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.

First question I failed to ask Mr. Hall was whether he have had any treatment for his cough. It is always important to ask about self-treatment patient may have tried and the response. Determine what the patient has done to minimize the symptoms including whether he has altered normal activity or taken any medication prescribed or OTC(Goolsby and Grubbs, p.207). Second question was whether he has had a cough like this one before. The quality of symptoms is important. For cough the potential qualities includes whether the cough is mild and tickling or sharp and paroxysmal, it is also necessary to determine the exact location to the symptoms and whether patient has noticed any radiation to other sites and how it relates to respiration (Goolsby and Grubbs, pag 207)

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.

I did not auscultate the anterior and posterior chest in the correct order. Auscultation is the most important technique to assess air flow through the tracheobronquial tree. According to (Bickley. 2017). Using patter from percussion should be follow to auscultate moving from one side to the other and comparing symmetric areas of the lungs. Listen to at least one full breast in each location. I did not document right the adventitious sound heard when assessing Mr. Hall’s right lung. The correct documentation should be coarsed crackles, which are somewhat louder, lower in pitch, while fine crackles are soft, high pitch(Brickley.2017)

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.

 I found out that the patient had coarse crackles in his right lung during the auscultation of the breath sounds. According to Bickley (2017), the origin of coarse crackles is at the period of early inspiration. Then they proceed during the biphasic period through the expiration with a specific popping sound. Their characteristic feature is that the change in a body position does not cause any variation in the crackles and they can be heard in all lung regions. Fine crackles last for a shorter period of time and have higher frequency. Besides, coarse crackles get to the mouth, and they disappear or transform while coughing. Having obtained this result, I used it as a finding that indicated pneumonia as a diagnosis. Goolsby (2014) claimed that consolidation caused by the increase in breath sounds throughout the peripheral regions of lungs can indicate having pneumonia. According to Bickley (2017), the reason for crackles may be either lung parenchyma abnormalities, in particular pulmonary fibrosis, pneumonia, atelectasis, interstitial lung disease, heart failure, or problems with the airways, in particular bronchiectasis, bronchitis, or other ones.

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 did not indicate Crackles in the RLL in my differential diagnosis although I noted it during the physical assessment. This abnormal finding is important as it implies having diagnostic testing and obligatory follow-up. The non-musical sounds of crackles may be of different types: early inspiratory, biphasic, or late. The patient had a characteristic popping sound for coarse crackles, which was evident on his physical anterior and posterior assessment and RLL (Bickley et al., 2017). The cause of coarse crackles can be gas boluses which pass through opening and closing airways. It is a symptom in the patients who have bronchiectasis, COPD, heart failure, pneumonia, or asthma (Bickley et al., 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 missed Pneumonia community acquired as an important differential diagnosis. Pneumonia involve inflammation and consolidation of lung tissues. It’s broadly categorized by whether if occurs outside the hospital(Community adquired pneumonia), or within the hospital(Nosocomial, or hospital adquired pneumonia).The symptoms of pneumonia are quite varied. Usually the patient complaint of cough associated with fever, malaise, shaking chills, rigor and chest discomfort. Abnormal vital signs include tachycardia and tachypnea and fever. There is uneven fremitus and the area over the consolidation percusses dull. On auscultation there are bronchial breath sound, often with crackles.(Goolsby and Grubbs. P. 214)

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.

The first question I missed was “Has there been any change in your cough over time?” The importance of this question is related to the duration of the length of the time the patient has been experiencing the cough.  An acute cough is a cough that lasts up to three weeks, a subacute cough lasts three to eight weeks, and a chronic cough lasts eight weeks or longer (Goolsby & Grubbs, 2014).  The second question that I missed asking was “Have you ever had a cough like this before?”  This question is important to ask to determine history of present illness in the patient (Goolsby & Grubbs, 2014).  It is important to determine whether the patient has experienced this illness before and if so, which treatment was performed and if it was effective or not.  

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 errors I made in my physical exam was failing to inspect the eyes.  Inspecting this patient’s eyes is important because of the important information that can be revealed through this exam.  An eye exam can show systemic conditions, local bacterial infections, or ocular infections such as cytomegalovirus retinitis (Goolsby & Grubbs, 2014).   The secont exam I failed to complete is inspecting the head.  This is of particular importance for this patient as patients who have HIV frequently have lipodystrophy.  Lipodystrophy is when fat is redistributed as a secondary occurrence to antiretroviral therapy.  This HIV-related lipodystrophy presents in two ways: lipohypertrophy and lipoatrophy.  Lipohypertrophy is the excess accumulation of local fat tissue and lipoatrophy is the loss of local fat tissue.  A head inspection can reveal if this is occurring (Goolsby & Grubbs, 2014).  

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 that I performed was inspecting the mouth and pharynx.  This particular exam reveals information such as head trauma and general neurological status (Goolsby & Grubbs, 2014).  It can also reveal issues such as a sore throat and swollen tonsils (Goolsby & Grubbs, 2014).  Examining the oral mucosa will also be done during an oral exam.  This indicates various signs of health, including hydration or dehydration.  Cyanosis around the oral area can indicate a decreased level of oxygenation, so this can also be noted at this time (Bickley, et al., 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.

Unfortunately, I left out the history of hypertension in this patient when assessing my patient.  This is important to include, especially when assessing the orthostatic blood pressure drop.  Orthostatic blood pressure is defined as a drop in systolic blood pressure of at least 20 mm Hg or drop in diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing (Bickley, et al., 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.

One diagnosis I missed was autoimmune disorder.  Many autoimmune disorders manifest in pulmonary manners.  Symptoms may include cough, dyspnea, hemoptysis, chest pain, fever, fatigue, lymphadenopathy, skin lesions, unintended weight loss.  Three examples of autoimmune disorders are sarcoidosis, systemic lupus erythematosus, and granulomatosis with polyangiitis (Grubbs & Goolsby, 2014).