DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

aNURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

Week 9

Shadow Health Comprehensive SOAP Note Template

 

Patient Initials: _______               Age: __28 years_____                            Gender: __Female_____

 

 

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.

 

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