NURS 6512 Digital Clinical Experience

Name:

Type your narrative-style documentation for each section of the assignment into the corresponding dialogue boxes below. When you are ready to submit your documentation, ‘Save As’ with this title format: “[LastName_FirstName] Shadow Health Documentation Template – Comprehensive – NURS 6512”

Comprehensive Assessment

Height: 170 cm Weight: 84 kg

BMI: 29 Blood Glucose Level: 100 Temperature: 99F

BP: 128/82 HR: 78

RR: 15

O2: 99%

Vitals

Health History

Miss Jones is a 28-year-old African American single female. She is presenting to the clinic for a pre-employment physical health exam. She is the chief and primary source of information and offers it freely and without any contradictions. Her speech is clear and coherent. She is able to engage and maintains eye contact all through the interview session.

Identifying Data

Ms. Jones is alert and oriented to time, place and person. She is seated comfortably and upright on the interview table and appears to be in no apparent distress. She is well-developed, well- nourished and her hygiene is appropriate.

General Survey

Ms. Jones is presenting to the clinic for a physical health exam required for her new employment. She states that: I came in because I’m required to have a recent physical exam for the health insurance at my new job.

Reason for Visit

Ms. Jones reports that she recently secured employment at Smith, Stevens, Stewart, Silver & Company. As such, she is required to obtain a pre-employment physical health exam prior to starting her job. Her last visit to the clinic was 4 months ago when she had sought her annual gynecological exam. During the visit, the gynecologist diagnosed her with PCOS (polycystic ovarian syndrome), for which the doctor prescribed oral contraceptives.

She reports that she is tolerating the oral contraceptives well. She has type 2 diabetes, which she has managed to control through diet, regular exercise and metformin medication. She reports having started taking the metformin medication 5 months ago. She reports no side effects associated with metformin use at the moment. She also has asthma, for which she uses Flovent inhaler for daily maintenance, and a rescue inhaler (Proventil), when needed. She reports to be in generally good health as she is taking better care of herself now as compared to the past. She is looking forward to starting her new job.

History of Present Illness

Flovent (Fluticasone propionate), 110 mcg, 2 puffs BID for asthma. Last use this morning.

Metformin 850 mg PO BID for diabetes, last use this morning. Drospirenone / ethinyl estradiol PO DQ for PCOS. Last use this morning.

Albuterol 90 mcg/ spray MDI 2 puffs Q4H prn or asthma. Last use three months ago.

Ibuprofen 600 mg PO TID prn for menstrual cramps. Last take six weeks ago.

Acetaminophen 500-1000mg PO prn for headaches.

Medications

Penicillin – symptoms include rash.

Cats and Dust – exposure to allergens results in runny nose, itchy eyes, and increased asthma symptoms.

She denies food or latex allergy.

Allergies

Asthma: Diagnosed at age two and half. Uses albuterol inhaler when around cats. Last asthma attack was six months ago. Which was resolved using the inhaler. Last hospitalized with asthma when in high school. Never been intubated.

Type 2 diabetes: Diagnosed at 24 years. Began metformin treatment 5 months ago. Reports initially having side effects that include gastrointestinal problems, which have since resolved. Uses a glucometer to take daily readings of her blood sugar level. Reports average blood sugar reading as 90.

History of hypertension, which has since normalized following her recent decision to exercise more and eat healthier meals. No history of surgeries.

OB/GYN: Menarche at 11 years. First sexual encounter at 18 years. Identifies as straight, sex with men only. No children. Never been pregnant. Last menstrual period was 2 weeks ago.

Diagnosed with polycystic ovarian syndrome 4 months ago.

Reports having regular menstrual cycle for the past four months, with moderate bleeding. Currently in a new relationship. Sexual contact not yet initiated. Never tested for HIV/AIDS. Last test for STIs was four years ago.

Medical History

Health Maintenance

Family Hx: Mother: Aged 50. Has high cholesterol and blood pressure. Father: Deceased at 58. Cause of death was car accident. Had a history of high blood pressure and cholesterol. Brother: Aged 27. Overweight. Sister: Aged 15. Healthy but asthmatic. Rarely gets asthma attacks. Maternal grandmother: Deceased at 73. Died of stroke. Had a history of high blood pressure and cholesterol. Maternal grandfather: Deceased at 80 of heart attack. Had a history of blood pressure and cholesterol issues. Paternal grandmother: Alive. Aged 82. Has high blood pressure and cholesterol. Paternal grandfather: Deceased of colon cancer. Had a history of high blood pressure and diabetes. No family history of other cancers, thyroid problems, sickle cell anemia, kidney disease or mental illness. Reports paternal uncle had a problem with alcoholism.

Social Hx: Never married. No children. Currently lives at home with the mother and younger sister. Plans to move out to a new apartment in about a month. Intends to begin her new job position at Smith, Stevens, Stewart, Silver, & Company. Has a strong support system of family members. Enjoys doing Bible studies, church community projects and volunteering. No history of tobacco use. No history of substance abuse. Uses alcohol about two to three times a month when out with friends. Reports taking no more than 3 drinks in one sitting. Typical breakfast comprises of fruit smoothie with unsweetened yoghurt. Typical lunch comprises vegetables with brown rice or sandwich on wheat bread on low-fat pita. Typical dinner is roasted vegetables and protein. Typical snack is carrot sticks or an apple. Denies coffee intake. Reports taking diet coke soda, 1 to 2 drinks per day. Participates in such exercises as walking, yoga or swimming, four to five times a week.

Family History

Reports last pap smear was 4 years ago. Last eye check-up was 3 months ago, corrective lenses recommended. Last dental exam was 5 months ago.

Immunizations: Received tetanus booster. Influenza vaccination not up to date. Never received HPV vaccine. She reports that she believes she is up to date with all childhood vaccines. Received meningococcal vaccine in college, at age 19.

Safety: Has smoke detectors installed at home. Uses sunscreen when taking a walk outdoors. Usually takes a cab after a night out. Always wears seatbelt when in an automobile.

N/A

Social History

Reports reduced stress levels. Improved sleep of 8 to 9 hours per night. Reports feeling really good these days. No stress or anxiety. She is alert and oriented to place, person and time. Well groomed. Able to converse freely and is cooperative. She is in a pleasant mood. Her speech is fluent with clear words.

Mental Health History

General: No frequent illnesses. No chills, fever, fatigue or night sweats. Reports having recently lost 10 pounds of weight due to diet changes and exercise.

Review of Systems – General

Objective

HEENT: Head: Normocephalic and atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows. No lesions, ptosis or edema. Eyes: Pink conjunctiva, white sclera, no lesions. EOM intact bilaterally. PERRLA bilaterally. No nystagmus. Right eye with mild retinopathic changes. Left fundus with sharp disc margins. No hemorrhage. Snellen: Right and left eye 20/20 with corrective lenses. Ears. Bilaterally intact and pearly gray TMS, positive reflex to light. Whispered words heard bilaterally. Nose: Non-tender frontal and maxillary sinuses on palpation. Nasal mucosa is moist and pink. Septum is midline. Mouth: Oral mucosa with no ulcerations, or lesions. Midline uvula on phonation. Intact gag reflex. Dentition with no carries or infection. Throat: Bilateral tonsils, 2+. Smooth thyroid no nodules present. No goiter. No lymphadenopathy.

Respiratory: Symmetric chest with respiration. Chest bilaterally clear on auscultation. No cough or wheeze. Chest is resonant throughout on percussion. In office spirometry: FVC – 1,78 L FEV1 – 1.549 L.

Cardiovascular: Regular heart rate. S1, S2 present without murmurs, gallops or rubs. Left and right carotids bilaterally equal with no bruits. PMI at the midclavicular line, 5th intercostal space. No heaves, thrills or lifts. Peripheral pulses are equal bilaterally. Capillary refill is less than 3 seconds in all extremities. No peripheral edema.

Abdominal: Abdomen is protuberant and symmetric. No visible masses, scars or lesions. Excessive hair growth on the pubis to umbilicus region. All quadrants with normoactive bowel sounds. Abdomen is tympanic all through. Palpation reveals no tenderness or guarding. No CVA tenderness.

Musculoskeletal: Bilateral upper and lower extremities with strength of 5/5. No swelling, masses or deformity noted. Full range of motion. No pain on movement.

Neurological: Graphesthesia and stereognosis results normal. Bilaterally normal rapid alternating movements. Cerebellar function test is normal. DTRs 2+, bilaterally equal in all extremities. Plantar surfaces with decreased nanofilament sensation.

Skin, Hair & Nails: Face with scattered pustules. Facial hair present on upper lip. Posterior neck with Acanthosis nigricans.