Discussion Board Of Advanced Health Assessment Paper
Discussion Board Of Advanced Health Assessment Paper
(This is a discussion board, please write about at least 2 pages and answer all the questions.)
Select one of the following cases to discuss. In the subject line of your post, please identify which prompt you are responding to, for example, choice #2 19-year-old male.
Case 1: An 89-year-old female complains of a “stabbing chest pain” and points to the area just below her scapula at the right mid-clavicular line. She states that she had an upper respiratory infection last week that “just seems to hang on.” No other complaints. Discussion Board Of Advanced Health Assessment Paper
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Case 2: A 58-year-old male presents with a complaint of severe chest pain over the last hour. He states that he did not call 911 because he cannot afford an ambulance.
Case 3: A 15-year-old immigrant was brought to the clinic by her mother because the patient complains of shortness of breath, chest pains, diaphoresis, and easy fatiguability. She claims she has had on and off bouts of tonsillitis since she was a child which resulted in tonsillectomy surgery when she was 12. Last week, she was unable to participate in the cheerleading tryouts because of knee pain and a rash that she noticed on her trunk for the past 2 weeks.
For the case you have chosen, post to the discussion: Discussion Board Of Advanced Health Assessment Paper
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive findings that validate your main diagnosis
Pertinent negative findings that make you think of other differential diagnoses
The treatment plan, including pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
The initial post must have a minimum of 300 words, excluding references.
TEXTBOOK :
Physical Examination and Health Assessment
• Author: Jarvis, C.
• Publisher: Saunders
• Edition: 7th
Advanced Health Assessment & Clinical Diagnosis in Primary Care
• Author: Daines, J. E., Baumann, L. C. and Scheibel, P.
• Publisher: Mosby Elsevier
• Edition: 5th
Covered Chapters :
• Jarvis
o Chapters 17-20
• Dains
o Chapters 6,11,14,8,26,33 Discussion Board Of Advanced Health Assessment Paper
Choice 1# an 89-year-old with stabbing chest pain.
SOAP note
Patient information
Patient initial: R.G. Gender: female. Race: Caucasian Age: 89
CC: Stabbing chest pain
HPI: R.G, an 89-year-old Caucasian female, presented alone to the clinic with a chief complaint of stabbing chest pain below her scapular at the right MCL. The patient also claimed to have had an upper respiratory illness in the last week, which seemed to have “hanged on.” She denies any other symptoms.
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Additional information needed
I would have to ask the patient when she first experienced the symptoms and whether any were exacerbating or alleviating variables. Whether the discomfort radiates to other places such as the neck, shoulder, or back, and whether she has previously experienced similar symptoms. The patient’s history must be obtained, including current medications, surgeries, and chronic conditions. She must detail the upper respiratory ailment she claims to have and whether she sought antibiotics to treat it. I would also need to know about her vaccination history, post-hospitalizations, significant family history, and substance abuse history. Discussion Board Of Advanced Health Assessment Paper
ROS
General: no fever, chills, and general fatigue reported
HEENT: no changes in vision or hearing reported.
Cardiovascular: No orthopnea reported but admitted having stabbing chest pain.
Respiratory: reported having had an upper respiratory infection. No symptoms were specified.
GI: No nausea and vomiting reported.
GU: No dysuria or polyuria reported
Msk: No joint or muscle pain was reported.
Neurologic: No dizziness or issue with gait reported.
Endocrine: No issue with heat or cold intolerances reported.
O.
PE
Regarding physical examination, I would take the patient’s vital signs to detect deviations, focusing on her breathing rate and temperature. I would also have to determine her oxygen saturation. I would perform a HENT examination to rule out any malformations. I would inspect her lungs and percuss them appropriately to determine lung sounds and resonance abnormalities. I would check her cardiovascular system to rule out any thrills, murmurs, gallops, or rub. I would also have to examine for any anomalies in the S1, S2, and S3 sounds. Because she is 89 years old, I would need to examine her spine to evaluate whether the curvature of the cervical, thoracic, and lumbar regions is within their limits, as well as any gait instability. I also need to assess her mood, judgment, intuition, and memory. Discussion Board Of Advanced Health Assessment Paper
Lab test and result
I would request a chest X-ray
Diagnoses
Differential diagnoses
Pneumonia
This respiratory condition is distinguished by severe or stabbing chest discomfort. It also causes fever, coughing, and difficulty breathing. While there are several varieties of pneumonia, determining the particular cause is frequently challenging. Pneumonia may be a complication of another respiratory illness; in many situations, untreated Upper respiratory tract infection (Palmucci et al., 2022). Thus, most likely a diagnosis.
Other possible diagnoses include
COPD
COPD is a chronic lung disease that damages the lungs’ air sacs. Shortness of breath is the most common symptom (Meek et al.,2019). Individuals may have chest discomfort, although it is typically minimal and is caused by breathing issues.
Pulmonary edema
Pulmonary edema is a condition in which the lungs flood with fluid. This might result in difficulties breathing and chest discomfort (Herrero et al., 2018)Discussion Board Of Advanced Health Assessment Paper. It is further distinguished by bloody froth, groaning, and abdominal enlargement, none of which were evident.
Plan
Lab test: Further lab test on CBC, and pulse oximetry is needed.
Medication: Give azithromycin 500mg PO as a single dose on the first day, then 250mg PO QDX4 (Chou et al.,2019).
Patient education: Encourage the patient to take medicine as directed to avoid the development of antibiotic resistance. Teach the client how to perform chest physiotherapy to improve and optimize oxygenation. She needs to be educated on good nutrition and the need to drink plenty of water.
Follow-up: The patient should return to the clinic after seven days for further assessment. Since she is elderly and quickly forgets, one of her family must be contacted to remind her of the same Discussion Board Of Advanced Health Assessment Paper.
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References
Palmucci, S., Galioto, F., Fazio, G., Ferlito, A., Cancemi, G., Di Mari, A., … & Basile, A. (2022). Clinical and radiological features of lung disorders related to connective-tissue diseases: a pictorial essay. Insights into Imaging, 13(1), 1-26.
Meek, P., Lareau, S., Fahy, B., & Austergard, E. (2019). Surgery for chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 200(2), P5-P6.
Herrero, R., Sanchez, G., & Lorente, J. A. (2018). New insights into the mechanisms of pulmonary edema in acute lung injury. Annals of Translational Medicine, 6(2).
Chou, C. C., Shen, C. F., Chen, S. J., Chen, H. M., Wang, Y. C., Chang, W. S., … & Medicine, C. C. (2019). Recommendations and guidelines for the treatment of pneumonia in Taiwan. Journal of Microbiology, Immunology and Infection, 52(1), 172-199 Discussion Board Of Advanced Health Assessment Paper