iHuman case: Rand Hall V3 PC
Complete only the History, Physical Exam, and Assessment sections of the iHuman case: Rand Hall V3 PC
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Do you have any pain or other symptoms associated with your cough?
The patient complained of cough and painful inspiration.  It is important to ask about the pain associated with the cough to determine possible causes.  According to Goolsby & Grubbs (2014) a cough is classified as acute (lasting up to 3 weeks), subacute (lasting 3-8 weeks, and chronic (lasting 8 weeks or longer). iHuman case: Rand Hall V3 PC
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Have you had the pain in your chest before? 
It is important to determine if the chest discomfort is a new symptom or has occurred previously.  The practitioner must question the patient to determine the severity of the pain and if it is sharp, aching, or dull (Goolsby et al., 2017).  If the patient has a cough and complains of chest pain or discomfort when coughing, it is important to pinpoint the exact location and determine if there is any radiation and how it relates to respirations (Goolsby et al, 2014).
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
Administered a pain stimulus to a conscious patient.
A verbally conscious patient is able to describe his pain and does not need a pain stimulus administered.  There are several pain scales that can be used.  Examples of these scales include the numeric rating scale (NRS), visual analog scale (VAS), and the verbal rating scale (VRS) (Goolsby et al., 2014).  Regardless of the scale used, it is important to assess each patient’s pain using the PQRST mnemonic.  This stands for palliative/provoking, quality, radiation, severity, and timing (Goolsby et al., 2014).
During the HEENT exam, I did not inspect the eyes.
Inspection of the eye is the primary technique when assessing the eyes (Goolsby et al., 2014).  It is important to access the lid, looking for any ptosis and to check the lid location is relation to other structures, such as the pupil and iris (Goolsby et al., 2014).  Also, according to Goolsby et al. (2014), it is equally important to inspect the conjunctiva and sclera for any redness or discharge.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text. iHuman case: Rand Hall V3 PC
During the physical exam, one key finding that I included was bronchial breath sounds.  Lung sounds are auscultated first on the posterior side and then moving to the anterior, both in a ladder motion (Bickley, 2017).  Bronchial breath sounds are harsher, louder, and higher-pitched than bronchovesicular or vesicular breath sounds (Bickley, 2017).  There is a short silence between inspiration and expiration and expiratory sounds last longer than inspiratory sounds (Bickely, 2017).  They should normally be heard over the manubrim (the larger proximal airways).  If the breath sounds are heard in a location distant from this location, the practitioner should suspect replacement of air-filled lungs by air or consolidated tissue (Bickely, 2017).
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
During the assessment phase of the visit, I left out the orthostatic blood pressure drop.  Orthostatic blood pressure is classified as a drop of at least 20 mm Hg in systolic pressure or 10 mm Hg drop in diastolic pressure within 3 minutes of standing (Bickley, 2017).  This is common problem of older adults and should be suspected if the patient is noted to have a substantially lower blood pressure when past blood pressures have been significantly higher.  It is accessed by measuring the blood pressure and heart rate in the supine and standing positions (Bickley, 2017).  The normal finding is that as the patient changes from the horizontal position to the standing position, the systolic pressure remains unchanged or drops slightly and the diastolic pressure rises slightly (Bickley, 2017).
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.
I listed pneumonia, pneumocystis as a diagnosis. However, this was not correct.  The correct differential diagnosis should have been community-acquired pneumonia.
This type of pneumonia occurs outside of the hospital and is most commonly caused by Streptococcus pneumoniae, Staphyloccus aureus, and Haemophilis influenzea (Goolsby et al., 2014).  The symptoms of community-acquired pneumonia include cough, fever, malaise, chills, rigors, and/or chest discomfort (Goolsby et al., 2014).  Many times, the patient will present to the clinic obviously ill.  Signs include abnormal vital signs, uneven fremitus, and the area over the consolidation will be dull when percussed (Goolsby et al., 2014).  When auscultating the lungs, bronchial breath sounds can be heard, with crackles many times (Goolsby et al., 2014).  The CURB-65 is a tool used to determine if the patient warrants a hospital admission (Goolsby et al., 2014).  It rates confusion, BUN, respiratory rate, blood pressure, and age and each area is given one point if it is present (Goolsby et al., 2014).  If the total score is 3 to 5, will require hospitalization for treatment (Goolsby et al., 2014).
 
References
Goolsby, J. M., & Grubbs, L. (2014). Advanced Assessment: Interpreting Findings and Formulating Differential Diagnoses (3rd ed.). [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780803645011/
Bickley, L. S. (2017). Bates’ Guide to Physical Examination and History Taking (12th ed.). [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9781496354709/
 
 
 
 
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Two questions that I did not ask specifically were:
Does the pain in your chest radiate someplace else? Where? And, any change in your chest pain since it began? I really missed more than two questions about chest pain. I asked about pain associated with his cough but did not explore his complaint of chest pain to the depth the expert said I should have. Although the pain the patient described did not seem to be cardiac in nature, according Goolsby (2015) any complaint of chest pain should be thoroughly investigated in all patients. Initially, determine whether the patient is having active cardiac symptoms during the evaluation, which would require emergent referral. Start by asking the patient about current medicines and comorbidities. Ask whether this is the first episode of chest pain or a recurrent symptom. Ask how long the chest pain has been going on, whether it is constant or intermittent, and whether it radiates to either arm, back, neck, or jaw Goolsby (2015). iHuman case: Rand Hall V3 PC
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
Two errors during the physical exam were:
Failure to assess and measure the jugular venous pressure. Jugular venous pressure can be useful in the differentiation of different forms of heart and lung diseases and should be included during a cardiopulmonary exam (Buttaro et al., 2017). An elevated Jugular venous pressure measurement could be a sign of right side heart failure, pulmonary hypertension, and tricuspid stenosis (Buttaro et al., 2017).
Incorrect lung sound documentation: Adventitious breath sounds are extra and abnormal sounds detected in addition to the expected breath sounds. Terms such as rhonchi, wheezes, and crackles are used to describe these adventitious sounds. It is important to provide as many descriptors as possible relative to the adventitious sound. Descriptors can include details of the detected pitch, amplitude, and quality of the sound. For instance, crackles can be described as loud or soft, coarse or fine. Wheezes, or rhonchi, can be described as loud or soft, high- or low-pitched, coarse/sonorous, squeaking, or hissing/sibilant. Another important characteristic to note is whether adventitious lung sounds occur early or late in the respiratory cycle. All of these characteristics are helpful in determining the cause Goolsby (2015) iHuman case: Rand Hall V3 PC.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
One key finding was: Tactile fremitus.
The quality of tactile fremitus is determined by palpating symmetrical areas with the palmar surface of the hands and fingers, as the patient is directed to speak, usually repeatedly saying “99” or “1-2-3” in a loud and a low-pitched voice. This maneuver provides only a rough estimate of lung condition but is useful in guiding further assessment. Areas of increased fremitus should raise the suspicion of conditions resulting in increased solidity or consolidation in the underlying lung tissue, such as in pneumonia, tumor, or pulmonary fibrosis. Conversely, areas of decreased fremitus raise the suspicion of abnormal fluid- or air-filled spaces, such as occurs with pleural effusion, pneumothorax, or emphysema. In the instance of an extensive bronchial obstruction, no palpable vibration is felt in the related field Goolsby (2015) iHuman case: Rand Hall V3 PC.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
I listed pneumonia as a diagnosis but did not specify that it was community acquired. The correct diagnosis should have been community-acquired pneumonia. This type of pneumonia occurs outside of the hospital and is most commonly caused by Streptococcus pneumoniae, Staphyloccus aureus, and Haemophilis influenzea (Goolsby et al., 2015).  The symptoms of community-acquired pneumonia include cough, fever, malaise, chills, rigors, and/or chest discomfort (Goolsby et al., 2015).  Many times, the patient will present to the clinic obviously ill.  Signs include abnormal vital signs, uneven fremitus, and the area over the consolidation will be dull when percussed (Goolsby et al., 2015).  When auscultating the lungs, bronchial breath sounds can be heard, with crackles many times (Goolsby et al., 2015).
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.
I missed: Angina as a differential diagnosis
According to Bickley (2017), the complaint of chest pain should warrant the provider to elicit the seven attributes of chest pain (OLDCART) to determine its cause. A cardiac origin for the chest pain should always be kept on the list of differential diagnoses for all adults
I missed: Angina as a differential diagnosis
 
Bickley, L. (2017). Bates’ guide to physical examination and history taking. (12th ed.) [South University]. Retrieved rom https://digitalbookshelf.southuniversity.edu/#/books/9781496354709/
Goolsby, Jo, M., Grubbs, Laurie. (2015). Advanced assessment: Interpreting findings and formulating differential diagnoses. [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/978080364501 iHuman case: Rand Hall V3 PC