Advanced Health Assessment and Diagnostic Reasoning

Advanced Health Assessment and Diagnostic Reasoning

Discussion: Assessing the Heart Lungs and Peripheral Vascular System
Take a moment to observe your breathing. Notice the sensation of your chest expanding as air flows into your lungs. Feel your chest contract as you exhale. How might this experience be different for someone with chronic lung disease or someone experiencing an asthma attack?
In order to adequately assess the chest region of a patient, nurses need to be aware of a patient’s history, potential abnormal findings, and what physical exams and diagnostic tests should be conducted to determine the causes and severity of abnormalities.
In this Discussion, you will consider how a patient’s initial symptoms can result in very different diagnoses when further assessment is conducted.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the video case studies in this week’s Learning Resources titled Advanced health assessment and diagnostic reasoning. Also, your Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
To prepare:
With regard to the case study you were assigned:
Review this week’s Learning Resources and consider the insights they provide.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Discussion – Week 6”) with “Review of Case Study” identifying the number of the case study you were assigned.
Post:

scenario #2 Advanced health assessment and diagnostic reasoning.

1. a description of the health history you would need to collect from the patient in the case study you were assigned.
2.Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
3. List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

SOAP SAMPLE:

Patient Initials: _JM___                      Age: __46__                           Gender: __M__

SUBJECTIVE DATA:

Chief Complaint (CC): New onset of rash

History of Present Illness (HPI): Jerry Morgan is a 46-year-old Caucasian male who presents today with complaints of a new onset of a red rash that has developed over the past few days on his trunk area.  He has noticed no associated symptoms, aggravating or relieving factors, and has not attempted any treatments of this rash.  He states that the rash is not severe or impacting his daily life, but he is concerned that it may be something serious.
Medications:
Metoprolol 25mg PO BID
Pravastatin 40mg PO at bedtime
Xarelto 20mg PO daily with dinner
Over-the-Counter Pepcid AC 10mg PO daily

Allergies: Penicillins- rash, Sulfa drugs-rash, bees.

Past Medical History (PMH):
Hypertension- well controlled
Atrial Fibrillation- well controlled
Gastroesophageal Reflux (GERD) – takes daily OTC acid reducer
Dyslipidemia- well controlled

Past Surgical History (PSH):
Tonsillectomy (1976)
Vasectomy (2005)
Cholecystectomy (2010)
Total Knee Replacement (2014)

Sexual/Reproductive History: Patient denies any reproductive issues or risky sexual behavior. Currently married with 4 children and has had a vasectomy. No history of STIs.

Personal/Social History: Patient has smoked 1.5 packs of cigarettes/day x 30 years; drinks 5-10 beers/week; admits to regular marijuana use x 30 years. Patient does not have regular exercise habits but considers himself fairly active through outdoor work and occasional kayaking/hiking trips; his diet is regular and he admits is not healthy, mainly consisting of fried, fatty foods.

Immunization History: His last Tdap was in 2006 and he declines the Flu and Pneumonia vaccinations.

Significant Family History:
Father- Atrial Fibrillation, Hypertension, Myocardial Infarction, Diabetes-Type 2, Dyslipidemia –died at age 68 of heart attack.
Mother- Ischemic Stroke, Hypertension, Dyslipidemia-died at age 70 from complications of stroke.
Siblings- two sisters with history of hypertension and diabetes-type 2, one with history of breast cancer in 2006.
Children-all healthy with no medical issues

Lifestyle: He currently owns and operates his own pest control business and has for the past 15 years.  He has been married once and has 4 children with his wife.  They live in a suburban middle-class neighborhood with good transportation and school systems.  He enjoys outdoor activities and often works on household issues in his free time.  He has a strong support system through family and friends.  He gets yearly check-ups for physical, vision, and dental health maintenance.

Review of Systems: From head-to-toe, include each system that covers the Chief Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses). Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).
General: Negative for recent weight changes, fever, chills, night sweats, or changes in energy levels
Respiratory: + for occasional productive cough with dark sputum in the mornings, denies any shortness of breath on exertion or exposure to tuberculosis
Cardiovascular/Peripheral Vascular: Negative for chest pain, palpitations, edema, claudication, exercise intolerance.
Gastrointestinal: + for heartburn; negative for nausea, vomiting, bowel changes
Skin: + for ruby red papular rash on trunk, denies pruritus, pain, eruptions, or pigmentation changes.
Hematologic: + for prolonged bleeding times and easy bruising, negative for anemia
Allergic/Immunologic: + for drug allergies to penicillin and sulfa drugs, bees. Denies any recent new drug use. No current issues.

OBJECTIVE DATA:

Physical Exam:
Vital signs: T- 98.9 oral; P- 72, irregular; BP- 128/72 left arm, sitting, long cuff; RR- 18; Pain 0/10 Ht: 6’2” Wt: 210 lbs BMI: 27

General: AAO x3, moves all extremities, gait normal, well developed, well nourished, not malodorous. Appears comfortable and not in any apparent distress.
Chest/Lungs: Breath sounds clear and equal AP&L bilaterally
Heart/Peripheral Vascular: Irregular rhythm, controlled rate. No murmur, rub, or gallop. Pulses +2 bilateral radials and +2 bilateral pedals.
Abdomen: Bowel sounds present x4 quadrants. Soft, non-tender, non-distended. No organomegaly.
Skin: Ruby red papular rash on the trunk with no itching or pain present. No edema, clubbing, or cyanosis. No palpable nodules.

Lab Tests and Results:
CBC- RBC 5.7, PLT 250, HGB 15, HCT 44
PT/INR- 22/2.1
PTT- 27 sec.

ASSESSMENT:

Priority Diagnosis: Cherry Angioma

Differential Diagnoses:
Drug eruption
Pityriasis Rosea
Thrombocytopenic purpura

The primary diagnosis selected in this patient is cherry angioma, as the clinical presentation and history best supports this diagnosis.  The patient presented with a non-painful, non-pruritic papular rash limited to the trunk of the body with no other negative symptoms.  A drug eruption could be responsible for a red rash on the patient’s trunk, but the patient denies any use of new medications and the rash is not generalized, pink, and morbilliform, how drug rashes usually are presented (Ball et al., 2015).  Pityriasis Rosea meets some of the criteria, but the rash is not itchy, scaly, or in oval patches, and the patient denies any recent illnesses (Dains, Baumann, & Scheibel, 2016).  Thrombocytopenic purpura is a contender for a priority diagnosis since the patient is on blood thinners and at risk for increased bleeding, but lab results show that platelet and other blood counts are within normal limits, and the rash is not generalized (Ball et al., 2015).