Week 9: Tina Jones Head-To-Toe Health Assessment Paper
Week 9: Tina Jones head-to-toe health assessment
Patient Initials: T.J Age: 28 years old Gender: Female
Chief Complaint (CC): “Complete physical examination for health insurance”
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History of Present Illness (HPI): T.J is a 28-year-old African American female patient who presented to the clinic for a complete physical examination as a requirement by her job for health insurance. She was recently employed at Smith, Stevens, Stewart, Silver & Company. She reports no medical condition at the moment, with her last medical check-up done 4 months ago during her routine gynecological exam annually. She was diagnosed with PCOS and prescribed appropriate oral contraceptives which seem to be effective to date. She also reports a history of type 2 DM well managed using metformin as an adjunct to exercise and dietary interventions. She however looks healthy, with no other medical condition at the moment.
- Metformin 850mg twice daily for type 2 DM
- Flovent inhaler 110 mcg 2 puffs twice daily
- Proventil rescue inhaler- 90mcg (base)/actuation, two puffs PRN
- Birth control drospirenone and Ethinyl estradiol orally, once every morning.
- Advil 600mg PRN for management of menstrual cramps
- No known latex or food allergies.
- Drug allergies- Penicillin
- Confirms dust and cat allergies
- Allergic response- running nose, swollen and itchy eyes, and worsened asthma symptoms.
Past Medical History (PMH): Diagnosed with asthma when she was only 2 and a half years old. Utilizes Albuterol inhaler twice or thrice a week in presence of dust or cats. The last time she used the inhaler was three days ago, when she was exposed to cats. At age 24, she was diagnosed with diabetes, which she has been managing using metformin, until 3 years ago when she stopped taking the drug secondary to flatulence side effects. She denies monitoring her blood sugar levels since then. She reports that the last time her blood sugar levels spiked was in the emergency room a week before the present visit.
Hospitalization: When she was in high school because of an asthma attack. Denies intubated.
Past Surgical History (PSH): None
Sexual/Reproductive History: First menstrual cycle at the age of 11 years. Heterosexual with the first incidence of sexual intercourse at the age of 18 years. Denies ever getting pregnant. Report’s irregular and heavy menses lasting for 9-10 days, after every 4 to 8 weeks, in the past year, with the last menses about 3 weeks before the present visit. Confirms using oral contraceptive pills in the past, but currently, she has no partner. Denies using condoms whenever sexually active. Denies ever having an HIV/AIDS test with no history of STI or STD symptoms. She reports that her last pap smear test was about 4 years ago.
Personal/Social History: The patient has never been married with any children. She has been living alone ever since she was 19 years, but ever since her father died about a year back, she moved back into their single-family home, with her sister and mother for support. She however got a new job, which she plans to start two weeks from now. During her free time, she visits friends and attends Bible study. She also dances and volunteers at her church. She is an active church member and even views her family as a strong social support system. The main stressor affecting her family is her father’s death, which made her create a balance between school and work demands and her finances. She complements both the church and her family for being supportive during stressful times. She denies using tobacco, cocaine, heroin, or methamphetamine. She confirms occasional use of Canis from the age of 15 to 21years. She takes alcohol whenever out with friends, at least 2 to 3 times a month, with only 3 or fewer drinks per episode. She confirms taking about 4 caffeinated drinks each day. She has never been out of the country, with no pets. She denies being in an intimate relationship currently, and ended a serious monogamous relationship that lasted for 3 years about 2 years ago. She however hopes to get married and have kids someday.
The last time she had an eye examination was 3 months back. The last Pap smear was done 4 months ago. A dental examination was last performed 5 months ago. A negative PPD test was conducted 2 years ago.
Physical activity: No exercise
Nutrition: She can recall her diet for the past 24 hours. Claims to have skipped breakfast the day before the present visit had a sandwich for lunch and chicken or meatloaf for dinner. She takes snacks mainly made up of French fries or pretzels.
Safety: Her house has installed smoke detectors. She confirms wearing a seatbelt while in the car and denies riding bikes. Denies using sunscreen. Her dad’s guns are still in the home but locked in their parents’ room.
Immunization History: She received her last tetanus booster the previous year. Influenza vaccine not up to date. Did not receive her human papillomavirus vaccine. She received her meningococcal vaccine while still in college and believes that her childhood immunization is up to date.
Significant Family History: The patient’s mother is 50 years with HTN and hypercholesterolemia. Father passed at age 58 from a motor vehicle accident with a history of DM and hypercholesterolemia. Her brother is obese at age 25. Her sister is asthmatic at age 14. Maternal grandmother is deceased at 73 years from stroke, with a history of hypercholesterolemia and HTN. Maternal grandfather is also diseased from stroke at 78 years with a history of hypercholesterolemia and HTN. Paternal grandmother is hypertensive but still alive at age 82. Paternal grandfather died at 65 years from cancer of the colon. Her paternal uncle is an alcoholic.
Review of Systems:
General: No fatigue, fever, or chills. Confirms losing 10 pounds over the past few weeks due to dietary changes and exercise.
HEENT: Head: No headache, or signs of head injury. Neck: No signs of enlarged lymph nodes or swelling. Eyes: No itchiness, excessive tearing, pain, or discharge. The last eye check-up was done 2 years ago. Ears/Nose/Mouth/Throat: 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. She last visited a dentist about 6 months ago as a result of a mild toothache.
Cardiovascular/Peripheral Vascular: No history of cyanosis or hurt murmurs. Denies chest pain or palpitations. Pulmonary: No cough, shortness of breath, wheezing, or sneezing. Denies pleuritic pain. Gastrointestinal: No Tenderness, diarrhea, vomiting, abdominal pain or discomfort, bloating, jaundice, constipation, or changes in bowel movement.
Genitourinary: Denies changes in her menstrual cycle. No unusual discharge, itchiness, redness, or inflammation of the genital area.
Musculoskeletal: No muscle, back pain, joint pain, or stiffness
Neurological: Denies headache, dizziness, nausea, vomiting, ataxia, paresthesia of syncope.
Psychiatric: Denies any history of depression, anxiety, or mood disorders.
Skin/hair/nails: improved acne. The darkening of the skin on her neck has improved. Improved facial and body hair. Confirms a few moles on the skin.
Vital signs: Ht: 170 cm, Wt: 84 kg, BMI: 29, HR: 78, BP: 128/82, RR: 15,Temp: 99.0 F, Sp02: 99%
General: The patient appears generally healthy with no sign of distress. Alert and oriented in person, place, and time. Very cooperative and pleasant during the interview.
HEENT: Eyes: Moist conjunctiva, anicteric sclera; no lid lag; Mild retinopathy on the right eye. PERRLA bilaterally. Ears, Nose, Mouth & Throat: Clear oropharynx with moist mucous membranes. No signs of mucosal ulcerations. Full dentition with no signs of bleeding gums. Hard and soft palates were noted with no abnormalities.
Neck: Supple with no jugular vein distention. No rigidity. No masses or enlarged lymph nodes.
Chest/Lungs: Bilaterally clear to auscultation. Prolonged expiratory phase. No wheezing, rhonchi, or rales.
Heart/Peripheral Vascular: S1 and S2 noted. Systolic murmur, 2/6. Regular heart rate and rhythm. No gallop or rales were noted.
Abdomen: The patient had bowel sounds present, non-tender, non-distended, obese, soft, no CVA tenderness.
Genital/Rectal: Normal appearing female. No unusual excessive or smelly discharge. Displays mild erythematous area with slight breakdown, sacral or right buttock area.
Musculoskeletal: Full ROM for both the upper and lower extremities. No stiffness or joint pain.
Neurological: No focal neurological deficits. Full mentation and speech. Grossly intact Cranial nerves II through XII. Decreased sensation to monofilament in bilateral plantar surfaces.
Skin, Hair & Nails: Face with scattered pustules with upper lip facial hair. Posterior neck with acanthosis nigricans. No other nail or hair deformities.
Diagnostic results: Routine lab works include complete blood count (CBC), basic metabolic panel, thyroid function test, and kidney function test. Additional tests include cholesterol check, pap smear, breast, and cervical cancer screening. Imaging studies such as CT and X-rays may be done to assess the prognosis of PCOS (Sayer-Jones & Sherman, 2021).
ASSESSMENT: Based on the patient’s physical findings, her BMI is high showing that she is overweight.
- The monofilament test results also show decreased sensation in both the patient’s feet, which is a sign of peripheral neuropathy secondary to diabetes (Callaghan et al., 2018).
- Mild retinopathy was also noted on the right eye which indicates the early stages of diabetes (Nagda et al., 2021).
- Acanthosis nigricans noted on the patient skin is usually associated with systemic diseases like diabetes and obesity due to insulin resistance (Mourad et al., 2021).
- The facial hair on the upper lip may be associated with her previous diagnosis of PCOS (Sadeghi et al., 2022).
Generally, the patient’s care plan will depend on further evaluation of her overweight, diabetes, PCOS, and asthma.
Callaghan, B. C., Gao, L., Li, Y., Zhou, X., Reynolds, E., Banerjee, M., … & Ji, L. (2018). Diabetes and obesity are the main metabolic drivers of peripheral neuropathy. Annals of clinical and translational neurology, 5(4), 397-405. https://doi.org/10.1002/acn3.531
Mourad, A. I., Sigal, R. J., & Haber, R. M. (2021). Extensive pigmented abdominal plaque in a diabetic patient. JAAD Case Reports, 7, 11-13. https://doi.org/10.1016/j.jdcr.2020.07.022
Nagda, D., Mitchell, W., & Zebardast, N. (2021). The functional burden of diabetic retinopathy in the United States. Graefe’s Archive for Clinical and Experimental Ophthalmology, 1-10. https://doi.org/10.1007/s00417-021-05210-3
Sadeghi, H. M., Adeli, I., Calina, D., Docea, A. O., Mousavi, T., Daniali, M., Nikfar, S., Tsatsakis, A., & Abdollahi, M. (2022). Polycystic Ovary Syndrome: A Comprehensive Review of Pathogenesis, Management, and Drug Repurposing. International Journal of Molecular Sciences, 23(2), 583. https://doi.org/10.3390/ijms23020583
Sayer-Jones, K., & Sherman, K. A. (2021). Body image concerns in individuals diagnosed with benign gynaecological conditions: scoping review and meta-synthesis. Health Psychology and Behavioral Medicine, 9(1), 456-479. https://doi.org/10.1080/21642850.2021.1920949
Skin Comprehensive SOAP Note Template
Patient Initials: _______ Age: _______ Gender: _______
Chief Complaint (CC):
History of Present Illness (HPI):
Past Medical History (PMH):
Past Surgical History (PSH):
Significant Family History:
Review of Systems:
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.