NURS 6512 DIGITAL CLINICAL EXPERIENCE History of Present Illness (HPI): The patient is a 28-year-old African-American woman who has come for reemployment assessment. She stated that she has found employment at her new company. She does not have any acute concerns.

NURS 6512 DIGITAL CLINICAL EXPERIENCE: COMPREHENSIVE (HEAD-TO-TOE) PHYSICAL ASSESSMENT

Patient Information:

The patient is a 28-year-old African-American woman.

Subjective Data:

CC (Chief Complaint): “I have come for a reemployment assessment.”

History of Present Illness (HPI): The patient is a 28-year-old African-American woman who has come for reemployment assessment. She stated that she has found employment at her new company. She does not have any acute concerns. She last had a gynecological exam four months ago at SHGC. She was diagnosed with Polycystic ovary syndrome (POCS) and prescribed well-tolerated medications. The patient has a history of type 2 diabetes that she controls using diet, metformin, and having an active lifestyle. She does not suffer from any side effects.

Medications: The patient is on metformin, drospirenone and ethinyl estradiol, albuterol spray, ibuprofen and acetaminophen.

1. Metformin 850 mg per os twice a day. For blood sugar control.
2. Drospirenone and ethynyl estradiol per os 3/0.02 mg once a day for PCOS.
3. Albuterol inhaler two puffs a day. The last use was 3 months ago.
4. Acetaminophen 500-1000 mg per os PRN for headaches.
5. Ibuprofen 400 mg per os twice a day for menstrual cramps. Last taken 6 weeks ago.

Allergies: He has no known food or drug allergies.

Past Medical History (PMH):The patient was diagnosed with asthma when one and a half years old. The last asthma exacerbation occurred three months ago. My last asthma hospitalization was in high school. She has never been intubated. Has type 2 diabetes that was diagnosed at the age of 24 years. She has been taking metformin for five months without much side effects. Average blood sugar is 90 mg/dL and is monitored daily in the morning. She also exercises and diets to manage the condition as well as hypertension.

Past Surgical History (PSH): No history of surgery. No history of blood transfusion.

Sexual/Reproductive History: Menarche at 11 years. She is heterosexual. She has never been pregnant whilst her coitarche was at the age of 18 years. She has a new boyfriend

Personal/Social History: The patient does not have children and they were never married. 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 has a string of social support systems including the church and her family. She doesn’t consume tobacco whilst she used cannabis from ages 15-21 years of age. Does not abuse any other drugs. Uses alcohol in the company of friends at least 2-3 times monthly. She eats healthily in all her meals from breakfast, and lunch to supper. Does not take coffee but takes Diet Coke. Has not traveled outside recently and does not keep pets. She does mild exercise at least four times per week.

Health Maintenance: The patient attends the doctor’s appointment. She had a pap smear done four months ago. She had an eye exam 3 months ago. The dental exam was last conducted 150 days ago. She is negative for PPD which was done two years ago. Safety: Has smoke detectors in the home. She wears safety belts in the car. Does not ride the bike. Uses sunscreen in the sun. She has locked her father’s gun in their bedroom.

Immunization History:Her immunization status is up to date with tetanus and HPV vaccines. Childhood vaccines are up to date ad as well as meningococcal vaccine.

Significant Family History:There is a history of hypertension in all the grandparents from both sides and both parents. Both parents and maternal grandparents have hypercholesterinemia. Maternal grandparents died from a stroke. Paternal grandmother is alive and 82 years of age whilst grandfather died of cancer at 65 years of age. 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. There is a history of alcoholism in her paternal uncle whilst no other diseases exist in the family as well as her.

Mental Health History: She has enhanced her coping mechanism to stress. She has no history of suffering from depression, anxiety, or suicidal thoughts. She is alert to all faculties. She is dressed properly and easily converses and cooperatively offers information. She has a pleasant mood. Does not have tics or facial fasciculation. Her speech is fluent and her words are clear.