well. She is also diabetic and manages it with metformin and active lifestyle. She tolerates the medication well.
Medications: The patient currently uses Metformin 850 MG po BID Drospitenone and ethinyl estradiol PO QD. She also has Albuterol spay that she puffs twice and last use was three months ago. She occasionally uses Acetaminophen 500-1000 mg PO prn for headaches and Ibuprofen for menstrual cramps and last taken 6 weeks ago.
Allergies: The client reports allergic reaction to penicillin, which causes rashes. She also reports allergic reaction to dust and cats. She deniesfood and latex allergies.
Past Medical History (PMH): The client reports that she was diagnosed with asthma when 1 1/2 years old. Her last asthma exacerbation occurred three months ago. Last asthma hospitalization was when in high school. She report that she has never been intubated. The client reported that she has type 2 diabetes that was diagnosed at 24 years. She has been taking metformin for five months without much side effects. Her average blood sugar is 90 and she monitors it daily in the morning. She also exercises and diets to manage the condition as well as hypertension. She has never undergone any surgery.
Past Surgical History (PSH): She has no history of surgery.
Sexual/Reproductive History:She developed menarche at the age of 11. She has sex with men. She has never been pregnant whilst her had first sex at the age of 18. She has a new boyfriend.
Personal/Social History: She graduated with accounting degree and has been hired as an accounting clerk at Smith, Stevens, Steward, Silver & Company. The patient does not have children. She is not married. She lives with her mother alongside her sister in a single apartment but planning to move to her own once she starts work. She enjoys reading, attending Bible studies, dancing and attending church functions. She considers her social support to include the church, friends and her family. She does not use tobacco.She used cannabis from ages 15-21. She does not abuse any other drugs. She uses alcohol in the company of friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, lunch to supper. She does not take coffee. She takes diet coke. She has not travelled outside recently and does not keep pets. She does mild exercise at least four times per week. She denies being stressed or anxiety.
Health Maintenance: The patient attends to the doctor’s appointment as scheduled. She had a pap smear 4 months ago. She also had an eye exam 3 months ago. The dental exam was last conducted 150 days ago. She is negative for PPD that was done two years ago. Her immunization status is current bar tetanus and HPV vaccines. She swims at YMCA. She reports that she has smoke detectors in the home. She wears safety belts in the car. She does not ride the bike. She uses sunscreen in the sun. She has locked her father’s gun in their bedroom.
Immunization History:Her immunization status is current bar tetanus and HPV vaccines. Childhood vaccines are up to date as well as meningococcal vaccine.
Significant Family History: There is 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 latter also had a history of type 2 diabetes alongside the patient’s father who died in an accident. Has an overweight brother and an asthmatic sister. Alcoholism in paternal uncle. There are no other diseases in the family.
Review of Systems:
General: The client is dressed appropriately for the occasion. She maintains normal eye contact during the assessment. Her speech is of normal rate and tone. She denies, chills, night sweats, headache, fatigue, or weight changes
HEENT: The client denies headache or head injuries. She denies general hearing problems, changes in hearing, ear pain or discharge. She also denies eye pain, itchy eyes, eye redness, or dry eyes. She denies changes in smell, sneezing, runny nose, nose bleeds or sinus pain. Dental visit was five months ago. She denies general mouth problems, changes in sense of taste, dry mouth, mouth pain, gum problems, tongue or jaw problems, and dental problems. She denies difficulty in swallowing, sore throat, voice changes, neck pain, or lymphadenopathy.
Respiratory:She denies any current breathing problems. She chest tightness, wheezing, chest pain, or cough.
Cardiovascular/Peripheral Vascular:She denies palpitations, irregular heartbeat, easy bruising, edema, or circulation problems.
Gastrointestinal: She denies nausea, vomiting, stomach pain, constipation, diarrhea, or flatulence.
Genitourinary: She denies dysuria, nocturia, polyuria, blood stained urine, flank pain, abnormal vaginal discharge, breast lump or breast pain.
Musculoskeletal: She denies muscle pain, joint pain, muscle weakness, or swelling.
Neurological: She denies dizziness, vision disturbance, numbness or tingling, loss of coordination or sensation, seizures or balance problems.
Psychiatric:Has enhanced coping mechanism to stress. Does not suffer depression, anxiety, or suicidal thoughts. She is alert to all faculties. She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear. Skin/hair/nails:she uses sun-glasses when playing outdoors. She denies slow-healing wounds, with improving acne and some male-pattern hair growth. She denies sores, dandruff, nail fungus, dry skin or rashes.
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:She is dressed properly and easily converses and cooperatively offers information. Has pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and words are clear.
HEENT:Normocephalic head, and atraumatic as well. Bilateral eyes with equal hair distribution on lashes and eye brows, lids without lesions. No ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. OEMS intact bilaterally, no nystagmus. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMS intact and pearly gray bilaterally, positive light reflex. Whispered words bilaterally heard. 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 minus evidence of carries or infection. Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.
Neck:Tonsils 2+ bilaterally. Thyroid smooth minus nodules, no goiter. No lymphadenopathy.
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:Heart 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. No CVA tenderness.
Genital/Rectal:
Musculoskeletal:Strength 5/5 bilateral upper and lower extremities, without swelling, masses, or deformity and with full range of motion. No pain with movement.
Neurological:Graphesthesia, stereognosis, and rapid alternating movements are normal bilaterally. Cerebella function tests produced normal results. DTRs 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. The client has come for preemployment physical examination.
ASSESSMENT: The patient is a 28-year-old African American unmarried female that came to the clinic for pre-employment assessment. She is cooperative and offers information. She maintains normal eye contact and has normal speech. The client reports that she recently got a job that requires her to have a health insurance. She denies any acute concern. She reports that she had her gynecological exam four months ago where she was diagnosed with POCS and prescribed medications that she tolerates well. She is also diabetic and manages it with metformin and active lifestyle. She tolerates the medication well.The patient currently uses Metformin 850 MG PO BID Drospitenone and ethinyl estradiol PO QD. She also has Albuterol spay that she puffs twice and last use was three months ago. She occasionally uses Acetaminophen 500-1000 mg PO prn for headaches and Ibuprofen for menstrual cramps and last taken 6 weeks ago. Physical examination findings are unremarkable. She denies any mental health problems such as anxiety or depression. No diagnostic investigations were ordered during this client’s visit.
Sample Answer 3 for NURS 6512 Comprehensive (Head-to-Toe) Physical
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.