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.

One of the questions that I did not ask was, “Does she have any pain anywhere? If so where?” I guess I did not ask this because I assumed the patient wouldn’t be able to verbalize if she were having pain. The mother’s response was “I think she is having pain because she has been fussy, but she can’t tell me where.” I did ask if the patient had been tugging at her hears though. I should have asked this question to the mother and also used the FLACC scale and compare the patient’s facial expression. FLACC scale, for children aged two to seven, assesses a child’s pain based on their facial expression, leg and arm movements, the extent of crying and ability to be consoled (Sickkids Staff, 2009). I also did not ask if the patient was having discharge or bleeding from her ears. Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook explain, “Discharge in the canal without acute otitis externa suggests perforation” (p. 374). Purulent discharge in the ear canal may be sampled for culture and used as a basis for antibiotic selection (Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook, p. 374). This would be important information to have. The drainage would be beneficial to test for sensitivity especially if the ear infection were recurrent.

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.

An error in the physical exam I made was inspecting the eyes with an ophthalmoscope. I should have only assessed the eyes by looking at the conjunctiva to assess hydration. I would not use the ophthalmoscope on a 2-year-old because it would not be necessary for this patient and she would probably not sit still. If it were more serious to assess her eyes I would. Using the ophthalmoscope to visualize the fundus is one of the most challenging skills of physical examination, and one of the most critical when assessing head-ache and changes in mental status (Bickley, p. 238). The other physical examination that I missed was a visual inspection of the chest wall and lungs. Since the patient is having a cough, fever, and runny nose and diagnosis of upper respiratory infection is on my radar I should have chosen this exam in order to assess for retractions. If retractions are present then the patient is working to breathe and maybe in respiratory distress. Abnormal muscle retraction of the intercostal spaces occurs during inspiration, most visible in the lower intercostal spaces (Bickley, p. 319).

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 that I found was bilateral tympanic membranes with erythema and severe bulging. I visualized this by using the otoscope. The otoscope allows you to visualize the ear canal and drum (Bickley, p. 245). I will start by positioning the patient’s head so that I can see comfortably through the otoscope (Bickley, p. 245). Bickley explains how to inspect the ear using an otoscope as,

“First straighten the ear canal, grasp the auricle firmly but gently and pull it upward, backward, and slightly away from the head. Insert the speculum gently into the ear canal, directing it somewhat down and forward and through the hairs, if any. Inspect the ear canal, noting any discharge, foreign bodies, redness of the skin, or swelling. Cerumen, which varies in color and consistency from yellow and flaky to brown and sticky or even too dark and hard, may wholly or partly obscure your view. Identify the handle of the malleus, noting its position, and inspect the short process of the malleus. Gently move the speculum so that you can see as much of the drum as possible, including the pars flaccida superiorly and the margins of the pars tensa. Look for any perforations.” (p. 245-246).

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 statements that I did not include in my list is the patient being exposed to other sick children at school and a history of the common cold. The presence of sinus and nasal congestion is relevant because otitis media is typically secondary to a cold or sinus infection (Goolsby and Grubbs, p. 131). Signs and symptoms of otitis media commonly are a current or recent history of symptoms consistent with an upper respiratory infection, including nasal congestion, sinus pressure/fullness, or sore throat (Goolsby and Grubbs, p. 132). The patient has symptoms of fever, cough, and runny nose. Upon physical inspection, the patient’s pharynx noted to have erythema and exudate.

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 did not consider was influenza. I am not sure why I didn’t include this in my differential diagnosis list. Maybe if the scenario stated which time of year it was I would have considered it. Buttaro, Trybulski, Polgar-Bailey, and Sandberg-Cook explain, 

“Influenza is an acute infection of the respiratory tract caused by influenza virus type A or B. It is usually a self-limited disease that occurs in outbreaks, primarily during the winter months. Influenza is transmitted from person to person through respiratory secretions that contain the virus. These respiratory secretions are spread in the form of droplets that are produced when a person talks, coughs, or sneezes. The virus is detectable and maybe shed in respiratory secretions up to 24 hours before the onset of symptoms. After an incubation period of 1 or 2 days, there is an abrupt onset of symptoms. These symptoms include fever, chills, headache, malaise, myalgia, and loss of appetite. Respiratory symptoms are also present but are usually overshadowed by the severity of the systemic symptoms. Respiratory symptoms include dry cough, nasal congestion with clear discharge, and sore throat. The cough is usually the most prominent of these respiratory symptoms. The patient’s temperature rises rapidly after onset, peaking at 37.7° C to 40° C (100° F to 104° F) in about 12 hours. The fever typically begins to decline on the second or third day but may last as long as 4 to 8 days” (p. 1241).

Discussion 2

Discussion Question 1

 (In this week two assignment, I am still figuring out how to navigate iHuman.  The program completely froze up on me after nearly completing it, twice.  It also reported several questions as “missed”, even though I had asked those questions to this patient’s mother.  I am hoping to soon work out the kinks in iHuman and hopefully will not continue to have these difficulties in the coming weeks.)

One of my missed history questions was “How high is her fever?”  I did ask Emma’s mother if she had a fever but failed to ask how high her fever had spiked.  This is important to know as a health care provider, as a low-grade fever and a high fever can dictate very different plans of care (Goolsby & Grubbs, 2015).  Another question I failed to ask was “What treatments has she had for her fever?”  When her mother informed me that she had given Emma Tylenol, I assumed that she had given her Tylenol for her fever, but I should not have assumed this, and should have followed up on the timing and dosage of the Tylenol, as well as the reasoning behind why she had given the Tylenol.  In addition, I should have asked what Emma’s response to the Tylenol was, and whether her fever had responded to it. 

Discussion Question 2

            The two missed exams reported were eyes and chest wall and lungs- visual inspection.  It is important to check for conjunctivitis in any child with upper respiratory infection symptoms.  It is also important to check for the use of accessory muscle use when breathing in a child with upper respiratory infection symptoms (Bickley, Szilagyi, & Hoffman, 2017).  (Again, I did perform this exam, but must have done something wrong for it to not have registered on iHuman).  

Discussion Question 3

             One key finding I included was cough.  According to Goolsby and Grubbs (2014), a cough is common complaint, but nonspecific in nature.  A cough is an important defense mechanism and is often the reason why patients seek treatment.  Cough can be a symptom of a mild or serious ailment (Goolsby and Grubbs, 2014).  When a cough lasts less than three weeks, it is classified as acute.  If it lasts three to eight weeks, it is classified as subacute.  A chronic cough lasts eight weeks or longer.  These classifications help to distinguish potential diagnoses.  Performing a thorough history and physical helps to determine possible causes and differentiate between severe illnesses and mild illnesses, such as asthma, COPD, acute or chronic bronchitis, GERD, heart failure, or lower or upper respiratory infections (Goolsby and Grubbs, 2014, p. 211-212).  Taking a thorough medication history will help to exclude a cough that is induced by an ACE inhibitor.  The patient’s prior treatment for cough, whether prescribed or self-treated, should also be recorded.     

Discussion Question 4

One missing category in my assessment was an influenza PCR.  I did send a rapid influenza diagnostic test, but I should have also sent an influenza PCR.  An influenza PCR can be more specific than a rapid influenza test and so should have been done. 

Discussion Question 5

            I did not include the possible diagnosis of pertussis.  Pertussis is a cough that is paroxysmal with a “whoop” at the end (Bickley, et al., 2017, p. 923). Due to the increase in pertussis infections, both the CDC and ACOG recommend that women receive the TDaP during pregnancy, between the 27th and 36thweeks (Bickley, et al., 2017, p. 937).