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

Sample Answer for NURS 6512 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment  Included After Question

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. 

A Sample Answer For the Assignment: NURS 6512 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment 

Episodic/Focused SOAP Note

 Patient Information:

Initials: J.K.L             

Age: 40 years

Sex: Female                           

Race: African American

Source: Patient

S.

CC: “I have a headache around my forehead.”

HPI: J.K.L is a 40-year-old African American female who presents with a complaint of a headache across her forehead for a week. The headache is squeezing and feels like pressure behind the eyes. It is non-radiating. The headache is constant and varies in severity ranging from 2/10 at its best to 8/10 at its worst. It is usually worse in the morning and while bending. Acetaminophen reduces the severity of the headache to 4/10 and occasionally 2/10. It is associated with fever, postnasal drip, nasal congestion, sneezing, and occasional non-productive cough. She takes Sudafed HCL 120 mg every 12 hours to obtain some relief. The symptoms have significantly impaired her concentration at work and made her feel very tired. Finally, she reports a head cold three weeks ago.

Current Medications: Pseudoephedrine 120 mg BID for nasal congestion and acetaminophen for headaches.

Allergies: She has no known food and drug allergies.

Past Medical History: During her last visit to the primary care physician 2 months ago, she was noted to be prehypertensive and was advised on lifestyle modifications. No prior hospitalization. No previous surgeries or blood transfusions.

Social History: She is married with two children both alive and well. She works as a secretary Her husband is a college teacher. She neither drinks alcohol nor smokes tobacco. She does not use marijuana or other illicit drugs. She strictly adheres to dietary advice from her nutritionist and she exercises regularly. Denies caffeine intake.

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Family History: Father alive aged 60 years and with hypertension while her mother is 58 years old alive and well. Her brother and sister are 35 and 20 years old respectively, alive and well. Her paternal grandfather died at the age of 80 years due to a heart attack while her paternal grandmother is 78 years and is hypertensive. Her maternal grandfather is 77 years with a history of type 2 diabetes and high cholesterol while her maternal grandmother died at the age of 70 years due to a stroke. No family history of malignancies, mental illness, asthma, sickle cell, or diabetes.

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

ROS:

GENERAL: Reports fatigue and occasional fever. Denies weight loss, night sweats, and chills.  

HEENT:  Reports headaches, nasal congestion, post nasal drip, and sneezing. No blurring of vision, visual loss, hearing loss, tinnitus, nose bleeds, ear pain, mouth sores, or sore throat.

SKIN:  no skin lesion or rashes. No abnormal pigmentation.

CARDIOVASCULAR: Negative for palpitations, chest pain, paroxysmal nocturnal dyspnea, and peripheral limb edema.

RESPIRATORY:  Occasional non-productive cough. No difficulty in breathing, dyspnea, or orthopnea.

GASTROINTESTINAL: Reports loss of appetite and occasional nausea and vomiting. Denies change in bowel habits, abdominal pain, or distention.

GENITOURINARY: No frequency, dysuria, nocturia, and polyuria. No vaginal itchiness or abnormal vaginal discharge.

NEUROLOGICAL: Reports headache. Denies dizziness, lightheadedness, numbness, tingling, loss of sensation, syncope, and convulsion.

MUSCULOSKELETAL: No muscle pain, joint pains, muscle weakness, or muscle swelling.

HEMATOLOGIC:  No anemia, easy bruising, or bleeding.

LYMPHATICS: Normal lymph nodes

PSYCHIATRIC:  Denies anxiety, depression, suicidal ideations, or hallucinations.

ENDOCRINOLOGIC: Denies heat or cold intolerance, polyphagia, and polydipsia.

ALLERGIES:  Reports no allergies.

O.

Physical exam:

VITAL SIGNS: BP 125/78 mmHg, HR 88 b/min, Temp 99. 8 F, RR 20 b/min, saturation 95% on room air, Height 168 cm, weight 76 Kg. Pain level 5/10

GENERAL: A middle-aged African-American female, well kempt, not in any form of respiratory distress but slight discomfort. Maintains eye contact, coherent speech, and a stable mood. Well-hydrated and nourished. No palmar or conjunctival pallor, jaundice, central or peripheral cyanosis, cervical or inguinal lymphadenopathy, and peripheral limb edema.

HEENT: Normocephalic and atraumatic head. Non-tender scalp. Bilateral eyes with pink conjunctiva and white sclera. Pupils equally and bilaterally reacting to light, no ptosis or lid edema. Normal extraocular movements. Bilateral ears present, no impaction or skin lesions, tympanic membrane pearly grey bilaterally, and positive white reflex. Both nares are present and are discharging mucus, midline nasal septum, and pink and soft nasal mucosa. Tender maxillary and frontal sinus. Moist and pink oral mucosa, no oral lesions or ulceration. Normal dentition and teeth alignment.

NECK: Soft neck. The trachea is central. Full range of motion, non-tender, no cervical lymphadenopathy, and no thyroid enlargement.

CARDIOVASCULAR: Regular heart rate. Normoactive precordium. Point of maximal impulse in the 5th intercostal space in the midclavicular line. S1 and S2 head, no murmurs, thrills, gallops, rubs, or heaves.

RESPIRATORY: Symmetrical chest that moves with respiration. No scars or skin lesions. Equal chest expansion and equal tactile fremitus bilaterally. Equal air entry, vesicular breath sounds, no wheezes, and crackles, and equal vocal fremitus in all lung zones.

NEUROLOGICAL: GCS 15/15, oriented to time, place, and person, intact short-term and long-term memory, good concentration, and a clear coherent speech. Cranial nerves 1 to 12 intact. Normotonic across all joints, normal bulk, and power 5/5 across all muscle groups in upper and lower extremities, deep tendon reflexes 2+ and equal bilaterally in upper and lower limbs. Intact monofilament sensation across all dermatomes, good bowel, and bladder function. No spinal tenderness, normal gait, coordination, graphesthesia, and stereognosis. Normal finger nose, heel to the shin, and rapid alternating movements tests.

Diagnostic results:

J.K.L appears to have an inflammatory/infectious condition. Consequently, complete blood count and inflammatory markers particularly CRP and ESR are paramount. Similarly, bacterial or fungal cultures obtained endoscopically or by direct sinus aspiration are required to identify the possible pathogen. Additionally, a skin prick test is essential to exclude allergic rhinitis. Imaging modalities principally Sinus CT and MRI are recommended to evaluate for rhinosinusitis and intraorbital or intracranial involvement.

A.

Differential Diagnoses

Acute Sinusitis- refers to the inflammation of sinuses lasting less than 4 weeks (DeBoer & Kwon, 2022). The condition is more common in females and particularly during early fall to early spring (DeBoer & Kwon, 2022). It is most commonly caused by viral infection following a common cold although bacteria and fungi are not uncommon etiologies. J.K.L presents with clinical features that are typical of acute sinusitis including fatigue, fever, headache, facial pain, and pressure worse on bending (DeBoer & Kwon, 2022). Maxillary sinuses and frontal sinuses appear to be the affected sinuses in her as evidenced by pain around the forehead and tenderness of the maxillary and frontal sinuses (DeBoer & Kwon, 2022).

Rhinitis- Refers to the inflammation of the nasal mucosa. J.K.L presents with clinical manifestations suggestive of rhinitis including sneezing, nasal congestion, postnasal drip, and rhinorrhea (Liva et al., 2021). Similarly, she reports a “head cold” three weeks ago. Rhinitis is mostly caused by an upper respiratory infection or type 1 hypersensitivity reaction (Liva et al., 2021). However, an upper respiratory tract infection is likely the cause in her case.

Cluster headache- Cluster headache is a type of primary headache that is usually unilateral retro-orbital and characterized by sharp and stabbing pain (Goadsby et al., 2018). Cluster headache may present with symptoms of lacrimation, nasal congestion, rhinorrhea, ptosis, or miosis (Goadsby et al., 2018). However, it is unlikely the diagnosis in her as cluster headache usually lasts for a brief period. Similarly, cluster headaches mostly awake the patient at night.

Migraine headache- Migraine headache is another type of primary headache that may be preceded with or without aura. It is usually pulsating and moderate to severe (Pescador Ruschel & O, 2022). It is common in young women. However, it is unlikely the diagnosis as migraines last 4 to 72 hours if untreated and are typically associated with nausea, vomiting, photophobia, and phonophobia (Pescador Ruschel & O, 2022).

Rebound headache– Commonly referred to as medication overuse headache. Rebound headache predominantly occurs in individuals with primary headaches who overuse analgesia (Micieli & Robblee, 2018). Rebound headaches are more common in females and individuals less than 50 years. Drugs precipitating this headache include barbiturates, acetaminophen, opioids, ergotamine, and triptans (Micieli & Robblee, 2018). However, this is an unlikely diagnosis in J.K.L as a diagnosis of primary headache hasn’t been established.

References

DeBoer, D. L., & Kwon, E. (2022). Acute Sinusitis. https://pubmed.ncbi.nlm.nih.gov/31613481/

Goadsby, P., Wei, D.-T., & Yuan Ong, J. (2018). Cluster headache: Epidemiology, pathophysiology, clinical features, and diagnosis. Annals of Indian Academy of Neurology21(5), 3. https://doi.org/10.4103/aian.aian_349_17

Liva, G. A., Karatzanis, A. D., & Prokopakis, E. P. (2021). Review of rhinitis: Classification, types, pathophysiology. Journal of Clinical Medicine10(14), 3183. https://doi.org/10.3390/jcm10143183

Micieli, A., & Robblee, J. (2018). Medication-overuse headache. Journal de l’Association Medicale Canadienne [Canadian Medical Association Journal]190(10), E296–E296. https://doi.org/10.1503/cmaj.171101

Pescador Ruschel, M., & O, D. J. (2022). Migraine Headache. https://pubmed.ncbi.nlm.nih.gov/32809622/

Subjective Data Collection: 50 of 50 (100.0%)

Hover To Reveal…

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

  • Found: Indicates an item that you found.
  • Available: Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Current Health Status

  • Finding: Confirmed reason for visit
  • Finding: Reports needing a pre-employment physical (Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Example Question: Can I confirm that you are here for a physical?
  • Finding: Reports no current acute health problems (Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Example Question: Do you have any current health problems?
  • Finding: Asked about last visit to a healthcare provider
  • Finding: Last visit to a healthcare provider was 4 months ago (Found) Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Example Question: When did you see a healthcare provider?
  • Finding: Reason for last visit was annual gynecological exam (Found) Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Asking Tina why she saw a healthcare provider might indicate any recent health concerns or problems. Example Question: Why did you see a healthcare provider?
  • Finding: Last general physical examination was 5 months ago when she was prescribed metformin and daily inhaler (Found) Pro Tip: Establishing a timeline for which healthcare providers Tina has seen will allow you to develop a comprehensive health history. Example Question: When was your last physical exam?
  • Finding: Asked about current prescription medications
  • Finding: Reports taking diabetes medication (Found) Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she has been taking medication for her diabetes will indicate her treatment plan and the degree to which she is following it. Example Question: Have you been taking medication for your diabetes?
  • Finding: Reports using a daily inhaler (Found) Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Asking Tina if she still has her inhaler will indicate her treatment plan and the degree to which she is following it. Example Question: Do you use a daily inhaler?
  • Finding: Reports taking prescription birth control pills (Found) Pro Tip: The medications that a patient takes indicate their health concerns or problems, health literacy, and current treatment plans. Example Question: Are you taking any form of birth control?
  • Finding: Followed up about diabetes medication
  • Finding: Medication is metformin (Found) Pro Tip: Follow up questions about Tina’s medication history will help you to understand her treatment plan and recent health history. Example Question: What is the name of your diabetes medication?
  • Finding: Started taking metformin 5 months ago (Available) Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Example Question: How long have you been taking metformin?
  • Finding: Reports that eating probiotic yogurt helps with side effects and they have abated over time (Available) Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Example Question: Have you noticed any side effects from the metformin?
  • Finding: Followed up on metformin frequency and dose
  • Finding: Reports taking metformin twice daily (Found) Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Example Question: How many times a day do you take metformin?
  • Finding: Metformin dose is 850 mg (Found) Pro Tip: Follow up questions about Tina’s medication history and timeline will help you to understand her treatment plan and recent health history. Example Question: What is the dose of your metformin?
  • Finding: Asked about asthma medication
  • Finding: Reports using Flovent inhaler twice daily (Found) Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Example Question: How often do you use your daily inhaler?
  • Finding: Has a Proventil rescue inhaler (Available) Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina if she has a rescue inhaler for her asthma will indicate her treatment plan and the degree to which she complies with it. Example Question: Do you have a rescue inhaler?
  • Finding: Last use of Proventil inhaler was three months ago (Available) Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment. Example Question: When did you last use your rescue inhaler?
  • Finding: Has used Proventil inhaler twice in the last year (Available) Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s been using her inhaler more frequently since exacerbation can indicate how she’s been treating her symptoms since exacerbation. Example Question: How often do you use your rescue inhaler?
  • Finding: Followed up about birth control prescription
  • Finding: Started taking birth control 4 months ago (Available) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina how long ago she started taking birth control establishes a timeline of her current treatment plan. Example Question: How long ago did you start taking birth control?
  • Finding: Reason for birth control was to manage PCOS symptoms (Found) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina why she started taking birth control will allow Tina to express any concerns or problems in her own words. Example Question: Why did you decide to start taking birth control?
  • Finding: Birth control type is Yaz (drospirenone and ethinyl estradiol) (Found) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Confirming the name of Tina’s birth control pill will solicit information about her health history and current treatment plan. Example Question: What type of birth control do you use?
  • Finding: Takes birth control pill daily (Found) Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: How often do you take your birth control pill?
  • Finding: Takes birth control pill at the same time every day (Found) Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: Do you take your pill at the same time every day?
  • Finding: Reports no skipped days (Available) Pro Tip: Follow up questions about Tina’s birth control prescription can help you to understand how effectively she complies with her treatment plan. Example Question: Have you missed any days of your birth control pill?
  • Finding: Asked about current non-prescription medications
  • Finding: Reports rare Advil use for cramps (Found) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes non prescription drugs will indicate her current treatment plan. Example Question: Do you take Advil?
  • Finding: Reports no OTC herbal products (Available) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes herbal products will indicate her current treatment plan. Example Question: Do you use any herbal products?
  • Finding: Reports no OTC vitamins (Available) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes vitamins will indicate her current treatment plan. Example Question: Do you take any vitamins?
  • Finding: Reports no OTC supplements (Available) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes supplements will indicate her current treatment plan. Example Question: Do you take any supplements?
  • Finding: Asked about allergies
  • Finding: Confirms allergies (Found) Pro Tip: Discerning what’s making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, allergies, or movement that may have a bearing on Tina’s breathing. Asking Tina what triggers her allergies will indicate, in part, Tina’s health literacy. Example Question: Can you confirm your allergies?
  • Finding: Reports no new allergies (Available) Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible new triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing. Example Question: Have you noticed any new allergies?
  • Finding: Followed up on seasonal allergies
  • Finding: Reports no recent seasonal allergy symptoms (Found) Pro Tip: Discerning whether anything is making Tina’s asthma worse can point to possible triggers like environmental factors, bodily positions, or movements that may have a bearing on Tina’s breathing. Example Question: Have you been having seasonal allergies?
  • Finding: Reports no current medication for allergies (Available) Pro Tip: Tina’s response to a question about managing her allergies will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: Are you taking any medication for your allergies?
  • Finding: Asked about diabetes
  • Finding: Reports managing diabetes with diet and exercise in addition to medication (Found) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: How are you managing your diabetes?
  • Finding: Asked about blood glucose monitoring
  • Finding: Reports checking blood sugar once a day (Found) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: How often do you monitor your blood glucose?
  • Finding: Checks sugar in the morning (Found) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: When do you check your blood glucose?
  • Finding: Blood sugar number is usually around 90 (Available) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: What is your average blood sugar number?
  • Finding: Reports having adequate supplies (Available) Pro Tip: Tina’s response to a question about managing her diabetes will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans. Example Question: Do you have enough supplies to monitor your blood glucose?
  • Finding: Asked about asthma symptoms
  • Finding: Reports no current asthma symptoms (Available) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Do you have any difficulty breathing?
  • Finding: Reports no recent asthma exacerbations (Found) Pro Tip: Asthma severity might change over time for a variety of reasons. Asking Tina about the recent severity of her asthma will allow her to assess her condition. Example Question: Have you had recent asthma symptoms?
  • Finding: Reports last asthma exacerbation was three months ago (Available) Pro Tip: Soliciting a shallow history of a patient’s condition can provide a baseline for comparing an attack, exacerbation, and more regular breathing. Asking about breathing problems can elicit a response about recent troubles. Example Question: When was your last asthma exacerbation?
  • Finding: Asked about headache symptoms
  • Finding: Reports no recent headache (Found) Pro Tip: Soliciting a shallow history of a patient’s condition can provide a timeline for understanding when a patient experiences a condition. Asking Tina if she’s had a headache recently will allow you to assess the frequency of her headaches. Example Question: Have you had a headache recently?
  • Finding: Asked about vision
  • Finding: Reports optometrist visit (Found) Pro Tip: Asking Tina if she has been to an eye doctor will indicate the degree to which she’s seen her vision as something that has needed medical attention. Example Question: Have you been to an eye doctor?
  • Finding: Optometrist visit 3 months ago (Available) Pro Tip: Asking Tina when she last saw an eye doctor will indicate the degree to which she’s seen her vision as something that has needed medical attention. Example Question: When did you go to the eye doctor?
  • Finding: Reports prescription eyeglasses (Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Did you get prescription eyeglasses?
  • Finding: Reports that glasses improve overall vision (Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Do you like your glasses?
  • Finding: Reports reduction in blurry vision (Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Is your vision blurry?
  • Finding: Asked about palpitations
  • Finding: Reports no current palpitations (Found) Pro Tip: Conditions, like palpitations, might change over time. Asking Tina about the frequency and duration of her palpitations recently will allow you to assess the recent severity of her condition. Example Question: Are you having heart palpitations?
  • Finding: Reports no recent palpitations (Found) Pro Tip: Conditions, like palpitations, might change over time. Asking Tina about the frequency and duration of her palpitations recently will allow you to assess the recent severity of her condition. Example Question: Have you been having heart palpitations recently?
  • Finding: Asked about hypertension treatment
  • Finding: Reports that blood pressure responded to diet and exercise changes (Found) Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina how she has been treating her hypertension will indicate her treatment plan and the degree to which she complies with it. Example Question: How have you been treating your hypertension?
  • Finding: Asked about GERD
  • Finding: Reports no recent GERD symptoms (Found) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Have you had heartburn recently?
  • Finding: Reports no current GERD symptoms (Found) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Are you having any GERD symptoms?
  • Finding: Reports no current medication for GERD (Found) Pro Tip: The medication a patient takes indicates their health literacy, treatment plan, and access to healthcare. Asking Tina if she takes medication for heartburn will indicate her current treatment plan. Example Question: Are you still taking the medication for GERD?
  • Finding: Asked about back pain
  • Finding: Reports no current back pain (Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Asking Tina about her back pain can help you to treat any symptoms she is experiencing. Example Question: Are you having back pain?
  • Finding: Reports no recent back pain (Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. Asking Tina about her back pain can help you to treat any symptoms she is experiencing. Example Question: Have you had back pain recently?
  • Finding: Asked date of last menstrual period
  • Finding: Last menstrual period was 2 weeks ago (Found) Pro Tip: Finding out when a patient’s LMP was indicates whether she might be pregnant (although this question alone can’t rule out pregnancy). Example Question: When was your last menstrual period?
  • Finding: Asked about menstrual patterns
  • Finding: Reports a period every 4 weeks (Available) Pro Tip: Quantifying the frequency of a patient’s periods is a specific piece of subjective data that can show the severity of a patient’s irregularity. Example Question: How often do you get periods?
  • Finding: Reports that period lasts 5 days (Available) Pro Tip: Quantifying the number of days a period lasts will help you understand what is typical for the patient, and also can indicate related risks for health problems such as anemia. Example Question: How long do your periods last?
  • Finding: Reports some cramping (Found) Pro Tip: Asking a patient for her subjective report on the heaviness of her cramps will help you understand her feelings about her menstrual symptoms. Example Question: Do you still have menstrual cramps?
  • Finding: Reports a medium flow (Available) Pro Tip: Asking about the heaviness of a patient’s periods helps you understand what is typical for that particular patient, and can also indicate related risks for health problems such as anemia. Example Question: Do you still have a heavy menstrual flow?
  • Finding: Asked about weight changes
  • Finding: Reports recent weight loss (Found) Pro Tip: Weight changes can be indicative of underlying health problems or an unhealthy lifestyle. Asking Tina if she’s lost weight might indicate recent changes in health. Example Question: Have you lost weight?
  • Finding: Reports weight loss of about 10 pounds (Available) Pro Tip: Determining the exact amount of weight loss can indicate whether it’s within expected ranges, or extreme, which may indicate an underlying health problem. Example Question: How much weight did you lose?
  • Finding: Reports that weight loss was result of change in diet and increased exercise (Found) Pro Tip: Unintentional weight loss can be a sign of underlying medical conditions or a reflection of unhealthy lifestyle choices. Asking your patient about this can inform your care plan. Example Question: Was the weight loss intentional?

Psychosocial History

  • Finding: Asked about diet
  • Finding: Typical breakfast is fruit smoothie with probiotic yogurt or egg on wheat toast with probiotic yogurt (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for breakfast will illustrate her recent dietary patterns. Example Question: What is your typical breakfast?
  • Finding: Typical lunch is dinner leftovers or tuna or chicken sandwich on wheat bread (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for lunch will illustrate her recent dietary patterns. Example Question: What is your typical lunch?
  • Finding: Typical dinner is vegetables with a protein and brown rice or quinoa (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for dinner will illustrate her recent dietary patterns. Example Question: What is your typical dinner?
  • Finding: Typical snack is carrot sticks or an apple (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what she typically has for a snack will illustrate her recent dietary patterns. Example Question: What is a typical snack?
  • Finding: Asked about caffeine intake
  • Finding: Reports limiting caffeine since heart and sleep problems (Available) Pro Tip: Asking Tina if she has limited her caffeine intake will indicate her current nutrition habits and whether or not she sees her caffeine intake as a concern. Example Question: Have you limited your caffeine intake?
  • Finding: Reports no coffee drinking (Available) Pro Tip: Finding out specifically if a patient drinks coffee helps you understand what constitutes her typical caffeine intake. Example Question: Do you drink coffee?
  • Finding: Reports only caffeine is diet Coke (Found) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina if she drinks soda will illustrate her recent dietary patterns. Example Question: What caffeinated drinks do you like?
  • Finding: Reports drinking 2 diet Cokes per day (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many diet cokes she drinks a day will illustrate her recent dietary patterns. Example Question: How much soda do you drink a day?
  • Finding: Asked about alcohol intake
  • Finding: Drinks 2-3 nights per month (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many drinks she typically has in a week will illustrate her recent dietary patterns. Example Question: How many nights a week do you drink?
  • Finding: Has 2 or 3 drinks when out with friends (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina how many alcoholic drinks she typically has at a time will illustrate her recent dietary patterns. Example Question: How many drinks do you have in a sitting?
  • Finding: Orders single drinks (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what size her alcoholic drinks are will illustrate her recent dietary patterns. Example Question: What size are your alcoholic drinks?
  • Finding: Usually orders rum and diet Coke (Available) Pro Tip: Because diet is such a large part of the GI system, asking Tina questions about her diet can be particularly informative. Asking Tina what alcohol she usually drinks will illustrate her recent dietary patterns. Example Question: What kind of alcohol do you usually drink?
  • Finding: Asked about exercise
  • Finding: Reports mild to moderate exercise (Found) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how much exercise she gets can help you to assess her current levels of health and nutrition. Example Question: How much exercise do you get?
  • Finding: Reports walking four or five times a week (Found) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how many days a week she exercises can help you to assess her current levels of health and nutrition. Example Question: How many days a week do you exercise?
  • Finding: Reports that a typical walk is thirty or forty minutes (Found) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how long her walks are can help you to assess her current levels of health and nutrition. Example Question: How long are your walks?
  • Finding: Reports weekly swimming at YMCA (Found) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina what exercise she does can help you to assess her current levels of health and nutrition. Example Question: What exercise do you do?
  • Finding: Reports no asthma exacerbation during exercise (Available) Pro Tip: Exercise, in addition to diet, is a key part of physical and mental health. Asking Tina how her breathing is when she exercises can help you to assess her current levels of health and nutrition. Example Question: How is your breathing when you exercise?
  • Finding: Asked about relationship status and current sexual activity
  • Finding: Reports no new sexual partners (Found) Pro Tip: Asking Tina if she has any new sexual partners will help you to assess whether or not she engages in high-risk sexual practices. Example Question: Have you had any new sexual partners?
  • Finding: Reports new month-old relationship (Found) Pro Tip: Asking about Tina’s relationship status will help you to understand her current sexual activity and practices. Example Question: Are you currently in a relationship?
  • Finding: Plans to use condoms if sexually active in the future (Available) Pro Tip: Asking Tina whether or not she uses condoms will help you to assess whether or not she engages in high-risk sexual practices. Example Question: Will you use condoms if you are sexually active?

Social Determinants of Health

  • Finding: Asked about education
  • Finding: Reports graduated with accounting degree (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Did you graduate from college?

Finding: Asked about work

  • Finding: Reports being hired at Smith, Stevens, Stewart, Silver & Company (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Where do you work?
  • Finding: Reports job title is Accounting Clerk (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: What is your job title?
  • Finding: Reports will start work in 2 weeks (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: When do you start working?

Finding: Asked about living situation

  • Finding: Reports currently living at home with mom and sister (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: What is your current living situation?
  • Finding: Reports moving into her own apartment near work in 1 month (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: What are your housing plans?

Finding: Asked about support system

  • Finding: Reports strong friendships (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Do you have close friends?
  • Finding: Reports strong familial relationships (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Are you close with family?
  • Finding: Reports church remains a strong support system (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Are you still involved with your church?

Mental Health

  • Finding: Asked about stress
  • Finding: Reports feeling less stress after graduation and passing CPA exam (Found) Pro Tip: Follow-up questions about possible causes or aggravating factors will elicit essential information about a patient’s complaint. When Tina says she is stressed out about the future, it is important to follow up in order to determine if her situation could be contributing to, or causing, her feelings of anxiety. Example Question: Are you feeling stressed?
  • Finding: Reports improved ability to cope with stress (Found) Pro Tip: A patient’s experience with and ability to handle stress is important to your understanding of her stress history as well as its current severity. Asking about coping strategies will give you an understanding of Tina’s support system and usual outlets for dealing with stress. Example Question: How do you cope with stress?

Finding: Asked about indicators of depression

  • Finding: Reports no depression (Found) Pro Tip: While a patient with depression does not always know she has it, it is important to ask. If Tina had depression, it could be contributing to her sleep disturbance, or her sleep disturbance could be causing or aggravating or depression. Example Question: Are you feeling depressed?
  • Finding: Reports feeling positive about upcoming life changes (Found) Pro Tip: A broad question asking how a patient feels about her life can help you to assess a patient’s level of mental health, anxiety, or depression. Example Question: How do you feel about your life?

Finding: Asked about anxiety

  • Finding: Reports anxiety improved with relief of stressors and passing of time (Found) Pro Tip: Anxiety is a common cause of sleep disturbance, and lack of sleep can also contribute to anxiety issues. If Tina had a history of anxiety, it could be causing or aggravating her current sleep disturbance. Example Question: Are you feeling anxious?
  • Finding: Reports coping well with upcoming life changes (Found) Pro Tip: A patient’s strategies for coping with stress can indicate her experience with and ability to handle stress. An open question about Tina’s usual stress coping strategies will help you assess how experienced she is with stress and how capable she is of coping with it. Example Question: How are you coping with your life changes?

Finding: Asked about sleep

  • Finding: Reports no current difficulties falling asleep (Found) Pro Tip: Knowledge of the character of a complaint will aid your diagnosis. In Tina’s case, her sleep quality is important in determining what kind of sleep disturbances she is suffering, as well as possible effects it may have on her daily life. Example Question: Do you still have trouble falling asleep?
  • Finding: Reports sleeping 8 or 9 hours a night (Available) Pro Tip: Asking for the average number of hours of sleep a patient gets in one night will elicit the specific information you need to assess the severity of her sleep disorder. In Tina’s case, she is getting less sleep per night than is considered healthy. Example Question: How many hours do you sleep a night?

Review of Systems

  • Finding: Asked general indicators of health
  • Finding: Reports no recent or frequent illness (Available) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Have you been sick recently?
  • Finding: Reports no fatigue (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fatigue, details the way her individual symptoms and pain manifest. Example Question: Are you fatigued?
  • Finding: Reports no fever (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like fever, details the way her individual symptoms and pain manifest. Example Question: Have you had fevers?
  • Finding: Reports no chills (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like getting chills, details the way her individual symptoms and pain manifest. Example Question: Have you had chills?
  • Finding: Reports no night sweats (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her injury, like night sweats, details the way her individual symptoms and pain manifest. Example Question: Have you had night sweats?
  • Finding: Asked about review of systems for head
  • Finding: Reports no current or recent head problems (Found) Pro Tip: Assessing how a patient feels in the current moment can allow you to juxtapose their chief complaint alongside symptoms they experience. Asking Tina if she currently has a headache solicits information about how she is feeling now. Example Question: Do you have a headache?
  • Finding: Reports no head injury (Available) Pro Tip: People who’ve experienced head injuries are at increased risk for sinusitis. Asking Tina whether she’s ever had a head injury solicits health history information that might explain the cause of her symptoms. Example Question: Have you had any head injuries?
  • Finding: Asked about review of systems for ears
  • Finding: Reports no general ear problems (Found) Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Example Question: Have you had ear problems?
  • Finding: Reports no change in hearing (Available) Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Example Question: Has your hearing changed?
  • Finding: Reports no ear pain (Found) Pro Tip: Ear pain can suggest an ear infection, during which the middle of the ear becomes clogged with fluid and mucous, which can affect hearing. Asking Tina if she has ear pain might indicate a possible ear infection and a reason for changes in her hearing. Example Question: Have you had ear pain?
  • Finding: Reports no ear discharge (Available) Pro Tip: Ear discharge is the leakage of blood, pus, or wax from the ear and can be the result of a ruptured eardrum, eczema, or swimmer’s ear. Asking whether she’s noticed ear discharge could indicate whether she has a ruptured eardrum. Example Question: Have you had ear discharge?
  • Finding: Asked about review of systems for eyes
  • Finding: Reports no eye pain (Found) Pro Tip: Sinusitis can create pressure behind the eyes, causing eye pain. Asking Tina whether she is experiencing eye pain solicits information about possible symptoms. Example Question: Have you had eye pain?
  • Finding: Reports no itchy eyes (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had itchy eyes?
  • Finding: Reports no eye redness (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had red eyes?
  • Finding: Reports no dry eyes (Available) Pro Tip: Dry eyes occur when the eyes do not produce enough tears to lubricate them. Asking Tina if she has dry eyes solicits information about one particular symptom. Example Question: Have you had dry eyes?
  • Finding: Asked about review of systems for nose
  • Finding: Reports no general nose problems (Found) Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems. Example Question: Have you had nose problems?
  • Finding: Reports no change in sense of smell (Available) Pro Tip: Changes in sense of smell could be a symptom of acute sinusitis. Asking Tina if she’s had any changes in her sense of smell indicates whether she might be suffering from acute sinusitis. Example Question: Has your sense of smell changed?
  • Finding: Reports no sneezing (Available) Pro Tip: Infected sinuses can manifest as nose problems. Asking Tina about her nasal symptoms solicits information about her sinuses and possible sinus problems. Example Question: Have you been sneezing?
  • Finding: Reports no nosebleeds (Available) Pro Tip: Nosebleeds are often caused by sinusitis. Asking Tina if she ever gets nosebleeds solicits information about her medical history. Example Question: Have you had nosebleeds?
  • Finding: Reports no sinus pain (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had sinus pain?
  • Finding: Reports no sinus pressure (Available) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had sinus pressure?
  • Finding: Reports no runny nose (Found) Pro Tip: Follow-up questions will enable Tina to more fully and specifically describe her condition, experience, or symptoms. Example Question: Have you had a runny nose?
  • Finding: Asked about review of systems for mouth and jaw
  • Finding: Reports no current dental problems (Available) Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she’s had any dental problems might indicate a problem area that has caused infection. Example Question: Have you had any recent dental problems?
  • Finding: Reports last dental visit was 5 months ago (Available) Pro Tip: Seeing a dentist regularly can assure that among other things, tooth infections, which can cause sinusitis, do not go untreated. Asking Tina when she last saw a dentist will reveal her health literacy and indicate whether or not her mouth is a problem area. Example Question: When did you last see a dentist?
  • Finding: Reports no general mouth problems (Found) Pro Tip: Broad, open questions will allow Tina to describe, in her own words, the specific pain and discomfort that she is experiencing. Example Question: Do you have any mouth problems?
  • Finding: Reports no change in sense of taste (Available) Pro Tip: Sinusitis can result in decreased smell or taste. Asking if Tina’s sense of taste has changed lately might indicate a sign of sinusitis. Example Question: Has your sense of taste changed?
  • Finding: Reports no dry mouth (Available) Pro Tip: Sinusitis can result in dry mouth. Asking if Tina’s recently had dry mouth might indicate a sign of sinusitis. Example Question: Have you had dry mouth?
  • Finding: Reports no mouth pain (Found) Pro Tip: In some cases, infection can spread to a cheekbone through an infected tooth. Asking Tina if she’s had mouth pain might indicate a problem area that has caused infection. Example Question: Have you had mouth pain?
  • Finding: Reports no mouth sores (Available) Pro Tip: In some cases, infection can spread to a cheekbone through an infection in the mouth. Asking Tina if she has any mouth sores might indicate a problem area that has caused infection. Example Question: Have you had mouth sores?
  • Finding: Reports no gum problems (Available) Pro Tip: If left untreated, gum problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her gums solicits information about possible causes of her symptoms. Example Question: Have you had gum problems?
  • Finding: Reports no tongue problems (Available) Pro Tip: If left untreated, tongue problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her tongue solicits information about possible causes of her symptoms. Example Question: Have you had tongue problems?
  • Finding: Reports no jaw problems (Available) Pro Tip: If left untreated, jaw problems, like abscesses, can result in sinusitis. Asking Tina if she has problems with her jaw solicits information about possible causes of her symptoms. Example Question: Have you had jaw problems?
  • Finding: Asked about review of systems for neck and throat
  • Finding: Reports no difficulty swallowing (Available) Pro Tip: Difficulty swallowing can indicate sinusitis. Asking Tina if she’s had difficulty swallowing might suggest sinus troubles that she’s experiencing. Example Question: Have you had difficulty swallowing?
  • Finding: Reports no sore throat (Available) Pro Tip: A sore throat can indicate sinusitis. Asking Tina if she’s had a sore throat might suggest sinus troubles that she’s experiencing. Example Question: Have you had a sore throat?
  • Finding: Reports no history of throat problems (Available) Pro Tip: Throat problems are often linked to sinusitis. Asking Tina if she has a history of throat problems will illustrate her medical history in relation to similar concerns. Example Question: Do you have a history of throat problems?
  • Finding: Reports no voice changes (Available) Pro Tip: Sinusitis can often lead to tonsil problems and voice changes. Asking Tina if she has noticed any changes to her voice would indicate whether her symptoms might be caused by sinus problems. Example Question: Have you had voice changes?
  • Finding: Reports no general neck problems (Found) Pro Tip: Neck pain, soreness, or soft tissue damage might result in sinus pain. Asking Tina if she has neck pain is soliciting information about a possible cause of her symptoms. Example Question: Have you had neck pain?
  • Finding: Reports no history of lymph node problems (Found) Pro Tip: Swollen lymph nodes may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her lymph nodes will solicit a history of her condition. Example Question: How are your lymph nodes?
  • Finding: Reports no swollen glands (Available) Pro Tip: Swollen glands may appear in the neck when an infection is present. Asking Tina whether she has had any problems with her glands will solicit a history of her condition. Example Question: Do you have any swollen glands?
  • Finding: Asked about review of systems for respiratory
  • Finding: Reports no current breathing problems (Found) Pro Tip: Asking about how Tina is recently breathing can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns or conditions. Example Question: Have you had breathing problems?
  • Finding: Reports no wheezing (Available) Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she’s been wheezing illustrates how her asthma is presenting. Example Question: Have you been wheezing?
  • Finding: Reports no chest tightness (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like chest tightness, details the way her individual symptoms and pain manifest. Example Question: Have you had chest tightness?
  • Finding: Reports no pain while breathing (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like pain when breathing, details the way her individual symptoms and pain manifest. Example Question: Does it hurt when you breathe?
  • Finding: Reports no coughing (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like coughing, details the way her individual symptoms and pain manifest. Example Question: Have you been coughing?
  • Finding: Asked about review of systems for cardiovascular
  • Finding: Reports no palpitations (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina if she’s had palpitations specifies the way her individual symptoms manifest. Example Question: Have you had palpitations?
  • Finding: Reports no irregular heartbeat (Found) Pro Tip: Soliciting a shallow history of a patient’s condition can provide a baseline for comparing a current condition, concerns, and medical history. Example Question: Has your heartbeat been irregular?
  • Finding: Reports no easy bruising (Available) Pro Tip: Bleeding or bruising easily means that the capillaries under the skin break easily and often and can be indicative of a severe blood disorder. Asking Tina whether she has been bruising easily allows you to assess other conditions that might be affecting her chief complaint. Example Question: Have you noticed bruising more than usual?
  • Finding: Reports no edema (Available) Pro Tip: When the heart weakens and pumps blood less effective, the resulting fluid that accumulates can lead to edema. Asking Tina whether she’s experienced edema allows you to assess if her heart is pumping less effectively. Example Question: Have you noticed any swelling in your legs?
  • Finding: Reports no circulation problems (Available) Pro Tip: Poor circulation is the result of other diseases like obesity, diabetes, or cardiac conditions. Asking Tina whether she’s experienced poor circulation indicates whether she might suffer from underlying cardiac concerns. Example Question: Do you have circulation problems?
  • Finding: Asked review of systems for gastrointestinal
  • Finding: Reports no nausea (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like nausea, details the way her individual symptoms and pain manifest. Example Question: Have you had nausea?
  • Finding: Reports no vomiting (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like vomiting, details the way her individual symptoms and pain manifest. Example Question: Have you been vomiting?
  • Finding: Reports no stomach pain (Found) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like stomach pain, details the way her individual symptoms and pain manifest. Example Question: Does your stomach hurt?
  • Finding: Reports no constipation (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like constipation, details the way her individual symptoms and pain manifest. Example Question: Do you have constipation?
  • Finding: Reports no diarrhea (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like diarrhea, details the way her individual symptoms and pain manifest. Example Question: Do you have diarrhea?
  • Finding: Reports no flatulence (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like flatulence, details the way her individual symptoms and pain manifest. Example Question: Do you have flatulence?
  • Finding: Asked review of systems for genitourinary
  • Finding: Reports no dysuria (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if it is painful when she urinates can help you to determine the cause of Tina’s symptoms. Example Question: Does it hurt when you urinate?
  • Finding: Reports reduction in nocturia (Found) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has to wake up to urinate can help you to determine the cause of Tina’s symptoms. Example Question: Do you wake up at night to urinate?
  • Finding: Reports no polyuria (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if she has been urinating more than usual can help you to determine the cause of Tina’s symptoms. Example Question: Do you urinate frequently?
  • Finding: Reports no blood in urine (Available) Pro Tip: Bladder dysfunction can indicate a GI problem. Asking Tina if her urine is ever red can help you to determine the cause of Tina’s symptoms. Example Question: Do you ever notice blood in your urine?
  • Finding: Reports no flank pain (Available) Pro Tip: Determining where Tina’s pain is occurring will allow you to most effectively treat her symptoms. Asking Tina if she has flank pain will help you to determine precisely where her pain is located. Example Question: Do you have flank pain?
  • Finding: Reports no vaginal itching or irritation (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like vaginal burning, details the way her individual symptoms and pain manifest. Example Question: Do you experience vaginal burning?
  • Finding: Reports normal vaginal discharge (Available) Pro Tip: Symptoms often vary from patient to patient. Asking Tina about the symptoms she is experiencing with her pain, like vaginal discharge, details the way her individual symptoms and pain manifest. Example Question: What is your vaginal discharge like?
  • Finding: Asked review of systems for breasts
  • Finding: Reports no general breast problems (Found) Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s had problems with her breasts will help you to assess whether she is at risk for breast cancer. Example Question: Do you have any problems with your breasts?
  • Finding: Reports no breast lumps (Available) Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s noticed any lumps in her breasts will help you to assess whether she is at risk for breast cancer. Example Question: Have you noticed any lumps in your breasts?
  • Finding: Reports no breast pain (Found) Pro Tip: Checking breasts for lumps is important in monitoring for signs of breast cancer. Asking Tina if she’s had any pain in her breasts will help you to assess whether she is at risk for breast cancer. Example Question: Have you felt pain in your breasts?
  • Finding: Asked review of systems for musculoskeletal
  • Finding: Reports no muscle pain (Available) Pro Tip: The most common causes of muscle pain are strain, overuse, illness, or infection. Asking Tina if she has any muscle pain allows her to describe any pain or symptoms that she is experiencing. Example Question: Do you have muscle pain?
  • Finding: Reports no joint pain (Available) Pro Tip: Joint pain may suggest a major underlying health concern. Asking Tina if she’s experiencing joint pain will allow you to reach a differential diagnosis. Example Question: Do you have joint pain?
  • Finding: Reports no muscle weakness (Available) Pro Tip: Muscle weakness may suggest a major underlying health concern. Asking Tina if she’s experiencing muscle weakness will allow you to reach a differential diagnosis. Example Question: Do you have muscle weakness?
  • Finding: Reports no muscle swelling (Available) Pro Tip: Muscle swelling may suggest a major underlying health concern. Asking Tina if she’s experiencing muscle swelling will allow you to reach a differential diagnosis. Example Question: Do you have muscle swelling?
  • Finding: Asked review of systems for neurological
  • Finding: Reports no dizziness or lightheadedness (Found) Pro Tip: Asking Tina if she’s felt dizzy might indicate whether she is experiencing symptoms of a traumatic brain injury. Example Question: Do you get dizzy?
  • Finding: Reports no vision disturbance (Available) Pro Tip: People with traumatic brain injuries commonly report seeing spots. Asking Tina whether she’s noticed any spots can indicate that she suffered a traumatic brain injury during her accident. Example Question: Do you ever see spots?
  • Finding: Reports no numbness or tingling (Available) Pro Tip: Tingling sensations after a car accident can suggest a herniated disc. Asking Tina whether she’s experiencing tingling sensations might indicate additional musculoskeletal damage caused by the accident. Example Question: Do you ever get tingling?
  • Finding: Reports no loss of coordination (Available) Pro Tip: People with traumatic brain injuries commonly report loss of coordination. Asking Tina whether she’s lost coordination can indicate that she suffered a traumatic brain injury during her accident. Example Question: Do you notice being more clumsy than usual?
  • Finding: Reports no loss of sensation (Available) Pro Tip: Diabetic patients often struggle with neuropathy, especially in the arms, legs, hands, and feet. Patients should be asked about their sensations. Example Question: Do you have a loss of sensation anywhere?
  • Finding: Reports no seizures (Available) Pro Tip: A car accident can result in a traumatic brain injury (TBI). Asking Tina if she’s had seizures might indicate whether or not she is experiencing symptoms of a traumatic brain injury. Example Question: Have you ever had a seizure?
  • Finding: Reports no problems with balance (Available) Pro Tip: People with traumatic brain injuries commonly report loss of coordination. Asking Tina whether she’s lost coordination can indicate that she suffered a traumatic brain injury during her accident. Example Question: Do you lose your balance often?
  • Finding: Asked review of systems for skin, hair and nails
  • Finding: Reports no rashes (Available) Pro Tip: Chronic or severe skin rashes might require a patient to be seen by a dermatologist. Asking Tina if she has skin rashes will illustrate a skin condition that she might be concerned about. Example Question: Do you get skin rashes?
  • Finding: Reports using sunscreen while exercising outdoors (Available) Pro Tip: Wearing sunscreen is important in protecting the skin from the sun’s powerful UV rays. Asking Tina when she wears sunscreen solicits information about the ways in which she cares for her skin. Example Question: When do you wear sunscreen?
  • Finding: Reports no recent slow-healing wounds (Available) Pro Tip: Slow healing wounds might suggest an infection that requires medical treatment. Asking Tina if she has any wounds that healed slowly solicits information about her health history. Example Question: Have you had any wounds that healed slowly?
  • Finding: Reports improving acne (Found) Pro Tip: Adult acne can suggest stress or changes in hormone levels. Asking Tina if she still has acne solicits information about her overall health. Example Question: Do you still have acne?
  • Finding: Reports some male-pattern hair growth (Found) Pro Tip: Increases in body hair can suggest changes in hormone levels. Asking Tina if she’s experienced an increase in body hair is good practice in soliciting a health history. Example Question: Do you have an increase in body hair?
  • Finding: Reports no changes in moles (Available) Pro Tip: Monitoring moles is key in preventing cancerous growths. Asking Tina if her moles have changed will indicate whether any of her moles are health concerns. Example Question: Have your moles changed?
  • Finding: Reports no sores (Available) Pro Tip: Sores are a skin problem that leave the body vulnerable to infection. Asking Tina if she has any sores will help you to assess her general health. Example Question: Do you have any sores?
  • Finding: Reports no dandruff (Available) Pro Tip: Dandruff is a chronic scalp condition characterized by flaking skin. Asking Tina whether she has dandruff will help in your assessment of her skin conditions. Example Question: Do you have dandruff?
  • Finding: Reports no nail fungus (Available) Pro Tip: Nail fungus might cause discoloration and disfigurement of the nails. Asking Tina if she has nail fungus is important in assessing the health of her nails. Example Question: Do you have nail fungus?
  • Finding: Reports no dry skin (Available) Pro Tip: Chronic or severe dry skin might require a patient to be seen by a dermatologist. Asking Tina if she has dry skin will illustrate a skin condition that she might be concerned about. Example Question: Do you have dry skin?

A Sample Answer For the Assignment: NURS 6512 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment 

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

Patient Information:

CT, 32 years old

S.

CC (chief complaint) “I feel tired and my hair is falling off”

HPI: Chantal is a 32-year-old female who visited the facility with complaints of feeling tired and her hair falling out. She reports that she has gained 30 pounds of weight in the past year. Chantal also reports that her appetite has significantly decreased. She denied accompanying symptoms such as nausea, vomiting, and pain. She reports that engaging in active physical activities worsens the fatigue that she is experiencing.

Current Medications: Chantal denies any current use of medications

Allergies: Chantal reports seasonal allergies. She denies food or drug allergies.

PMHx: Chantal’s immunization record is up-to-date. Her last tetanus vaccination was 10/10/23. She has no history of hospitalization or chronic illnesses. She also denied any history of surgeries.

Soc Hx: Chantal is married with no children. She works as a teacher. She lives with her husband in a rented apartment. She does not smoke or abuse any drugs. She loves spending her leisure time with her husband and family. She wears a seat belt while driving. Their home has smoke detectors. She engages in regular exercises at least four times weekly.

Fam Hx: Chantal’s mother was diagnosed with cervical cancer a year ago and has been on treatment. Her father is an alcoholic and has hypertension and asthma. Her paternal grandfather died of heart disease. Her paternal grandmother died of major depression. Her maternal grandmother died of diabetes mellitus type 2.

ROS:

GENERAL:  Chantal was dressed appropriately for the occasion. She was alert and oriented to herself, time, and events. She reported fatigue and weight gain. She denied fever, pain, or chills.

HEENT:  Eyes: Chantal denies blurred vision, eye drainage, pain, or double vision. Ears, Nose, Throat:  Chantal denies ear pain, decreased hearing, ringing, or ear fullness. She denies sneezing, nasal drainage, or septum deviation. She denies a sore throat, difficulty swallowing, or postnasal drainage.

SKIN:  Chantal reports her hair falling out. She denies abnormal changes in her skin color, itching, or skin rashes. CARDIOVASCULAR: Chantal denies palpitation, peripheral edema, palpitations, or chest pain and discomfort.

RESPIRATORY:  Chantal denies wheezing, cough, dyspnea, cyanosis, or sputum. GASTROINTESTINAL:  Chantal reports decreased appetite. She denies nausea, vomiting, diarrhea, heartburn, abdominal pain, or bleeding.

GENITOURINARY:  Chantal reports that her last menstrual period was 24/12/2023. She denies urgency, frequency, or dysuria.

NEUROLOGICAL:  Chantal denies loss of balance, difficulty with movement, tingling sensations, syncope, dizziness, or paralysis. Her bowel and bladder movements are normal.

MUSCULOSKELETAL: Chantal denies fractures, joint pains, muscle pain, stiffness, and back pains.

HEMATOLOGIC:  Chantal denies easy bruising and a history of excessive bleeding and bleeding disorders

LYMPHATICS:  Chantal denies any enlarged notes or a history of splenectomy. PSYCHIATRIC:  Chantal has no history of any mental health disorders

ENDOCRINOLOGIC:  Chantal reports weight gain, feeling cold, fatigue, and disturbance in her sleeping pattern. She denies polydipsia or polydipsia.

ALLERGIES:  Chantal reports a history of her hair falling out.

O.

Physical exam:

Vital signs: T 37.3, RR 20, BP 102/62, P 70, and SPO2 96%, Weight 276 lbs Height 5’5

Skin: Scarce hair distribution, dry and cold skin to touch

Diagnostic results: A complete blood count and thyroid function tests were ordered. This was to rule out infections and abnormal thyroid hormones as the cause of Chantal’s problems.

A.

Differential Diagnoses

Hypothyroidism: Hypothyroidism is Chantal’s primary diagnosis. Hypothyroidism is a thyroid disorder that develops from low thyroid hormone levels. Hypothyroidism develops due to central or secondary causes. Central hypothyroidism arises from inadequate stimulation of the thyroid gland by the central nervous system while secondary hypothyroidism develops due to other causes such as thyroid surgery. Patients suffering from hypothyroidism experience symptoms such as cold intolerance, skin changes, puffiness, decreased sweating, gastrointestinal disturbances, hair loss, voice changes, fatigue, sleep disturbances, and weight gain. They also experience galactorrhea and menstrual cycle abnormalities (Patil et al., 2023; Wilson et al., 2021). Chantal has symptoms seen in hypothyroidism, hence, her primary diagnosis.

Major depression: Major depression is the secondary diagnosis that should be considered for Chantal. Major depression is a mental health disorder characterized by a severely depressed mood on most days, throughout the day. Patients also report additional symptoms such as fatigue, feelings of worthlessness and guilt, and changes in appetite, sleep patterns, and weight. Patients are also easily distracted, and experience difficulties concentrating and making decisions, suicidal thoughts, plans, and attempts (Bode et al., 2021). Chantal has some symptoms of major depression such as weight and appetite changes and sleep disturbances. However, she does not have a depressed mood, hence; major depression is the secondary diagnosis.

Sleep apnea: Sleep apnea is the other differential diagnosis that should be considered for Chantal. Sleep apnea is a sleep disorder characterized by problems with sleeping patterns. The affected patients experience repeated episodes of interrupted sleep due to the stopping of the breathing process. Patients experience symptoms such as snoring loudly, feeling tired after a night’s sleep, gasping for air during sleep, morning headaches, and irritability (Gottlieb & Punjabi, 2020; Malhotra et al., 2021). Chantal has sleep disturbance problems, which do not qualify her for sleep apnea, hence, it being a secondary diagnosis.

Chronic fatigue syndrome: Chronic fatigue syndrome is the other differential that should be considered for Chantal. Chronic fatigue syndrome is a condition associated with symptoms such as profound tiredness despite bed rest. The symptoms worsen when patients engage in any activity that requires intensive mental or physical activity. Additional symptoms associated with the syndrome include light sensitivity, headaches; tender lymph nodes, insomnia, and difficulties with concentration (Deumer et al., 2021; Sandler & Lloyd, 2020). Despite Chantal reporting fatigue, she does not suffer from chronic fatigue syndrome because of the presence of other symptoms such as weight gain and cold intolerance.  

Addison’s disease: Addison’s disease is the other differential diagnosis that should be considered for Chantal. Addison’s disease develops from insufficient production of steroid hormones by the adrenal gland. Patients experience symptoms that include skin hyperpigmentation, low blood pressure, nausea, vomiting, diarrhea, constipation, and abdominal pain, weight loss. Patients might also experience fever, convulsions, severe gastrointestinal disturbances, and hypoglycemia during adrenal crises (Husebye et al., 2021; Saverino & Falorni, 2020). Addison’s disease is Chantal’s least likely diagnosis because of weight gain, cold intolerance, and lack of skin hyperpigmentation.

P.  

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

References

Bode, H., Ivens, B., Bschor, T., Schwarzer, G., Henssler, J., & Baethge, C. (2021). Association of Hypothyroidism and Clinical Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry, 78(12), 1375–1383. https://doi.org/10.1001/jamapsychiatry.2021.2506

Deumer, U.-S., Varesi, A., Floris, V., Savioli, G., Mantovani, E., López-Carrasco, P., Rosati, G. M., Prasad, S., & Ricevuti, G. (2021). Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): An Overview. Journal of Clinical Medicine, 10(20), Article 20. https://doi.org/10.3390/jcm10204786

Gottlieb, D. J., & Punjabi, N. M. (2020). Diagnosis and Management of Obstructive Sleep Apnea: A Review. JAMA, 323(14), 1389–1400. https://doi.org/10.1001/jama.2020.3514

Husebye, E. S., Pearce, S. H., Krone, N. P., & Kämpe, O. (2021). Adrenal insufficiency. The Lancet, 397(10274), 613–629. https://doi.org/10.1016/S0140-6736(21)00136-7

Malhotra, A., Ayappa, I., Ayas, N., Collop, N., Kirsch, D., Mcardle, N., Mehra, R., Pack, A. I., Punjabi, N., White, D. P., Gottlieb, D. J., & for SRS Task Force. (2021). Metrics of sleep apnea severity: Beyond the apnea-hypopnea index. Sleep, 44(7), zsab030. https://doi.org/10.1093/sleep/zsab030

Patil, N., Rehman, A., & Jialal, I. (2023). Hypothyroidism. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519536/

Sandler, C. X., & Lloyd, A. R. (2020). Chronic fatigue syndrome: Progress and possibilities. Medical Journal of Australia, 212(9), 428–433. https://doi.org/10.5694/mja2.50553

Saverino, S., & Falorni, A. (2020). Autoimmune Addison’s disease. Best Practice & Research Clinical Endocrinology & Metabolism, 34(1), 101379. https://doi.org/10.1016/j.beem.2020.101379

Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: Diagnosis and Treatment. American Family Physician, 103(10), 605–613.

A Sample Answer For the Assignment: NURS 6512 Digital Clinical Experience Comprehensive (Head-to-Toe) Physical Assessment 

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

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.

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