Documentation of History and Physical Exam Comprehensive Nursing Essay Example

Documentation of History and Physical Exam Comprehensive Nursing Essay Example

Patient Name (Initials only): D.C. DOB: November 1, 2021 Gender: Female Date examined: July 7, 2023

CHIEF COMPLAINT “We brought D.C. for a routine check-up”
HISTORY OF PRESENT ILLNESS
D.C., an 18-month-old African American female, is brought to the clinic in the company of her mother for a routine 18-month well-child visit. D.C. lives with both parents, but only the mother is present for this appointment. She has an older brother and sister who are in preschool and third grade, respectively. The mother is attentive to the child’s growth and presents to answer questions regarding the client’s development milestones. The mother states that D.C. eats pleasantly and is not picky. She reports that the client drinks between 7 and 17 oz. of whole milk daily from the feeder cup, mostly feeding herself the milk and other meals without help or any issues. The mother states the child can sleep by herself through the night in her own bed. Her bedtime is around 0800 every night. The mother does not allow her to use a sippy cup at bedtime, and she no longer uses the pacifier. The mother reports she brushes D.C.’s teeth twice daily. She is very interactive with peers in daycare, and the mother denies any reported concerns at daycare. The mother denies any issues during this check-up and believes the child is on track since the previous well-child visit when she was 14 months. (Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
PAST MEDICAL HISTORY
Childhood & Adult Illness
The mother reports that D.C. has not experienced any major illness to date and that she has not history of major health problems.
Previous Hospitalizations/Surgery/Trauma The mother denies any history of hospitalization, surgery, or reported or evaluated trauma.
Medications She is currently on Zyrtec children’s allergy 1mg/ml 5 ml per day.
Allergies/Adverse Reactions She experiences seasonal allergies, but no specific allergy tested so far.
Immunizations:  Immunizations are up to age Completed the following: Flu Hep BRotavirusDTap- Forth dose at 15-18 m/oHibPCV 13IPV- third dose at 11-12 m/oMMR- first dose at 12-15 m/oVaricella- second dose at 12-15 m/o She is due to receive her Hep A vaccine today. The mother is due to decide to get annual influenza vaccine, which will happen when the flu clinic initiates.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
FAMILY HISTORY
The mother is 32 years old alive and well. The father is 35 years old alive and well. Both maternal grandparents are alive and with no significant medical history or health problems. Paternal grandparents are also alive, with grandmother at 55 and grandfather at 57 years old. The paternal grandfather has obesity and high blood pressure and the paternal grandmother suffers from arthritis.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
SOCIAL HISTORY D.C. lives with both parents. She has an older brother and sister in pre-school and third grade, respectively. The mother denies any tobacco, alcohol, or illegal drug use. The mother reports that both parents work, and the client attends daycare from Monday to Friday. The mother reports the client using a 5-point harness car seat with a latch system. They rely on city water for drinking. Their insurance coverage is under Blue Cross Blue Shield, including prescription drug coverage. The mother reports the client has a strong support system comprising immediate and extended family.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
REVIEW OF SYSTEMS
Constitutional
Mother denies any fever, chills, loss of appetite, weight changes, fatigue, or night sweats.
Eyes
Mother denies any vision problems. The client does not use visual aids such as eyeglasses or lenses. She went for an eye exam the last time on August 2022, and the results indicated everything was completely normal. (Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Ears/Nose/Throat
Denies any altered sensitivity of ears or nose, vertigo, tinnitus, pain, discharge, bleeding, hoarseness, or lesions. Denies runny nose, sore throat, difficulty swallowing.
Mouth / Dental
Mother denies any tooth decay or gum disease. Denies mouth ulcers. Her last dental visit was August 2022. Denies speech problems, sinus drainage, or snoring. 
Breast
Mother denies family history of breast cancer.
Cardiovascular Denies any current or recent chest pain, palpitations, discomfort, or racing heart. Mother denies hypertension, feelings of shortness of breath when laying down or playing.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Respiratory Denies any current or recent breathing difficulties, persistent cough, or pain while breathing.
Gastrointestinal
Denies any current or recent weight or appetite changes. Denies any abdominal pain, diarrhea, or constipation. Denies bowel movement difficulties, with her last being today morning, which was soft inconsistency, brown in color, and no blood stains. Mother reports bowels movements 2-4 times daily. 
Genito-Urinary
Denies pain during urination or problem passing out urine. Reports regular frequency.
Male Reproductive
N/A
Female Reproductive
Denies any recent rashes, itching, swelling, lesions, acne, moles, or urticaria. Denies nipple discharge or pain.
Musculoskeletal Denies any joint or muscle stiffness, swelling, or pain. Denies muscular tiredness and fatigue. Denies tenderness.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Neurological
Denies fatigue, weakness, syncope, or problems with balance. Mother denies history of current or recent falls or loss of balance. Denies seizures, headache, vertigo, numbness, loss of vision, diplopia, loss of sensation, paralysis, tremors, or limb numbness.
Skin
Denies itching, rash, lump and bumps, hair changes, nail changes, or depigmentation.
Endocrine
Denies excessive hunger, thirst, or changes in hair thickness, texture, or distribution. Denies recent changes in weight. Denies heat or cold intolerance or any thyroid issues.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Hematologic/Lymphatic:
Denies abnormal bruising, anemia, or excessive bleeding. Denies any enlarged or tender lymph nodes, petechia, or puparia.
Psychiatric
Denies sleeping difficulties and reported feeling well-rested. Denies any feelings of stress, anxiety, or mood changes. Mother states that D.C. enjoys day care and denies experiencing bullying. D.C. is active outside and indoors and likes riding her bike, which has hind-supported wheels. Denies agitation. Denies memory loss.
PHYSICAL EXAMINATION
Vital signsHt: 32.8 inches Wt: 26 lbs BMI: 17.3 
 Temp: 97.9 Pulse: 120 BP: 96/62 
 RR: 26 Pain: 0/10   
General Appearance
D.C. is alert and oriented ×4. The client is sitting upright independently and does not seem to be in any distress or discomfort. D.C. appears well-groomed, hygienic, well-dressed, and nourished. She maintains eye contact. She is comfortable with or without movement.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Head Head is symmetric and normocephalic. No trauma, no hair loss, no dryness, rashes, or lesions noted. Hair blonde with no scalp dryness or flakes.
Eyes Eyes symmetrical, sclera white, conjunctiva pink, PERRLA bilaterally, extraocular motions intact bilaterally. Red reflex noted. The patient has 20/20 vision on the R and L eye with the Snellen chart. A visualized optic disc is sharp and round. No hemorrhages or drainage noted, and no arteriovenous (AV) nicking or cotton wool bodies.
Ears/Nose/Throat
Clear external auditory canals, pinnae normal shape, no pre-auricular pits or skin tags. TM’s visualized, pink-grey bilaterally with no bulging noted. No erythema or discharge. Nares patent bilaterally, septum midline, normal pink mucosa, no polyps, no discharge.
Mouth / Dental
10 teeth w/ -caries, tonsil without exudate, buccal mucosa moist, positive gag reflex. Oropharynx w/ no signs of erythema or ulceration. Normal movement of soft palate.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Neck Supple with no lymphadenopathy. Trachea midline with full ROM. No JVD is appreciated.
Respiratory Lungs clear to auscultation bilaterally. Patient is breathing comfortably on room air.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Cardiovascular
Regularly irregular rate and rhythm, S1 and S2 were heard with no rubs, murmurs, or gallops. No S3 or S4 noted.
Gastrointestinal Abdomen soft, non-tender, non-distended, bowel sounds are present in all four quadrants. No organomegaly is palpated.
Musculoskeletal: Symmetrical with full ROM. Negative kyphosis, lordosis, joint swelling.
Genitourinary/Gynecological: Genitals within normal limits for developmental age, Tanner stage I, no swelling, lesions, or masses noted. No external hemorrhoids.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Lymphatic No lymph nodes felt (auricular, cervical, submental, submandibular, axillary, and epitrochlear)
Skin Dry, pink, intact, no scars, rashes, ecchymoses, or lesions noted. Hair is evenly distributed. Nail beds are pink with a cap refill of 2 seconds(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Back, Extremities, Musculoskeletal
No clubbing or cyanosis and noted. Bilateral lower extremities with no edema. Plus, two pedal pulses noted bilaterally. Calves supple none tender.
Neurological Patient is awake and alert with no focal deficit. Moves all extremities symmetrically with appropriate tone; DTRs with negative tremor/clonus; positive sensation.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Psychiatric Mood and affect appropriate. Well-adjusted and comfortable during exam.
Previous Diagnostic Testing/Lab Results No reported previous diagnosis or lab results.
List 3 Differential Diagnoses with Rationale
Well child exam without abnormalities (Z00.129):  D.C. is being evaluated as a well-child at the clinic. The well-child visits are annual, and it is recommended to continue with the same to monitor her development and any changes that might indicate abnormalities in health and development relative to age. The well-child assessment allows for a robust examination of the child and an opportunity for further evaluation if the provider identifies any abnormalities in health or development (Turner, 2019). The examination was head-to-toe and involved reviewing growth. This assessment also allows the assessment of accidental injuries and self-harm behavior. (Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Seasonal Allergies (Z91.0):  The mother reports the patient experiences seasonal allergies. However, no specific allergies have been diagnosed or detected yet. Patients with seasonal allergies report experiencing sneezing, nasal pruritis, clear rhinorrhea, and nasal congestion (Akhouri & House, 2019). Besides the nasal symptoms, individuals with seasonal allergies might present with or develop allergic conjunctivitis, chronic sinusitis, Eustachian tube dysfunction, and non-productive cough.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example) 
 Immunization (Z23):  The client’s immunization schedule is up to date relative to age-related vaccines, as per the mother’s report. She receives flu vaccine annually during every winter season as required by the CDC (2022). The schedules are per the CDC and have been followed to the latter without exceptions.(Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
ASSESSMENT Well child exam without abnormalities (Z00.129): Well child exam without abnormalities is the conformed diagnosis. D.C. is being evaluated as a well-child at the clinic. The well-child visits are annual, and it is recommended to continue with the same to monitor her development and any changes that might indicate abnormalities in health and development relative to age. The well-child assessment allows for a robust examination of the child and an opportunity for further evaluation if the provider identifies any abnormalities in health or development (Turner, 2019). The examination was head-to-toe and involved reviewing growth. This assessment also allows the assessment of accidental injuries and self-harm behavior. (Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
PLAN Diagnostics:  The client, a pleasant 18-month-old female, is sitting on a chair at the clinic. D.C. is developmentally appropriate relative to age. Besides the well-child examination, D.C. will receive her Hep A vaccine today. The MCHAT and Autism screening indicate no health concerns. Per the CDC growth chart, the child’s height and weight are relative to age and are in the 75th percentile. I have discussed with the mother regarding health maintenance directives listed below under patient education which she will adopt for the next six months before the next well-child visit(Documentation of History and Physical Exam Comprehensive Nursing Essay Example). I clarified all the mother’s questions regarding the development of her child. The parent will be provided with educational materials she will use for her child.  Medications: Continue with Zyrtec children’s allergy 1mg/ml 5 ml per day. Referral/Consults: The mother should see an allergist to evaluate the seasonal allergies the patient experiences and establish a specific diagnosis.   Education: educate parent on health maintenance. Health Maintenance Directives: Ensure car safetyPromote water safety and purify tap waterEnsure D.C. wears a helmet on her bike Promote a safe home environment Ensure medications, cleaning elements and detergents, and other substances that might be poisonous are out of reach. Ensure appropriate behaviors by using strategies such as time-outsConverse and read with the child.Avoid sugary drinks and foods.Continue using whole milk until the child is 2 years old. Continuing brushing her teeth twice daily.Use materials provided for toilet training tips. Follow Up: A follow up is scheduled for the next 6 months, but the mother will return for the annual flue vaccine when the clinic initiates the influenza vaccination. (Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
REFERENCE Akhouri, S., & House, S. A. (2019). Allergic rhinitis.  In: StatPearls [Internet]. Treasure Island (FL). StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538186/ Centers for Disease Control and Prevention. (2022, November 22).  Child and Adolescent Immunization Schedule. Retrieved from https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html Centers for Disease Control and Prevention. (2022, November 22).  Who Needs a Flu Vaccine. Retrieved from https://www.cdc.gov/flu/prevent/vaccinations.htm Turner K. (2019). Well-Child Visits for Infants and Young Children. American family physician98(6), 347–353. https://pubmed.ncbi.nlm.nih.gov/30215922/  (Documentation of History and Physical Exam Comprehensive Nursing Essay Example)
Documentation of History and Physical Exam Comprehensive Nursing Essay Example
Documentation of History and Physical Exam Comprehensive Nursing Essay Example 1

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