Week 9 passing score 90

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Please complete the attached SOAP note with the information provided 5 citations/references no older than 5 years 

Week 9

Shadow Health Comprehensive SOAP Note Template

Patient Initials: _______ Age: _______ Gender: _______

SUBJECTIVE DATA:

Chief Complaint (CC):

History of Present Illness (HPI):

Medications:

Allergies:

Past Medical History (PMH):

Past Surgical History (PSH):

Sexual/Reproductive History:

Personal/Social History:

Health Maintenance:

Immunization History:

Significant Family History:

Review of Systems:

General:

HEENT:

Respiratory:

Cardiovascular/Peripheral Vascular:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Skin/hair/nails:

OBJECTIVE DATA:

Physical Exam:

Vital signs:

General:

HEENT:

Neck:

Chest/Lungs:.

Heart/Peripheral Vascular:

Abdomen:

Genital/Rectal:

Musculoskeletal:

Neurological:

Skin:

Diagnostic results:

ASSESSMENT:

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

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Vitals

Student Documentation

Model Documentation

Vitals

BP 120/82 SPO2 – 99 RR – 15 T – 37.2

N/A

Health History

Student Documentation

Model Documentation

Identifying Data & Reliability

Ms. Tina Jones is a 28 years old African American female. Not married and does not have children, currently in relationship with a boyfriend. Presently living with her mother and young sister. Ms. Jones presents to our consult for physical assessment as she newly got hired by a new employer. She is alert, allowing the pertinent data and well articulate. She is able to maintain eye contact, appropriately communicate and engage in the assessment.

N/A

General Survey

Ms. Jones is alert, engaged in her health matters and compliant with the follow ups. Seating in upright posture, articulate, with not stressed appearance , groomed well nourished , appropriately dressed and maintains good hygiene.

N/A

Reason for Visit

” I came because I ‘am required to have a recent physical exam for the health insurance at my new job”

N/A

History of Present Illness

Ms. Jones 28 years old African American female that presented for physical examination for the insurance of new job. She states that she does not have any present medical concern. The patient does have history of Diabetes, asthma and High blood pressure. The patient was prescribed with metformin around 5 months ago during her last physical exam, and also was diagnosed with PCOS by ger gynecologist at this time birth control medication was prescribed. Ms Jones reports some side effects associated with metformin , but also stated that those side effects were managed using yogurt. She stated stopping the use of Advil for cramps. MS Jones claims to be feeling currently healthy and looking forward the new employment.

N/A

Medications

Advil for cramps occasionally Metformin 850 mg twice a day Flovent daily inhaler and Proventil as a recue inhaler , she is presently using estradiol as birth control medication.

N/A

Allergies

Not food allergies identified. Allergic to cats and dust , she is also allergic to penicillin that given her rushes.

N/A

Medical History

Ms, Jones was diagnosed with asthma when she was 2 years old, for which presently she use Flovent and Proventil in the morning and evening. She is allergic to cats and dust. She was also diagnosed with diabetes 4 years ago and now treated with metformin she started treatment 5 months ago. She has been regularly checking her blood sugar since and stated currently being in the 90’s. She reported that initially she had some side effects from metformin , but she had since manage it . She also has High Blood pressure, which she has been able to manage with exercises and diet. She stated being heterosexual , does not have STDs and has been sexually inactive for while but presently she does have a boyfriend, About 5 months ago Ms. Jones was diagnosed with POCS and estradiol was prescribed. She reported using Advil occasionally for cramps.

N/A

Health Maintenance

Ms. Jones is aware of the importance of dieting and exercise and expressed being engaged in both. She stated being active physically. She stated she does not strain herself and does not have any breathing problems. As per patient she occasionally goes swimming with friend and plays active roles in the church. Ms Jones last physical examination was 5 months ago , her immunization are up to date , she had a tetanus booster about a year ago and her last flu shot was 5 to 6 years ago. She stated taking tetracycline for her acne when she was in high school and her skin has been better since then. MS Jones strives to maintain safety in everything she does and ensure she live a healthy productive life.

N/A

Family History

Ms Jones is overweight. She does have a sister who is 15 years old and has asthma under control , Ms. Jones father died when 2 and half years ago in a car accident he was 58 years old, he had High blood pressure , high cholesterol , and diabetes. Her mother is 50 years old she does have high cholesterol and high blood sugar . Paternal grandfather is 82 also with high cholesterol and high blood pressure, maternal grandfather dies of heart attack at the age of 80 he also had high cholesterol and high blood pressure. The maternal grand mother died of colon cancer when she was 73 and also had the high cholesterol and high blood pressure.

N/A

Social History

Ms Jones has never married, but she currently has a boyfriend and they are to have sex. She lives with her sister and her mother since her father died. She is about to move to her own place.MS jones recently graduated and stated having a good relationship with her family , occasionally goes swimming with friend, goes to church , uses diet coke as source of caffeine , does not smoke cigarettes and drinks alcohol socially no more that 2 drinks. She does not use recreational drugs. She used marijuana in the past it has been 6 years since,

N/A

Mental Health History

Ms. Jones stated not being depressed , currently exicted about her new job, never had suicidal ideations , expressed getting stressed in the past by school.

N/A

Review of Systems – General

High blood glucose about 5 month ago. Has not had fevers, chills or night sweats. recently some weight lost but not willingly. No headaches , no nausea.

N/A

HEENT

Student Documentation

Model Documentation

Subjective

Reports t have had headaches in the past, specially related to school work, she has not had headache for while , no pain , not itchiness on ayes or ears , sinuses clear , sense of smell intact , hearing intact , she does got glasses for eyesight like 3 months ago, does not have problems with throat, no soreness or dryness reported or seen , no difficultly swallowing or breathing

N/A

Objective

Head normocephalic no traumatic lesion noted, symmetric ears, no drainage , nares pink and moist , eyelids symmetric no swelling . vision 20/20 with glasses, conjunctiva pink ,hearing is intact. PERRLA . Gag reflex intact. Eye lids upper and lower symmetric , pink and moist. Internal bilateral ears pearly gray, JAw with appropriate movement no clicks . No masses on the scalp . No palpable nodes in the neck . No Nodules or goiter palpated in the thyroid. No pain reported in the sinus , no axillary nodes palpable. Intra ocular movement intact. Vision intact

N/A

Respiratory

Student Documentation

Model Documentation

Subjective

Does not have problems breathing, does not report cough or chest pain

N/A

Objective

Her chest is symmetric with even and unlabored respirations present to auscultation bilaterally. resonant percussion throughout . FVC1.78 L, FEV11,54 . Posterior chest wall resonant bilaterally. Thoracic expansion symmetric

N/A

Cardiovascular

Student Documentation

Model Documentation

Subjective

Does not report any issues with heart or beathing , denies chest pain

N/A

Objective

S1 and S2 noted , no murmurs or gallops . PMI at midclavicular line 5th intercostal , no haves , thrills lifts. Has bilateral carotid without bruit, bilateral peripheral pulses present equally. Capillary refill less that 3 seconds. No lower leg edema bilaterally . Bilateral right and left brachial pulses present +2, lower peripheral pulses present +2, right ankle left carotid +2 no thrill , auscultated no bruit bilaterally , abdominal arteries no bruit

N/A

Abdominal

Student Documentation

Model Documentation

Subjective

Does not report diarrhea or issued with the abdomen , no GERT, no dysuria , no vaginal itching does not feel boated does not experience nausea or vomiting

N/A

Objective

Abdomen is symmetric and protuberant , no scars , masses or lesions. Hair from pubis and the umbilicus is coarse , bowel sounds normoactive present in all quadrants. No organomegaly , CVA or tenderness noted. Liver 1 cm below right costal margin , no palpated kidneys or masses , not palpable spleen . Percussed liver span 7 MCL on percussion. CVA tenderness or right none reported

N/A

Musculoskeletal

Student Documentation

Model Documentation

Subjective

reports no pain in the shoulder, arms , muscle or joint. HAd some back pain some weeks ago when she helped a friend carry heavy items when she was moving , she does not have back pain presently, no swelling

N/A

Objective

Upper and lower extremities all have 5/5 strength no masses or swelling , no noted deformities , full range of motion in all extremities

N/A

Neurological

Student Documentation

Model Documentation

Subjective

Alert and oriented times 4 , no light headedness or loss of balance reported the coordination is intact , speech is intact

N/A

Objective

Cerebral function intact upon assessment , good memory , graphesthesia intact with appropriate alternating movements bilaterally. DTRs 2 + and equal bilaterally

N/A

Skin, Hair & Nails

Student Documentation

Model Documentation

Subjective

Has acne when was young at high school , it stopped with the use of medication. Zits present usually managed by birth control pills

N/A

Objective

Scattered pustules on the face and facial hair on upper lip. Has acanthosis nigricans on the neck . Nails appropriate no abnormalities noted

N/A

Nursing 6512
Advanced Health Assessment & Diagnostic Reasoning

Episodic/Focused SOAP Note
Review of Case #3
Week 9 Initial Post

Patient Initials: K. T. Age: 33 Gender: F Ethnicity:
African American

SUBJECTIVE DATA:

Chief Complaint (CC): “Drooping on the right side of face”

History of Present Illness (HPI): MH is a 33-year-old Caucasian female

presents to the office today with right side facial drooping that she

observed when she woke up this morning. She says that her right eye has

been watering constantly, and that she can’t stop drooling out of the right

side of her mouth. She denies any pain.

Medications:

Ibuprofen 200mg-2 PO as needed

Tylenol 325mg-2 PO every 4 hours as needed

Woman’s Multivitamin daily

Allergies: No Known Allergies

Past Medical History (PMH): Diagnosed with asthma when she was a

child. All immunizations are up to date. Denies ever having any surgeries

or hospitalizations.

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Social History: K. T. is a heterosexual, sexually active individual who

lives with her husband and children. She denies any tobacco, alcohol or

illicit drug use & wears her seatbelt whenever operating a motor vehicle.

She enjoys time with her family, evening walks with her children when

weather permits and front porch sitting with a good book in hand. She

denies any issues with sleep and reports getting approximately 8-10 hours

of sleep a night.

Family History: Both of her parents are still living. Her father is 55 with a

history of arthritis and hypertension. Her mother is 54 without any

significant health history. Her younger sister, age 30, does not have any

significant health history. She has two children, ages 7 & 5 who are

healthy.

Review of Systems (ROS):

General: No unexplained weight loss or weight gain, no decreased

appetite, no fever, chills or fatigue

HEENT: No blurred or loss of vision, no loss of hearing, hearing difficulty

or ringing in ears, no congestion, runny nose, sore throat or hoarseness,

no swelling/tenderness in lymph nodes.

Skin: No changes in skin such as rashes, lesions dryness or persistent

itching

Respiratory: No SOB, cough or sputum production.

Cardiovascular: No chest pain, pressure or palpitations, no edema or

pain with walking

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Gastrointestinal: No change in bowel habits, indigestion,

nausea/vomiting or diarrhea. No abdominal pain or tenderness

Genitourinary: No burning with urination, itching, difficulty starting

stream or increased frequency

Musculoskeletal: No muscular or joint pain

Hematologic: No anemia or bleeding, not easily bruised

Endocrinological: No heat or cold intolerances, no sweating, no polyuria

or polydipsia.

Neurological: No dizziness, LOC, or headaches. Moves all extremities

without tremors

Psychiatric: No mental illness, depression or anxiety

OBJECTIVE DATA:

Physical Exam:

Vital Signs: Temp: 98.2. Pulse: 82, Respirations: 20 and non-labored.

SpO2: 100% on RA, BP: 116/72 mmHg. Weight 140lbs. H: 5’8’ BMI: 21.3

General: Well-groomed and well-nourished, answering questions

appropriately

HEENT: Normocephalic, atraumatic, wears glasses, no hearing difficulties,

good oral hygiene, no swelling/tenderness in lymph nodes.

Skin: Intact, appropriate for ethnicity, no rashes, lesions dryness

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Cardiovascular: No chest pain or palpitations. RRR without murmur, no

edema, pulses palpable bilaterally to lower extremities, cap refill greater

than 3 seconds

Respiratory: No SOB, chest expansion equal and symmetric with clear

lung sounds, no cough or sputum production.

Gastrointestinal: No nausea, vomiting, diarrhea, or discomfort,

nondistended, nontender, BS present, and normoactive x4, no

organomegaly.

Genitourinary: Genitalia not examined. No dysuria or incontinence.

Neurological: AOx4, + for paresis on right side of face, + for difficulty

making facial expressions, moves all extremities without tremors or

weakness

Psychiatric: Calm, cooperative, concerned about symptoms

Allergic/Immunologic: No known allergies, no immune deficiencies.

ASSESSMENT:

Lab Tests:

Complete blood count to assess for possible infectious causes

Enzyme-linked immunosorbent assay [ELISA] or Enzyme immunoassay

[EIA] to assess for Lyme’s

Diagnostics:

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Computed Tomography (CT) or magnetic resonance imaging (MRI) to

identify infection, inflammation, tumor, fractures, or other potential

causes for facial nerve involvement.

Electromyography (EMG) testing – A test in which a needle electrode is

inserted into affected muscles to record both spontaneous

depolarizations and the responses to voluntary muscle contraction.

Electroneuronography (ENoG) testing (neurophysiologic studies) – A

test used to examine the integrity of the facial nerve, in which surface

electrodes record the electrical depolarization of facial muscles

following electrical stimulation of the facial nerve.

Glasgow Coma Scale & NIH Stroke Scale – to rule out stroke

Cerebrospinal fluid (CSF) analysis – to identify the presence of

increased protein and white blood cells; for this test, a needle is

inserted into the spine between vertebrae and a small amount of fluid

is withdrawn. While some protein is normally present, an increased

amount without an increase in the white blood cells in the CSF may be

indicative of Guillain-Barré syndrome.

Diagnosis:

Bell’s Palsy – According to Baugh, et al (2013). Bell’s Palsy, named

after the Scottish anatomist, Sir Charles Bell, is the most widely

recognized acute mono-neuropathy, or on the other hand issue

influencing a solitary nerve, and is the most normal determination

related with facial nerve weakness/loss of motion. Bell’s Palsy is a

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sudden one-sided facial nerve paresis (weakness) or loss of motion

(complete loss of development) of obscure reason. The condition

prompts the fractional or complete failure to deliberately move facial

muscles on the influenced side of the face. Albeit commonly self-

constrained, the facial paresis/loss of motion that happens in Bell’s

palsy may cause noteworthy brief oral ineptitude and a powerlessness

to close the eyelid, prompting potential eye damage.

Differential Diagnoses:

Facial Nerve Schwannomas – Facial nerve schwannomas (FNSs) are

slow-growing developing favorable tumors that can occur along any

section of the facial nerve. Indications can be variable relying upon the

size and area of the tumor, yet usually incorporate facial paresis,

hearing loss, and vestibular side effects (Jacob, Driscoll, & Link, 2012).

Guillain-Barre Syndrome: Typically starts as paresthesia and

weakness and continuously rising, manifestations incorporate facial

droop, diplopia, dysphagia, dysarthria, and pupillary aggravations

(Andary, 2017).

Mastoiditis – a bacterial contamination of the temporal bone and

gives the accompanying side effects; otalgia, otorrhea, swelling,

delicacy, and facial paralysis is an intra-transient complication (Devan,

2016).

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Stroke – Strokes often present with facial drooping, but it usually

affects one side of the body. If a patient can raise their eyebrows

normally and symmetrically but the lower part of their face is

paralyzed the health care provider will need to rule out a stroke (EBM

Consult, 2015).

Lyme disease – Lyme Disease is a disease caused by bacteria that

ticks can carry. It can cause bell’s palsy because advanced symptoms

of Lyme disease can affect the nervous system (Roth & Cirino, 2016).

References

Andary, M. (2017). Guillain-Barre Syndrome. Retrieved

fromhttp://emedicine.medscape.com

/article/315632-overview

Baugh, R. F., Basura, G. J., Ishii, L. E., Schwartz, S. R., Drumheller, C. M.,

Burkholder R., Deckard, N. A.,

Dawson, C., Driscoll, C. M., Gillespie, B., Gurgel, R. K., Halperin, J.,

Khalid, A. N., Kumar, K. A., Micco, A., Munsell D., Rosenbaum, S., and

Vaughan, W. (2013). Clinical Practice Guideline: Bell’s Palsy.

Otolaryngology–Head and Neck Surgery. 149(3), pp. S1 – S27.

https://doi.org/10.1177

/0194599813505967

Devan, P. P. (2016). Mastoiditis clinical presentation. Retrieved from

http://emedicine.medscape.com/

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article/2056657-clinical#b3

EBM Consult. (2015). Stroke vs. bell’s palsy. Retrieved from

http://www.ebmconsult.com/articles/anatomy

stroke-vs-bells-palsy

Hinckley, A. F., Connally, N. P., Meek, J. I., Johnson, B. J., Kemperman, M. M.,

Feldman, K. A.,

White, J. L., & Mead, P. S. (2014). Lyme Disease Testing by Large

Commercial Laboratories in the United States. Clinical Infectious

Diseases, (59)5, pgs. 676–681, https://doi.org/10.1093/cid/ciu397

Jacob, J. T., Driscoll, C. L. W., & Link, M. J. (2012). Facial Nerve Schwannomas

of the Cerebellopontine

Angle: The Mayo Clinic Experience. Journal of Neurological Surgery. Part

B, Skull Base, 73(4), 230–235. http://doi.org/10.1055/s-0032-1312718

National Institute of Neurological Disorders and Stroke. (2018). Bell’s Palsy.

Retrieved from

https://www.ninds.nih.gov/Disorders/All-Disorders/Bells-Palsy-

Information-Page

Roth, E. & Cirino, E. (2016). Is it Lyme disease? Check your symptoms.

Retrieved from

http://www.healthline.com/health/lyme-disease-symptoms#Overview1

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Week 9 Patient Comprehensive Exam

Walden University

NURS 6512 Advanced Health Assessment

Dr. Vijayarani Suresh

August 2, 2021

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Week 9 Patient Comprehensive Exam

Week 9
Shadow Health Comprehensive SOAP Note Template

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

SUBJECTIVE DATA:

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

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

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

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

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

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

Past Surgical History (PSH): none

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

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

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

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

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

Review of Systems:

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

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

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

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

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

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

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

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

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

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

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OBJECTIVE DATA:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

ASSESSMENT:

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

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References

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

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

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

http://womenshealth.gov

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

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