NURS 6512 Comprehensive Assessment Notes 2020 – Walden University | NURS6512 Comprehensive Assessment Notes 2020

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NURS 6512 Comprehensive Assessment Notes 2020 – Walden University Tina Jones is awake, alert and oriented. Patient sitting upright on the examination table in no apparent distress. Patient appears ... well groomed, well-nourished, and is dressed appropriately. Speech is clear and coherent. Patient maintains good eye contact throughout the interview. Miss Tina Jones is a 28-year-old African American female who recently obtained a job at the Smith, Stevens, Stewart, Silver & Company and presents to the clinic to have a pre employment physical prior to starting her new job. Patient denies any acute complaints upon presentation. Her last primary care visit was 5 months ago. She has current medical conditions such as PCOS, type 2 diabetes, GERD, and asthma with symptoms that are well controlled with medications, diet, and exercise. Patient reports she feels healthy and is taking better care of herself. - - - - - - - - - - - - - - - - - -Gastrointestinal: Abdomen protuberant, symmetrical. No visible masses or lesions. Normoactive bowel sounds in all 4 quadrants. Bilateral upper and lower abdomen, tympanic on percussion. Spleen no dullness noted on percussion. Liver span: 7 cm MCL on percussion. No CVA tenderness noted bilaterally. Bilateral upper and lower abdomen, soft, non-tender, and no masses on light palpation. Bilateral upper and lower abdomen, no masses, guarding or rebound on deep palpation. Liver: palpable 1 cm below right costal margin. Spleen not palpable. Right kidney, not palpable, no masses Left kidney, not palpable, no masses. Musculoskeletal: Neck without swelling, masses or deformities. Neck full ROM upon extension, flexion, lateral bending, and rotation. Right shoulder, arm, elbow, wrist, and hand with no swelling, masses, or deformity noted. Left shoulder, arm, elbow, wrist, and hand with no swelling, masses, or deformity noted. Hips without swelling, masses or deformities. Bilateral legs, knees, ankles, and feet with no swelling, masses or deformities. Full ROM on right and left shoulders. Full ROM on right and left elbows. Full ROM on right and left wrists. Spinal rotation to left and right, full ROM. Spinal extension full ROM. Spinal flexion full ROM. Spinal bending to left and right, full ROM. Right and left hip full ROM. Right and left knee full ROM. Right and left ankles full ROM. Neck strength 5/5. Right and left shoulder strength 5/5. Right and left elbow strength 5/5. Right and left wrist strength 5/5. Right and left hand strength 5/5. Right and left hip strength 5/5. Right and left knee strength 5/5. Right and left ankle strength 5/5. Neurological: Awake, alert, oriented to person, place and time. Graphesthesia tested, patient identified number 8 drawn on the right hand and identified letter A drawn on the left hand. Light touch sensation intact to bilateral proximal and distal arms. Light touch sensation intact to bilateral proximal and distal legs. Bilateral proximal and distal arm dull pain sensation intact. Bilateral proximal and distal leg dull pain sensation intact. Bilateral proximal and distal arm sharp pain sensation intact. Bilateral proximal and distal leg sharp pain sensation intact. Decreased sensation to both feet when sensation was tested with monofilament. Position sense intact in fingers. Position sense intact on toes. Stereognosis tested, patient identified a key, paper clip and a coin on both hands within 5 seconds. DTR to bilateral triceps 2+. DTR to bilateral biceps 2+. DTR to bilateral brachioradialis 2+. DTR to bilateral knee 2+. DTR to bilateral ankle 2+. Bilateral index finger to nose coordination, smooth and accurate. Rapid alternating hand movements smooth and accurate. Heel to shin coordination, smooth and accurate. Skin: No dryness or scaling on scalp. Hair appears healthy. Normal scalp hair distribution. Scattered pustules on face and facial hair on upper lip. Acanthosis nigricans noted on neck. Coarse hair from pubis to umbilicus noted. Fingernail inspected, no ridges or abnormalities in nails with pink nailbeds. Toenails inspected, no ridges or abnormalities in nails with pink nailbeds. [Show More]

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