Comment using your own words but please provide at least one reference for each comment.

Do a half page for discussion #1 and another half page for discussion #2 for a total of one page.

Provide the comment for each discussion separate.

Discussion 1

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.

          During my history questioning I failed to ask the patient questions about their issues with edema.  The timing of the patient’s swelling could provide useful information about the possible cause of the edema (Bickley, 2016).  This patient was not asked, “When did your swelling start?”  This patient has extensive cardiac history and the previous occurrence of edema could indicate that this patient has history of congestive heart failure, likely making this a reoccurrence (Goolsby & Grubbs, 2015). This patient could provide useful information about his symptoms, if asked the appropriate questions.  This patient was noted to have 2+, pitting, bilateral, lower extremity, edema.  I also failed to ask, “How severe is your edema?”. Severe edema or edema that occurs more generalized could indicate other health issues such as kidney or liver failure (Goolsby & Grubbs, 2015).   

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.

          During the physical exam of this patient I did not miss any of the required exams, but I seem to have more issues with documenting the exams properly.  When listening to this patient’s lung sounds, I did not correctly identify the fine crackles.  Honestly, I am unsure if this was because I was listening with my 4-year-old son continuously talking next to me, or if I just missed the finding. Bibasilar crackles, pretibial edema, and dyspnea are all symptom this patient presented with, that are indicative of Congestive Heart Failure (Goolsby & Grubbs, 2015). 

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.

          The patient had complaints of cough, and actual coughing during his examination.  This finding would lead me to further assess his respiratory system, through auscultation of his lung fields.  Auscultation of lung fields reveals more about what the patient is experiencing than most other methods of examination (Bickley, 2016).  There are multiple methods of examining patient’s respiratory system, one abnormal finding should lead you to investigate more in-depth.  Percussion of the patient’s lung fields should be done to set the chest wall in motion, as it can help you assess whether the lung is air-filled, fluid-filled, or consolidate (Bickley, 2016). 

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.

          This patient has a positive S3 heart sound, which was not identified by me.  Ihuman and myself are still getting to know each other, and I was having trouble hearing the patient’s heart tones during auscultation.  As previously mentioned, I should avoid doing homework while my young son is present. The S3, also known as the ventricular gallop, is an abnormal finding in an adult patient (Goolsby & Grubbs, 2015).  It occurs as a result of decreased myocardial contractions, fluid volume overload, and congestive heart failure (Goolsby & Grubbs, 2015).  Mitral valve and tricuspid valve regurgitation can also produce the S3 heart sound (Goolsby & Grubbs, 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.

          One of the differential diagnoses that I missed for this patient was hypothyroidism.  Hypothyroidism can cause edema, cold intolerance, fatigue, and weight gain (Goolsby & Grubb, 2015).  Hypothyroidism can range in severity from mild to severe, the condition known as myxedema is the more severe form of the condition.  Myxedema can actually lead to hypothermia, hypotension, hypercapnia, hypoxia, and seizure (Goolsby & Grubbs, 2015).  Missing this diagnosis could be critical.

Discussion 2

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.

I asked the patient what home medications that he was currently on, but I did not ask if he was taking them as prescribed. Missed appointments, failure to follow up with a referral or a diagnostic test, and failure to comply with dietary, medication, or exercise recommendations are all obstacles to improved patient health and safety (Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook, p. 47). I also did not ask the patient about possible heat or cold intolerance. Cold intolerance can be related to hypothyroidism; heat intolerance, palpitations, and involuntary weight loss in hyperthyroidism (Bickley, p. 118). Hypothyroidism could be an underlying cause for the patient’s weight gain.

 
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.
 

One of the physical examinations that I missed was inspecting the skin. I normally inspect when BLE while evaluating the edema such as blisters or discoloration, but I did not actually click that I would do this. The article, Causes, and Signs of Edema states, “Congestive heart failure can cause both peripheral edema and abdominal edema (ascites). This is because the heart is too weak to pump blood around the body properly, so the blood gathers in front of the heart. Because of this, and due to the increased blood pressure in the veins, fluid seeps out into the surrounding tissue. This may cause swelling in the legs or a build-up of fluid in the abdomen” (2016, para. 8). I also did not percuss the abdomen. Percuss the abdomen for patterns of tympany and dullness (Bickley, p. 208). This can help detect ascites that can be caused by congestive heart failure. 

 
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 of the physical exams I chose to perform was measuring for jugular vein pressure (JVP). To do this, measure the vertical distance between this highest point and the sternal angle, normally <3 to 4 cm (Bickley, p. 174).  Elevated JVP in right-sided heart failure; decreased JVP in hypovolemia from dehydration or gastrointestinal bleeding (Bickley, p. 174).  There is a picture demonstrating how to measure this in Bickley on page 175.

 
 
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.
 

One of the problem categories that I did not pay attention to was inferolaterally displaced PMI. Stanford medicine states, “Lateral displacement of the PMI to the left is usually seen in an enlarged heart” (2019). A common chest radiographic finding in HF is cardiomegaly, with a cardiothoracic ratio (the ratio of the diameter of the heart at its widest point to the maximum width of the thoracic cavity; the normal ratio is less than 1:2) that is increased more than 50% (Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook, p. 559). This is something I will take into consideration in the future.

 
 
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.
 

One of the diagnoses that I missed was Cardiomyopathy. Cardiomyopathy, the most common cause of heart failure, is a disease process of the myocardium that affects the heart’s pumping ability (Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook, p. 555). Although the patient’s final diagnosis was heart failure, he could have an underlying diagnosis of cardiomyopathy from his cardiac disease. Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook  explain,

“Classification of heart muscle disease is complex; an expert panel defined cardiomyopathies as “a heterogeneous group of diseases of the myocardium associated with mechanical and/or electrical dysfunction that usually (but not invariably) exhibit inappropriate ventricular hypertrophy or dilatation and are due to a variety of causes that frequently are genetic. Cardiomyopathies either are confined to the heart or are part of generalized systemic disorders, often leading to cardiovascular death or progressive heart failure–related disability.” (p. 555, para. 5).