NURS 680A Advanced Health/Physical Assessment Week 6 Discussion Prompt

NURS 680A Advanced Health/Physical Assessment Week 6 Discussion Prompt

NURS 680A Advanced Health/Physical Assessment Week 6 Discussion Prompt

Complete your weekly discussion prompt.

Select one of the following case studies to address:

  1. A 9-year old female presents with her mother complaining of a dry cough that “wakes up everyone in the house” each night for the last 2 weeks. Denies prior hx of the same.
  2. A 29-year old newly immigrated woman complains of weakness, shortness of breath, cough and night sweats for the past month.

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For the case you have chosen, post to the discussion:

  • 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 and negative information
    • Differential and working diagnosis
    • 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.
  • In your peer replies, please reply to at least one peer who chose a different case study.

Sample solution

Subjective:

CC: A 9-year-old female presents with her mother complaining of a dry cough that “wakes up everyone in the house” each night for the last 2 weeks. Denies prior hx of the same.

HPI: How long does the cough last? What other symptoms does she have with the cough? How severe is the cough? Does she wheeze, get short of breath? What is she doing before it happens? Is the window open? Is there cold air circulating in the house? Is the fan on? How she had any colds? Is she around anyone that smokes? Does this cough occur during season or during exposure to tobacco smoke, perfume, household pets, fireplaces, woodboring stoves, mold, dust mites, or cockroaches? How often does the coughing wake her up? Does she do any physical activity? Is the cough worse at night or early morning? Does she have a sore throat? Do you have a fever, N/V/D, H/A, loss of appetite, or family history of asthma?

ROS: Assess HEENT, lymph nodes, heart, lungs, psych.

PMH: Do you have hx of DM, CAD, asthma or CA. Autoimmune disease?

Meds: Did you take any medications?

Allergies: Food allergies or medication allergies? Allergies to latex or animals?

FH: FH of CA, CAD, asthma or DM.

Social Hx: Does she go to school? Where do you live? Do you have any pets? Do you drink alcohol, smoke tobacco or cigarettes, marijuana, vape, or any illicit drugs?

Health Related Behaviors: All immunization up to date?

ROS: How are you feeling these days? Any heart or lung issues? Are you sleeping well? How school life?

Objective/PE: VS, BMI, overall appearance, heart, lungs, HEENT, and psychiatric.

Assessment: DDX:

  1. Asthma: + nocturnal cough, dry and hacking cough (Sawicki & Haver, 2022). – wheezing, allergies, weather induced, SOB, or chest tightness (Sawicki & Haver, 2022).
  2. URI: + cough (Cash & Glass, 2017). – sore throat, sneezing, purulent nasal or throat discharge, low grade fever, rhinorrhea, nasal obstruction (Cash & Glass, 2017; Deshazo & Kemp, 2022).
  3. Allergic rhinitis or sinusitis: + cough (Cash & Glass, 2017). – nasal congestion, sneezing, clear rhinorrhea, sore throat, itchy eyes, and allergies (Cash & Glass, 2017).

Plan:

Labs:

  1. Spirometry to help diagnosis airflow obstruction (Sawicki & Haver, 2022).
  2. CXR and CBC to r/o infection (Cash & Glass, 2017).
  3. Allergy testing if diagnosis is asthma (Cash & Glass, 2017).
  4. Bronchoprovocation testing- if spirometry is normal but symptoms suggestive of asthma (Sawicki & Haver, 2022).

Referral: Not now unless treatment given is not working.

Education/TM:

  1. Teaching on how to use nebulizer correctly (Cash & Glass, 2017).
  2. The importance of using peak flow monitor at home to monitor progress (Cash & Glass, 2017).
  3. Use Albuterol for acute occurrences and using Albuterol more than 2x a week for relief of symptoms means the patient does not have adequate asthma control and needs inhaled corticosteroid (Cash & Glass, 2017).
  4. Stay away from dust allergens, outdoor pollens, irritants, and smoke (Cash & Glass, 2017)
  5. If cold air triggers asthma symptoms wear something that covers your mouth and nose when you go outside (Cash & Glass, 2017).
  6. Color code your inhalers so you know which one is quick-relief and long acting (Cash & Glass, 2017).

Follow up: Check in with patient in a couple days to see if symptoms improve. If symptoms worse come back to clinic or ED.

Cash, C. J., & Glass, A. C. (2017). Family practice guidelines. Springer Publishing Company.

References