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 missed was the following: “Do you have any intolerance to cold or heat, sweating, appetite changes, increased thirst, or urination more frequent than usually?” It is wrong to skip that question as the mentioned symptoms indicate the diagnosis related to some endocrine system disorder. The other question that I did not ask was “Is there any skin retraction or dimpling on your breasts?” It is always essential to know the answer to this question as those symptoms indicate several different diagnoses, including mastitis, breast abscess, inflammation to the breast fat tissue, breast cancer, breast trauma, fat necrosis, obstruction of the duct, or even advanced breast cancer. (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.

       My documentation had two essential errors, related to the assessments of cardiac auscultation and lung auscultation. Both of them should be covered in the framework of a physical assessment. Observing the cardiac and lung baselines should be always done careful by the health care providers as it allows identification of the condition and possible abnormalities (Bickley, Sizlagyi, Hoffman, 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.

      My performed assessment included the breast examination as a key finding. Since the patient’s cousin and mother had been diagnosed with breast cancer, it was natural for her to express her concern as well. The exam of her breast demonstrated an irregular consistency of “lumpy bumpy” type and slight diffuse tenderness in both breasts. Breast examination started with careful inspection of the skin color and all possible non-typical skin patterns and thickenings. Then I assessed the symmetry and size of breasts and peculiar features of nipples. I performed palpation of the patient, while she was lying supine to make the breast tissue flat. I used a pattern of vertical strip using my second, third, and fourth fingers, palpating to the nipple from the axillary zone in small circular motions from light through medium to deep (Bickley, Sizlagyi, Hoffman, 2017). I made both medial and lateral examinations and assessed for the availability of all lumps and nodules. I know that in case of presence of lumps, it is important to evaluate their characteristics and assess the tenderness, consistency, mobility, firmness, location, and size (Bickley, Sizlagyi, Hoffman, 2017). I also checked the patient for the nipple discharge of all kinds.

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 list omitted the endocrine category. It was a mistake as skipping the endocrine category can result in disregarding such diagnosis as diabetes. It is essential to ask questions related to excessive sweating, troubles with thyroid, intolerance to cold or heat, excessive hunger, excessive thirst, change in the size of shoes and gloves, as well as polyuria (Bickley, Sizlagyi, Hoffman, 2017). The answers to those questions determine the direction of further investigation to be conducted by the provider in the field of endocrine system. It is a matter of crucial importance as the patient does insufficient exercise, has unhealthy lifestyle choices, and BMI, so there is risk for diabetes. (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.

      I did not recognize a possible diagnosis of cervical neoplasm, which was supposed to be taken into consideration owing to the age of the patient. All women older than thirty years are advised to undergo the screening for cervical neoplasm every three years in case they had negative smears before or every five years if their HPV and PAP testing were negative. As the patient told that the PAP smear exceeded that three years ago; thus, she has to undergo such screening. (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.

Missed: Tell me about your diet, what do you normally eat?  Do you use any recreational drugs?

Diet is important for those with an increased risk of breast cancer.  Eating a well-balanced diet is important to maintain health, but when at risk for a life-threatening disease it becomes more of a priority.  The DASH (Dietary Approaches to Stop Hypertension) diet was found to support a decreased risk of breast cancer (Petimar, Park, Smith-Warner, Fung, & Sandler).  This is important to the risk of this patient’s concern for developing breast cancer due to her family history. 

Using recreational drugs is thought to be an unhealthy habit, in general.  One study found evidence that the interaction between drugs of abuse (DOA) and breast cancer resistance.  The hBCRP (human breast cancer resistance protein) ATPase activity can be enhanced or inhibited depending on the drug (Wagmann, Mauer, & Meyer, 2018).  So, if a patient with an increased risk of developing breast cancer uses drugs of abuse, it will also heighten their chances. 

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.

Missed: Rectal exam, and did not listen for BS for at least 3 secs in each quadrant.

The recommended screening of a rectal exam for women or all adults is 50 to 75 years (CDC, 2019).  Anyone who is younger would be screened due to an increased risk of developing cancer or colorectal problems.  I did not think that this was pertinent to the physical exam of our patient, CC, who was 41 years old since she did not have a family history or any medical history of rectal problems.  I also did not listen long enough to each quadrant with auscultation of the bowels. Bickley (2015, p. 501) writes, “Before deciding that bowel sounds are absent, sit down and listen” for at least 2 minutes, but do not say to listen for at least 3 seconds.  Bowel sounds can be very active and in order to differentiate between different sounds, it is important to listen at least until some are heard in succession. 

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.

Breast exam.  A breast exam includes visual inspection and palpation of the breasts when flattened.  Inspection should be performed while sitting at rest with arms at sides, then with arms raised above head, and also while sitting forward.  This helps to visualize if there is dimpling or discoloration in any position, which may not be obvious at rest. Also, palpation is important to note any masses or tenderness.  Breasts are broken down into quadrants to specify the location of any abnormal findings. Any nodules which are felt in the tail of Spence, are hard or irregular shaped, or fixed to the skin can be a higher indication of cancer (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.

Cardiovascular.  Due to CC’s family history of hypertension and high cholesterol, CC should be screened for her own cardiovascular risk factors.  Hypertension, diabetes, and hyperlipidemia can be genetic and increase the risk of heart disease. I was aware of her family history but did not think to include it for a differential diagnosis. Goolsby and Grubbs (2015) write that there is a significant increase in the risk of myocardial infarction or hyperlipidemia with diabetes.  To ensure CC is monitored for diabetes and heart disease, screening laboratory tests should be done such as fasting blood glucose, hemoglobin A1C, and lipid panel.    

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.

Cervical Neoplasm.  It is recommended that women between the ages of 21-29 have a Pap smear every 3 years.  Between the ages of 30 and 65, screening for cervical changes is to be scheduled every 5 years (Goolsby and Grubbs, 2016).  CC has an increased risk neoplasm due to her family history of cancer and should continue her screening exams. Her routine exam should include this exam.  I missed this diagnosis because I was thinking that she was up-to-date with her screening. But when re-examining her risk factors, more investigation should be done to determine if another exam is indicated.