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NURS 6512 DCE: Tina Jones Comprehensive Assessment Final Paper

Tina Jones Comprehensive Assessment Final Paper

Name: Tina Jones

Comprehensive Assessment

Vitals: BP- 128/82,  HR- 78,  RR- 15, TEMP- 37.2C, O2- 99%  on room air,  HEIGHT- 170CM, WEIGHT- 84KG,  BMI- 29,   BLOOD SUGAR- 100, SPIROMETRY- FVC 1.78L, FEV1- 1.549L.

Health History

Student Documentation

Identifying Data & Reliability

Ms. Tina Jones is a 28 years old African American female who came into the clinic for pre-employment assessment. she came in alone, alert, and oriented X4, speech is clear and appropriate for her age makes eye contact. Patient dressed appropriately for the weather. Ms. Jones tolerated the assessment with ease. Tina Jones Comprehensive Assessment Final Paper

General Survey

Patient is oriented to time, place, and situation. Patient is obese but practicing healthy eating and physical activity in her daily routine. Patient appears not to be in distress. She is excited to start her new jo in the city.

Reason for visit Tina Jones Comprehensive Assessment Final Paper

Patient verbalized “I came in here because, I’m required to have a recent physical examination for the health insurance at my new job.”

History of Present illness

The patient is here, for physical assessment for work insurance for a new job. Patient presents with other health issues that is under control. She wears a prescription glasses to help with blurry vision and headaches. Tina Jones Comprehensive Assessment Final Paper

Medications 

Metformin 850 mg- started 5 months ago. BID to manage diabetes type 2, she takes yogurt with this medication, which helps with stomach upset.

Albuterol 90 mcg/spray MDI -two puffs every 4 hours PRN- inhaler to manage asthma exacerbation.

Fluticasone Propionate 88 mcg/spray- BID to manage asthma

YAZ- 1 pill every morning- for birth control and to manage PCOS

Advil – 2 tabs. for menstrual pain and headaches.

Allergies

Penicillin – Rash, hives, last taken as a childhood.

Cat – aggravates asthma symptoms.

Patient denied food, seasonal, and latex allergy.

Medical History 

Asthma: since childhood, takes albuterol, and Proventil.

Diabetes type 2: diagnosed at age 24 years. Takes metformin and daily blood sugar checks in the mornings and results normally in 90s.

PCOS: takes Drospirenone and ethinyl estradiol

Hypertension: normal blood pressure readings.

Near sighted and blurry vision- wears glasses to help with vision.

Health Maintenance Tina Jones Comprehensive Assessment Final Paper

Patient has been eating healthy, using recipes from online for diabetes. she is limiting carbohydrates “staying away from sweets and increasing vegetables”.

Typical meals daily include:

Breakfast – Smoothie, fruit, yogurt, and eggs.

Lunch – Sometimes left-over dinner or wheat bread sandwich.

Dinner – Chicken or fish, vegetables and rice or quinoa on the side.

She verbalized recent weight loss from exercise. Recently she is active. Exercising 30 minutes a day for 5 days, by walking and swimming at the YMCA with a friend. she drinks occasionally with friends once or twice a week Tina Jones Comprehensive Assessment Final Paper.

Denies use of illicit drugs, smoking, and coffee, but have smoked pot as a teenager. Her caffeine intake is reduced to 1-2 sodas per day. Visits her dentist, gynecologist- 4 months ago, and ophthalmologist 3 months ago. Brushes teeth twice a day. she monitors her asthma by using the peak flow.

Family History Tina Jones Comprehensive Assessment Final Paper

Mother- (50 years) hypertension and high cholesterol.

Father- (58 yrs.) deceased in car crash, hypertension, high cholesterol.

Type 2 diabetes – Maternal Grandparents: both deceased in age 70s-stroke, hypertension, high cholesterol.

Paternal grandmother- alive and well. 82 years, hypertension.

Maternal grandfather- deceased at 65 years- colon cancer and diabetes type 2.

Social History

Tina is excited about her new job and the idea of moving to the city and living alone. she likes to hang out with friends and family. She has a sister and a brother they all live at home with her mom Tina Jones Comprehensive Assessment Final Paper. Ms. Jones started taking 30 – 40 mins walks and swims once a week, which she said helps her control her type 2 diabetes. she does not smoke cigarette or use illicit drugs but once smoked pot as a teen.

Mental Health History Tina Jones Comprehensive Assessment Final Paper

Ms. Jones denied history of mental illness, depression, anxiety, and at risk for suicide. Patient verbalized coping well with stress and anxiety by having support from family and friends Tina Jones Comprehensive Assessment Final Paper. Patient verbalized sleeping well at night with no pain or discomfort. Denied family history of mental illness and Suicide.

Review of Systems

General: Ms. Jones is relaxed sitting on the edge of the examination table. she does not have active health issues. Patient is dressed appropriately for the weather. All health issues listed are under control with no complaints from patients Tina Jones Comprehensive Assessment Final Paper.

Vitals: BP:128/82, RR:15, HR:78, O2:99%, BMI:29, WEIGHT:84KG, HEIGHT:170CM, TEMP:99.

Subjective

Subjective

• Head: Patient reports no headaches, pain, or tenderness on scalp. Denies history of seizures and syncope.
• Eyes: No blurry vision corrected with glasses, no ptosis or eye pain, dry and itchy eyes.
• Ear: she denies earache, tinnitus, vertigo or drainage, no recent hearing changes.
• Nose: Patient verbalized no runny nose or cold symptoms, no congestion or pain on the nose. Denies history of hay fever, or sinus troubles.
• Mouth/Throat: Last dental visit was three months ago, she denied issues with teeth, gum, and sore throat. No vocal changes.
• Breast: No completes of pain, lumps, or discharge. Patient verbalized not aware of how to perform breast examination.
• Ob/Gyn: Patient verbalized, birth control is helping with cramps and heavy periods. Not presently having sexual intercourse. Recent normal pap smear.
• Respiratory: Patient denies shortness of breath, coughing, wheezing, or breathing difficulty. Patient has a history of asthma, which is under control by medications and staying away from cats. Rescue inhaler used 3 months ago, and twice over the year. Patient monitors breathing capacity with a peak flow
• Cardiovascular: Jones reports no chest pain, history murmur or palpitation. she denies swelling on lower extremities. Patient has hypertension but not taking medication. last check of blood pressure was normal according to the patient. she is staying healthy by exercising and healthy meals. Tina Jones Comprehensive Assessment Final Paper
• Abdominal: Patient verbalized no nausea/vomiting, constipation, or diarrhea, she denied history of heart burn or any issues. No change in bowel habit.
• Musculoskeletal: Ms. Jones denies muscle, bone pain. she also denies weakness in all extremities and spine. She reports no limitation on exercises and swimming. Patient can perform activities of daily living with no limitations. No limitation in all range of motions. Tina Jones Comprehensive Assessment Final Paper
• Neurological: Patient verbalized no form of dizziness, fainting spells, loss of sensation. No history of stroke or loss of consciousness. Gait, speech, and coordination intact.
• Skin, Hair, Nail: Patient denies dry scalp or flaking. Ms. Jones states acne on skin is improving with help of YAZ contraceptive use. She verbalized discoloration on neck has reduced. She mentioned feeling embarrassed about hair on upper lips and chin. Tina Jones Comprehensive Assessment Final Paper

Objective Tina Jones Comprehensive Assessment Final Paper

Head– is symmetric with no contusion, swelling, lesions and tenderness on scalp. Hair is evenly distributed with no bald patches.

Eyes– no swelling in eyes, sclera is white, conjunctiva is pink with no exudates. PERRLA, EOMS are intact. Patient wears a prescription glasses for short sightedness. Left disc round with sharp margins, patient has mild retinopathic changes on right and left eyes, no hemorrhage, vision is 20/20 bilateral with corrective lens Tina Jones Comprehensive Assessment Final Paper.

• Nose– clear nasal cavities, with pink turbinate’s noted, no growth or blockage noted. no discharge noted. Ear- ear canal is pink and free from cerumen, tympanic membrane appears pearly gray, no drainage, whisper tests heard bilaterally. Tina Jones Comprehensive Assessment Final Paper
• Mouth/Throat: teeth and gum are intact, no redness or lesions noted, gag reflex is intact, patient can swallow with no difficulty. sinus palpated with no tenderness noted, no clicks on jaw.
• Neck: no palpable lymph nodes, neck has full ROM, palpable thyroid with no nodules and goiter. no palpable lymph nodes on axillary and cervical noted.
• Respiratory Anterior and posterior Chest wall is symmetric with no deformities, no use of accessory muscles, chest rises and falls equally. Breath sounds presents equally in anterior lungs for bronchophony. Breath sounds present in posterior lungs for bronchophony. No adventitious breath sounds heard on auscultation. Palpated fremitus equally on all areas of the chest wall, thoracic expansion symmetric. Resonant percussed on all areas. Incentive spirometry results: FVC 1.78L, FEV1 1.549L. Tina Jones Comprehensive Assessment Final Paper
• Cardiovascular: Anterior chest wall inspected, carotid, brachial, radial, femoral, popliteal, tibial, and dorsalis pulses noted 2+ bilaterally, with no thrills or bruits. PMI nondisplaced, no heaves or lifts. Heart rate S1 and S2 heard, no murmurs, gallops, or rubs. capillary refill less than 3 seconds. No S3, S4 present on Erb’s point. RRR, S1, S2 with no murmur present on Erb’s point. No S3, S4 heard on aortic area. No bruit heard on right renal, iliac, and femoral artery. No bruit heard on left renal, iliac, and femoral artery. Capillary refill <3 secs on fingers and toes. RRR, S1, S2 with no murmur heard on aortic area. No S3, S4 on pulmonic area. RRR, S1, S2 with no murmur heard in pulmonic area. No S3, S4 heard on tricuspid area RRR, S3, S4 with no murmur heard on tricuspid area. No S3, S4 heard on mitral area RRR, S1, S2 with no murmur heard on mitral area Tina Jones Comprehensive Assessment Final Paper.
• Abdominal: Abdomen is protuberant on inspection, no visible masses, or lesions. coarse hair noted from pubis to umbilicus. Normoactive bowel sounds present in right upper quadrant, right lower quadrant, left upper quadrant, right lower quadrant. No bruit on aortic artery. Liver palpable 1cm below right costal margin, 7cm MCL on percussion Tina Jones Comprehensive Assessment Final Paper. Tympanic sound percussed on quadrants. dullness percussed on spleen. both kidneys and spleen not palpable, no masses. Light palpation on right and lower quadrant soft, no tenderness or masses.
• Musculoskeletal No deformity noted on inspection in all extremities, hips, spine, gait is smooth and with full range of motion with no crepitus. upper and lower extremities move in symmetric with no swelling or lesions. strength of 5/5 on all extremities, neck. deep tendon reflexes in upper and lower extremities 2+, No swelling, masses, or deformity on neck. No swelling, masses, or deformity on hips Tina Jones Comprehensive Assessment Final Paper.
• Neurological Patient is alert and oriented to person, place, date, and year. all motor skills are performed with ease – finger to nose, run heel down to shin Tina Jones Comprehensive Assessment Final Paper. Patient able to identify dull, sharp, and soft touch on all extremities. Position sense on toes and fingers intact. Bilateral shoulder shrug against resistance, patient able to turn head both sides, up and down with against resistance. Stereognosis and graphesthesia normal bilaterally. On testing for monofilament there was decreased sensation on both right and left great toes and right heel.
• Skin, Hair, Nails Skin is warm to touch. Acne and pustules on face with some darkening areas on her neck. no lesions detected. striae lines on abdominal areas towards the umbilicus. Coarse hair noted. body hair evenly distributed Tina Jones Comprehensive Assessment Final Paper. no clubbing, ridges or discoloration on fingers and toes. Darkening discoloration around neck, and axillary, and groin.

Assessment Tina Jones Comprehensive Assessment Final Paper

Diagnostic and Laboratory

• Complete Blood Count (CBC) is a blood test that is done for evaluation of overall health of a patient and to detect disorders; red blood cells, white blood cells, platelets, hemoglobin, hematocrit, mean corpuscular volume, reticulocyte count. Tina Jones Comprehensive Assessment Final Paper
• Thyroid stimulating Hormone (TSH) it is blood test that measures the amount of TSH in the blood.
• Lipid panel is blood test that measures total cholesterol, HDL cholesterol and LDL cholesterol, triglycerides to help determine risk of heart disease. Tina Jones Comprehensive Assessment Final Paper
• Chemistry Panel is a blood test done to measure glucose levels, electrolyte, fluid balance, and kidney function – BUN, calcium, carbon dioxide, chloride, creatine, potassium, and sodium.
• Liver Panel, this measures the blood levels of total protein, albumin, bilirubin, and liver enzymes

Differential Diagnosis 

• Diabetic Neuropathy as evidence to decreased sensation on both right and left great toes and right heels. This is the most common complication of diabetic mellitus. This is a clinical syndrome that affect distinct regions of the nervous system, singly or combined (Vinik, Casellini, & Nevoret, 2018). The loss of sensation results in the loss of thermal and pain perception. Tina Jones Comprehensive Assessment Final Paper
• Polycystic Ovary Syndrome (PCOS)is an ovarian disorder characterized by hyperandrogenism, ovulatory dysfunction and polycystic ovaries (Legro, 2017).

This diagnosis is because of patient’s history of dysmenorrhea and longer periods, and severe cramps, as a birth control was prescribed.

• Acanthosis Nigricans (AN) is termed a common cutaneous conditions that can be a manifestation of systemic disease that is associated with insulin resistance, diabetes mellitus, obesity, internal malignancy, endocrine disorders, and drug reactions (Patel, Roach, Alinia, Huang, & Feldman, 2018). The patient presents with a dark discoloration around her neck, which is evidence of inability to manage insulin levels Tina Jones Comprehensive Assessment Final Paper.

Tina Jones Comprehensive Assessment Final Paper References

1. Legro, R.S. (2017). Evaluation and treatment of polycystic ovary syndrome. Retrieved on July 26, 2020 from https://www.ncbi.nlm.nih.gov/books/NBK278959
2. Patel, N. U., Roach, C., Alinia, H., Huang, W. W., & Feldman, S. R. (2018). Current treatment options for acanthosis nigricans.
3. Vinik, A., Casellini, C., Nevoret, M. R. (2018). Diabetic neuropathies. Retrieved on July 26, 2020 from https://www.ncbi.nlm.gov/books/NBK279175