Comprehensive Paper Shirah Bass New Jersey City University

Abstract This paper outlines both subjective and objective information obtained for a thorough health assessment of patient AD. The subjective includes patient biographical data, heritage history, past health, and family history as well as a subjective review of systems. A full objective assessment of the patient is also included. The examiner then provides an assessment of the findings of the subjective and objective information. Finally, the paper outlines a plan for the patient to follow to maintain and improve health.

COMPREHENSIVE PAPER

I.

Subjective Data

Biographical Data Patient AD is a Caucasian female born on 11/1/88. Patients report seems reliable. Patient was raised as a Catholic but does not currently attend religious services or practice them in her home. She does not associate with any specific cultural group or participate in any ethnic activities. She is employed as a waitress and also attends school full-time in an accelerated BSN program. She is unmarried but reports having a significant other with whom she lives. Patient is seeking care due to an assignment for a school class. Patient received all routine childhood immunizations, including MMR, Polio, Hepatitis B, and DTap. Patient has allergy to pollen and penicillin, causing anaphylaxis as per patient. Patient contracted chickenpox at age 8 and had childhood asthma which has resolved. No other serious childhood illnesses occurred. Patient suffered head trauma at age 17 from colliding with a peer during cheerleading, resulting in a concussion and requiring sutures. Patient contracted MRSA from a family member who was infected, age 17, and mononucleosis, age 20. Patient has had no hospitalizations or operations. Patient has had no pregnancies. Current medication is orthotrycycline as an oral contraceptive. No paternal history is known. Heart disease present in maternal grandfather. Hypertension present in mother and maternal grandmother. Maternal grandmother died of a stroke at age 60. Maternal grandmother had diabetes. Both grandparents had arthritis. There is a history of alcoholism. Denied family history of cancer, allergies, asthma, mental illness, seizure disorder,

kidney disease, and tuberculosis. For family genogram, see Appendix.

Heritage Patient AD was born in Wildwood Crest, NJ to her American-born mother. Father is unknown, as well as any paternal family history. Patients maternal grandparents were both born in Newark, NJ and were raised in the US. Patient has one half sister and no other known siblings. She grew up in a suburban setting, living with her mother, half-sister, and step-father. Most of her immediate and extended family lives near the patient, but she mainly has contact with relatives on holidays. Beliefs Familys religious preference is Catholic, however patient reports not participating in religious services or traditions. Significant other and most friends are also Catholic. Friends and neighbors are of similar ethnic background as the patient. Native language of the patient and all family is English. Patients mother maintained health through conventional means, regular doctor visits, and promoting health by serving healthy meals. Home remedies used were chicken soup for colds, ginger ale for nausea, and head massages for headaches. Functional Patient seems to have a good self-concept and high self-esteem. She reports earning a

COMPREHENSIVE PAPER Bachelors degree and displays concern with furthering her education. Her financial status presently is low-income, but all of her needs are being met, including nutritional, housing, and clothing. Patient reports engaging in exercise 1-2 times weekly, running and doing resistance training. She reports eating mainly balanced meals and snacks. 24 hour diet recall is as follows:

breakfast is cereal, chocolate milk, and peach cup; lunch is bologna sandwich, cheese and crackers, and coffee; dinner is spaghetti and meatballs, stuffed mushrooms, and 3 cups root beer; snack is Fritos. Her diet is high in fat and calories, but she still maintains appropriate weight. She reports no problems with elimination. Patient reports sleeping 6-8 hours a night and naps during the day 3X weekly. Patient reports her support system consists of friends and her significant other. Patient reports a strained relationship with her mother where she reports being parentified. Patient reports sources of stress in her life to be finances, school, and her relationship with her mother. She manages stress with positive coping skills such as exercise and listening to music. Patient reports drinking caffeinated coffee 3X weekly. She denies any use of tobacco products. Patient reports drinking socially, ingesting alcohol 3 out of the last 30 days. Patient reports no use of street drugs or prescription pain medication presently or in the past. Patient reports living in a rented townhome in a safe area with adequate heat, utilities, and access to transportation. She reports using seatbelts regularly. Patient reports feeling safe in her current relationship, experiencing no domestic violence. Patient reports being emotionally abused in a prior relationship and was slapped once by a partner in high school, and promptly ended the relationship.

Patient is a nursing student and may be exposed to communicable diseases due to clinical experiences that she will have in health care settings. She utilizes PPE while on site, keeps vaccinations up to date, and has yearly PPD tests to reduce and monitor exposure. Patient views self as healthy and has no health concerns at this time. She defines health as eating healthy, maintaining low stress levels, getting a decent amount of activity. Active living. Patient reports a fear of being diagnosed with diabetes due to a strong family history. Her health goals include not being diagnosed with diabetes and maintaining a healthy lifestyle. She reports her expectations of nurses and physicians are that they ensure patients get the best health care possible. Review of Systems General overall status-Reports health is good. No recent weight changes. No fatigue, weakness, malaise, fever, chills or sweats. Skin, hair, nails-No history of skin disease, pigment change, unusual moles. Patient does not consistently wear sunscreen when outdoors. Reports no pruritus or excessive bruising. No recent hair loss. Nails have had no change in shape, color, or brittleness. Head-Patient suffered a head trauma at age 17, resulting in concussion and sutures. She reports painful headaches approximately 4X weekly, with photosensitivity. Reports no vertigo, dizziness, or syncope. Eyes and ears-Patient is mildly myopic and wears glasses regularly. Reports no eye pain, diplopia, watering, discharge, glaucoma, or cataracts. Patient has regular vision exams (last exam approximately 2 years ago). Reports no earaches, infections, discharge, tinnitus, or vertigo. Patient cleans ears daily with cotton swabs

COMPREHENSIVE PAPER Nose and sinuses-Patient reports seasonal allergies causing clear nasal discharge. Otherwise patient reports no other problems with nose, including pain, obstruction, nosebleeds, or changes in sense of smell. Throat and mouth-Patient reports intermittent pain at the site of eruption of wisdom teeth. Patient reports no bleeding gums, frequent sore throats, lesions in mouth or tongue, dysphagia, tonsillectomy, voice change, or altered taste. Patient reports performing appropriate oral care, including brushing teeth 2X daily and annual dental exams. Patient does not floss regularly, but is working on trying to floss more. Neck-Patient reports no pain in neck, limitation of motion, lumps, swelling, enlarged nodes, or goiter. Chest and breasts-Patient reports no pain, tenderness, or rash in breasts or axilla, no nipple discharge, no breast disease or surgery on breasts. Patient has never had a mammogram. Patient performs breast self-exams monthly.

Respiratory system-Patient reports childhood asthma which has since resolved. She also reports wheezing upon vigorous exercise. Patient has never smoked. Patient reports no history of emphysema, frequent bronchitis, pneumonia, tuberculosis, chest pain with breathing, shortness of breath, persistent cough, or excessive sputum. Reports no hemoptysis or exposure to toxins or pollution. Patient has yearly Mantoux tests for her job to screen for TB but does not get yearly flu shots.

Cardiovascular system-Patient reports no problems with cardiovascular system, including pain, palpitations, cyanosis, dyspnea, orthopnea, nocturia, or edema. Patient reports no history of heart murmur, hypertension, coronary artery disease, or anemia.

Peripheral vascular system-Patient reports occasionally numbness/tingling in

extremities. Patient reports no discoloration in hands or feet, varicose veins, claudication, or thrombophlebitis. Patient does report crossing the legs when sitting and being on her feet for extended periods of time. Gastrointestinal system-Patient reports a good appetite with no recent changes. Reports no food intolerance, dysphagia, indigestion, abdominal pain, N&V, or history of abdominal disease. Patient reports no unusual flatulence, no recent changes in character of stool, no rectal bleeding, no hemorrhoids, or fistula. Patient reports having a bowl movement daily. She denies use of any antacids or laxatives. Urinary tract system-Patient reports normal frequency and urgency of voiding. She usually does not wake in the night to urinate. Patient reports no dysuria, polyuria, or oliguria. Reports no pain on urination, incontinence, or history of urinary disease. Patient reports no pain in flank, groin, suprapubic region, or low back. Patient report clear, unclouded urine. Reports holding urine while at work, but is trying to urinate more promptly on feeling of urgency. Genitalia and sexual health-Patient reports menarche at age 11 with a regular cycle since that time. Last menstrual period about 2 weeks ago. Duration of menstrual period 3-4 days. Patient reports severe premenstrual pain for first day of menstruation. Patient reports white, sticky discharge during ovulation. Reports no vaginal itching. Last gynecological exam and Pap smear on 2/9/12. Patient is in a monogamous sexually satisfying relationship. Patient experiences no dyspareunia. Condoms are not used and oral contraception is the method of birth control (orthotrycyline). Patient has no knowledge of having contact with a partner who had any sexually transmitted infections.

COMPREHENSIVE PAPER Musculoskeletal system-Patient reports intermittent lower back pain upon exertion. Reports no history of gout, arthritis, joint pain or swelling, deformity or limitation of motion. In the muscles, patient reports no pain, cramps, weakness, stiffness, problems with gait, or problems with coordination. Patient reports doing a lot of walking at work, being on her feet most times while at work. Neurologic system-Patient reports intermittent tingling and numbness in extremities. Reports no history of seizure disorder, stroke, fainting, or blackouts. Reports no problems with motor functioning including weakness, tic or tremor, paralysis, or coordination problems. Reports no problems with cognitive function including memory disorder. Patient reports no mental health issues or hallucinations. Hematologic system-Patient reports no bleeding tendency of skin or mucous membranes, excessive bruising, lymph node swelling, blood transfusions, or exposure to toxins or radiation. Endocrine system-Patient reports no history of diabetes or thyroid disease. Reports no

intolerance to heat or cold, changes in skin pigmentation or texture, excessive sweating, abnormal hair distribution, nervousness or tremors. Reports no need for hormone therapy. II. Objective Data General Survey- Patient appears stated age and presents as appropriate gender. Patient is alert and oriented to time, person, and place. Skin tone is consistent with ethnic background and facial features are symmetrical. Height and weight are within normal range for gender and age and patient appears well-nourished. Patient weighs 124 lbs (56 kg) and measures 55 in tall (165 cm). Her BMI is 21 which is within normal range with a waist circumference of 27.5 inches. Body is

symmetrical and patient stands erect. Patient sits comfortably and faces the examiner. Gait is normal with a smooth walk and symmetric arm swing. Patient has normal range of motion with full mobility of joints. Patient maintains appropriate eye contact while conversing and seems relaxed and at ease. Patient is able to articulate clearly and word choice is appropriate. Patient is groomed and dressed appropriately to age and cultural background Vital Signs-T-98.6 (forehead strip) P-64 R-10 BP-98/58 R arm, 96/58 L arm Skin- Upon examination, skin is tan-pink in color and is smooth and soft with no suspicious nevi. Skin is warm bilaterally, intact, and not overly dry. Skin shows good turgor with no edema. Mild spider veins on the lateral side of the lower legs. Patient has no lesions, but has an elevated area of darker pigmentation measuring 4X2 on right arm lateral to the antecubital area. Hair-Patient states hair is dyed light brown, natural color is darker brown. Normal distribution and texture with no lesions of the scalp or parasites. Nails- No clubbing or brittleness of the nails. Nails are translucent with brisk capillary refill <2 seconds. Head- Head is normocephalic with a depression at the crown of the head that patient reports has been there since childhood, not related to any injury. Temporal artery is easily palpated and no crepitation at temporomandibular joint bilaterally. Face is symmetrical with no involuntary tics or edema. No masses or lesions visible. Neck is absent of abnormal pulsations and patient has normal ROM. Strength of cervical muscles is good. Trachea is midline and no enlargement of the thyroid or salivary glands. No cervical lymphadenopathy or masses. Eyes- Acuity by Snellen chart 20/20 in both eyes (with glasses). No evidence of peripheral vision loss by confrontation. Corneal light reflex is symmetrical. Extraocular muscles intact as

COMPREHENSIVE PAPER

11

per diagnostic positions test. Eyes are symmetrical with eyebrows and lashes present. No ptosis. Sclera are clear white and conjunctiva are pink. Lacrimal apparatus are not tender. No exudate or excessive tearing. PERRLA. Fundi-Red reflex present bilaterally. Retinal background and macula have even color on opthalmoscope examination. Ears- Pinna have no masses, lesions, or tenderness and skin is intact bilaterrally. No tenderness of tragus or mastoid process bilaterally. External auditory meatus is not red or tender bilaterally. On otoscopic inspection, canals are clear and tympanic membrane is intact and pearly gray. Responds appropriately to conversation. Whispered words are heard bilaterally. Result of Weber and Rinne tests are within normal limits. Nose, Mouth, and Throat-Nose- Nose is symmetrical and midline. Nares are patent. Nasal mucosa is pink without discharge. Septum is midline and turbinates are pink with no swelling. No sinus tenderness. Mouth and Throat-Lips are moist and mucosa and gingivae are pink and moist. Teeth are intact and without caries. Buccal mucosa is pink with no lesions or bleeding. Palate is pink and uvula rises with phonation. Tonsils are not red and 2+. Tongue is symmetrical and midline. Pharynx is pink without exudate. Breasts and Regional Lymphatics- As reported by patient, left breast is slightly larger than the right. Skin is smooth and evenly colored with no striae or lesions. Shape of the nipples is symmetrical and flat with no discharge. Patient denies breast tenderness, masses, retraction or lymphadenopathy. No rash or lesions in the axillae. Thorax and LungsInspection: AP: Transverse diameter 1:2. Respirations 10/min and regular. Patient is sitting upright and is alert with calm facial expression. Skin is evenly colored bilaterally.

Palpation: Chest expansion symmetric and tactile fremitus equal bilaterally. No tenderness to palpation. No masses or lesions. Percussion: Resonant to percussion over lung fields. Diaphragmatic excursion is 2 cm and = bilaterally. Ascultation: All breath sounds are clear and equal with no adventitious sounds. Heart and Neck VesselsNeck: Carotids 2+ and equal bilaterally. Internal jugulars visible when supine and absent when elevated to 30 bilaterally. Precordium: Skin color is appropriate for ethnic background. No heave or lift, but apical pulse is visible on chest wall. Apical pulse palpated at the left 5th intercostals space MCL. No thrill palpated. Auscultation: Heart sounds at aortic, pulmonic, Erbs point, tricuspid, and mitral areas are normal, S and S heard with no extra sounds or murmurs. Rhythm is regular and rate is 64. Peripheral Vascular and Lymphatics-Inspection-Extremities have pink-tan color without redness, cyanosis, or lesions. Extremity size is = bilaterally without edema or atrophy. PalpationTemperature is warm and = bilaterally. No lymphadenopathy. Brachial, radial, popliteal, posterior tibial, and dorsalis pedis pulses are 2+ and = bilaterally. Abdomen- Abdomen is flat and symmetric. Skin color is appropriate to ethnic background. No lesions or scars present. Umbilicus is midline and inverted. Bowel sounds are present and normal in all four quadrants with no vascular sounds. Percussion yields tympany predominantly. Liver span is 7.5 cm in right mid-clavicular line. Splenic dullness located at 10th

COMPREHENSIVE PAPER ICS in left midaxillary line. No ascites. Abdomen is soft with no involuntary guarding or tenderness. No organs are enlarged and no masses are noted. Liver, spleen, and kidneys are not

13

palpable and aortic pulsation can be palpated. No rebound tenderness or CVA tenderness. Rectal exam not performed Musculoskeletal- No crepitation, pain, swelling, masses, deformities of any joints. Normal curvature of vertebral column with no tenderness or deformity. Full extension lateral bending, and rotation of spine. Extremities symmetric with full ROM; movements smooth with no tenderness or crepitation. Able to maintain flexion against resistance without tenderness. Neurological- Mental Status: Appearance, behavior, and speech appropriate. Alert and oriented to person, place, and time. Recent and remote memory intact. Cranial Nerves I not tested II-Vision 20/20 in both eyes; peripheral fields intact by confrontation; fundi normal. III, IV, VI-EOMs intact bilaterally, no ptosis or nystagmus. PERRLA V-Sensation intact and equal bilaterally. Jaw strength equal bilaterally VII-Facial muscles intact and symmetric VIII-Hearing intact bilaterally by whisper test, Weber, and Rinne IX, X-Swallowing intact, gag reflex present, uvula rises midline on phonation XI-Shoulder shrug, head movement intact and equal bilaterally

XII-tongue protrudes midline without tremors

Motor No atrophy, weakness, or tremors. Gait steady and smooth. Able to tandem walk, negative Romberg. Rapid alternating movements; finger to nose smoothly intact. Sensory Pinprick, light touch, vibration intact. Stereognosis-able to identify key Reflexes Biceps, triceps, and quadriceps reflexes 2+ and equal bilaterally. Plantar reflex 2+ with negative Babinski. Genitourinary- As reported by patient, no lesions, discharge, or edema. Internal exam declined. III. Assessment Patient is in overall good health and practices good self-care for the most part. She does not utilize adequate sun protection when outdoors. Patient reports myopia for which she regularly wears her prescription glasses. She has frequent headaches of which she does not necessarily know the origin that she treats with ibuprofen. Patient cleans inside the ear canals with cotton swab sticks. Patient does practice good oral hygiene with brushing and regular dental exams but does not floss regularly. Patient does do regular breast self-exams allowing for early detection of breast cancer. Patient does not smoke and has never done so. However,

COMPREHENSIVE PAPER she does not get regular flu shots and does not participate in regular cardiovascular exercise. Patient is within normal weight limits for her height; however her high fat, high calorie diet

15

puts her at risk for cardiovascular disease in the future. Patients peripheral vascular system is intact, with some minor spider veins on the lateral upper legs. Patient reports intermittent low back pain for which she has never sought treatment. Finally, patient often holds her urine while at work which could increase her risk of urinary tract infections. IV. Plan

I would advise the patient to utilize sunscreen with an SPF of 15 or higher when exposed to the sun. According to the CDC, About 65%90% of melanomas are caused by exposure to ultraviolet (UV) light (CDC, 2012). She can reduce her risk of skin cancer by using sunscreen and limiting her exposure between the hours of 10 am and 4 pm. Patient should continue to wear her glasses regularly. As for her headaches, patient should try to pinpoint any triggers for her headaches. She can do this by keeping a diary of when she gets the headaches and try to name what precipitating factors may be present. I would also advise patient to use caution with the regular use of NSAIDs. The use of NSAIDs can cause gastrointestinal ulceration and bleeding and ulcers are found at endoscopy in 15% to 30% of patients using NSAIDs regularly (Laine, 2006). I would advise the patient to discontinue the use of cotton swabs inside the ear canal. Because the ear drum is so delicate, it can be easily ruptured by using even the gentlest of pressure when using a swab (Why you, 2012). I would prompt her to continue with regular teeth brushing and dental exams and advise her to floss regularly as this will decrease her risk of gingival disease. I would advise patient to continue to do breast self-exam and alert her physician to any abnormalities that she may encounter.

I would advise the patient on a few matters regarding her cardiovascular and musculoskeletal systems. She should continue to refrain from smoking but I would advise her to get a flu shot yearly, especially since she is entering a profession where she will be exposed to pathogens daily. I would also recommend that she increase her level of cardiovascular activity to at least 3o minutes 5 days weekly. Aerobic exercise reduces the risk of many conditions, including obesity, heart disease, high blood pressure, type 2 diabetes, stroke, and certain types of cancer. Weight-bearing aerobic exercises, such as walking, reduce the risk of osteoporosis (What aerobic, 2012). Though her weight is appropriate to height and gender and her BMI is within a healthy range, I would recommend that the patient reduce her intake of saturated fats and increase her intake of fruits, vegetables, and fiber. This can prevent heart disease and diabetes as well. As for patients lower back pain, I would advise her to use good body mechanics when lifting and moving to prevent injury. This is especially true now that she is going to be a nurse and will be moving and positioning patients. Wilkinson and Treas (2001) advise these measures to prevent back injuries: wear comfortable, low-heeled shoes, follow principles of body mechanics at all times, exercise regularly, avoid lifting excessive weight, and use a firm mattress that provides adequate support (Wilkinson & Treas, 2011). Lastly, I would advise the patient to avoid holding her urine when she has the urge to void. According to Wilkinson & Treas, urinate when you first feel the urge. Do not make a habit of postponing urination because bacteria can multiply in stagnant urine (Wilkinson & Treas, 2011).

COMPREHENSIVE PAPER

17

Appendix

COMPREHENSIVE PAPER

19

References (July 18, 2012.) Basic information about skin cancer. Retrieved July 31, 2012, from http://www.cdc.gov/cancer/skin/basic_info/index.html

(2012). Family health history. Retrieved from https://familyhistory.hhs.gov/fhh-web/home.action

Laine L. (2006). GI risk and risk factors of NSAIDs. Journal of Cardiovascular Pharmacology, 47(Suppl 1), 60-66. Jarvis, C. (2012). Physical examination & health assessment (6th ed.).; St. Louis, Mo.: Elsevier/Saunders. Jarvis, C. (2012). Student laboratory manual for physical examination & health assesment (6th ed.). St.

Louis, MO: Saunders, an imprint of Elsevier Inc. (Feb 12, 2012.) What aerobic exercise does for your health. Retreived July 31, 2012 from http://www.mayoclinic.com/health/aerobic-exercise/EP00002/NSECTIONGROUP=2 (April 20, 2011). Why you shouldnt clean your ears with a cotton swab. Retrieved July 31, 2012, from http://www.healthyhearing.com/content/articles/Hearing-loss/Causes/47773-Swab-hearing-loss.

Wilkinson, J., Treas, L. (2011). Fundamentals of nursing-volume 1: theory, concepts, and application (2nd ed.).; Philadelphia, PA.: F. A. Davis and Company.