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.

          The history questioning of patients, with i-Human, is difficult for me.  Mostly because I have trouble finding the questions I would like to ask, which is not the case for real patient interviewing.  When I first started speaking with this patient, I did not ask him his name, whereabouts, or the time.  When speaking with patients it is beneficial to know if they are alert and oriented.  If patients are not alert and oriented, they may not be able to accurately describe their symptoms, the duration of the symptoms, or provide you with accurate medical history (Bickley, 2016). 

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 portion of the assignment I inflated the blood pressure cuff too much, while checking the patient’s blood pressure.  Over-inflation of the cuff can cause unnecessary discomfort for a patient.  It is recommended that the appropriate size cuff be selected to avoid inaccurate blood pressure results (Fallon, 2015).  I honestly, get a little overzealous when I use the i-Human system and would not normally inflate a BP cuff to 230mmHg, even though many of my patients are known to have a BP that high.  During physical examination I failed to visually inspect the patient’s anterior and posterior chest walls.  Visual inspection can reveal recent traumas, skin changes, and abnormalities, such as redness, warmth, and edema (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.

          This patient had RLQ pain complaints, which prompted me to palpate his abdomen.  During palpation of the patient’s abdomen the patient has positive Psoas sign, and rebound tenderness.  This finding is indicative of appendicitis.  The Psoas test is performed by placing your hand on the right thigh, and asking the patient to raise the thigh against the hand. This maneuver contracts the psoas muscle putting pressure on the inflamed appendix (Goolsby & Grubbs, 2015).  

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.

          My documentation of the patient’s current symptoms during assessment was lacking the inclusion of parietal peritoneal tenderness, which should have been noted from the patient’s complaint of mid-abdominal tenderness, upon palpation.  Rebound tenderness is an indication of peritoneal irritation (Goolsby & Grubbs, 2015).  The severity of the pain could indicate inflammation of the appendix, or a complete rupture with resulting peritonitis infection.  

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.

Peptic Ulcer Disease (PUD) was a missed diagnosis for this patient.  The location of the patient’s abdominal tenderness leads me to believe his problem was located lower in the abdomen.  According to Goolsby and Grubbs (2015), any patient that presents with epigastric/gastric discomfort.  This patient also complained of not having an appetite, which can also be a symptom experienced by patients with PUD.  I also failed to test this patient for H. Pylori, which would also be warranted in patients with suspected Peptic Ulcer Disease (Goolsby & Grubbs, 2015). 

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.

Two questions that I failed to ask the patient were “What is your name” and “Where are you”. The level of consciousness indicates a patient’s level of arousal and awareness (Huntley, 2008). To accurately determine LOC, use objective criteria, such as eye-opening, motor response, and verbalization, both spontaneously and on command (Huntley, 2008). I did not ask these questions because the patient was able to answer my questions appropriately and did not seem disoriented during the assessment. 

 
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.
 

There was only one exam that I missed and it was a rectal exam. This is important because local tenderness can help identify if the appendix is retrocecal (Bickley, p. 212). Bickley explains, “To perform a rectal exam on a male have the patient lay on his left side and inspect the sacrococcygeal and perianal areas. Palpate the anal canal, rectum, and prostate” (p. 13).

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.
 

On the physical exam, I chose to palpate the abdomen. Bickley states, “Palpate all four quadrants. Firm, board-like abdominal wall suggests peritoneal inflammation, guarding if the patient flinches, grimaces, or reports pain during palpation. Rebound tenderness from peritoneal inflammation; pain is greater when you withdraw your hand than when you press down. Press slowly on a tender area, then quickly let go” (p. 208). Bickley also states, “Palpate deep with two hands for masses or tenderness. Abdominal masses may be: physiologic (pregnant uterus), inflammatory (diverticulitis), vascular (an AAA), neoplastic (colon cancer), or obstructive (a distended bladder or dilated loop of the bowel)” (p. 209).

 
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 missed was anorexia. This didn’t even cross my mind. Anorexia nervosa is an eating disorder characterized by weight loss (or lack of appropriate weight gain in growing children); difficulties maintaining an appropriate body weight for height, age, and stature; and, in many individuals, distorted body image (NEDA Feeding Hope, 2018). The patient stated that his pain started after he ate a turkey sandwich. At this point, I should have considered an eating disorder. Abdominal pain can also be a symptom of anorexia (NEDA Feeding Hope, 2018).

 
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 the diagnosis of pancreatitis. The patient stated his pain was near his belly button. Because of the location of the pain, this is why I did not consider pancreatitis. Goolsby and Grubbs state, “The pain of pancreatitis is severe, steady, and “boring” radiating from the epigastric region through to the back. It is often accompanied by nausea and vomiting, tachycardia, hypotension, and diaphoresis” (p. 180). Goolsby and Grubbs also state, “Alcohol abuse accounts for more than 80% of pancreatitis, making the history most helpful. Other causes include hyperlipidemia, drugs, toxins, infection, structural abnormalities, surgery, vascular disease, trauma, hyperparathyroidism and hypercalcemia, kidney transplantation, and hereditary pancreatitis” (p. 180).