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

Assignment 3 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment

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.

Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment

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 5^th 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

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

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, 5^th 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

NURS 6512 Assignment 3: Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment