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.

Missed: Any change in the pain since it began?  Pain or swelling in the testicle? 

A change in Mr. Baldwin’s pain could indicate what the cause of the pain might include.  For example, Goolsby and Grubbs (2015, p. 257) write that the pain from urinary calculus may be “severe and colicky” while the pain from an inguinal hernia worsens with “movement of the lower extremities.”  With a gastric obstruction, there is a gradual rise in pain and can be relieved after vomiting (Goolsby & Grubbs, 2015, p. 273). The type of pain, how it is described, and if it has changed (worsened or lessened) are important indicators of what is occurring to cause this pain. 

Swelling is an indicator of tissue damage.  If a patient has had trauma to the scrotum, the swelling can be bilateral or unilateral.  Testicular torsion may also produce swelling to the affected testicle. This is important to know because testicular torsion is a time-sensitive process whereby the tissue can become necrotic in a short amount of time (Goolsby & Grubbs, 2015, p. 336). 

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: Did not count at least 2 beats on required locations (pulses).  Pulse: irregular (correct was normal).

Assessing pulses can be difficult if a patient is unstable and the pulse feels weak.  Pulses tell about the patient’s cardiovascular status. It gives a piece of information to add to the picture.  Counting the pulse to assess heart rate is different from comparing the strength and quality of the pulse. I did feel a radial pulse to assess heart rate, but I assess the others too quickly.  I felt the radial pulse was irregular, but iHuman states it was “normal.” Assessing upper and lower extremity pulses for comparison can help to eliminate aortic coarctation from the diagnoses (Goolsby & Grubbs, 2015, p. 191).  A weak and thready pulse may not be noticed initially after a couple of beats, but assessing more than this gives a comparison to the beats around it. 

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.

Finding: left scrotal edema

Using a thumb and two-finger method, a scrotum examination is important to site abnormal findings.  Normal testes and scrotum should be “firm but not hard, symmetric, nontender, and without masses” (Bickley, 2016, p. 552).  If the scrotum is swollen or asymmetrical, it could indicate underlying tissue damage or an acute torsion which is a medical emergency.  Bickley (2016, p. 552) writes, “Tender painful scrotal swelling is present in acute epididymitis, acute orchitis, torsion of the spermatic cord, or a strangulated inguinal hernia.”

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.

Missed: cardiovascular- hypertension and tachycardia

This patient was tachycardic, diaphoretic, and hypertensive.  Tachycardia with increased pain is something taught is basic nursing.  Contrary to this belief there was a study found that little relationship between tachycardia and pain among black and white patients. The study also found that there may be a difference between races (Dayoub & Jena, 2015).  This subject is relevant because there are many other states a body goes through which can also give these signs. I find this pertinent in daily assessing patients and with associating pain as the 5th vital sign.  Often patients are tachycardic upon arrival and the heart rate slowly decreases with time and without intervention. Finding the reason for tachycardia and hypertension is more important because it may also be a finding which leads to a secondary diagnosis.  

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.

Missed: Testicular torsion

This patient could be arriving at the clinic with an emergent situation.  In order to quickly treat this patient, an ultrasound must be done as soon as possible to rule out testicular torsion, which is a twisting of the testicle on itself.  “Compromised blood flow results in swelling and tissue necrosis after 6 to 8 hours” (Goolsby & Grubbs, 2015. p.336). First, of course, a physical exam reveals signs such as unilateral scrotal edema.  This diagnosis can be indicative of other diagnoses such as strangulated hernia, testicular torsion, acute orchitis or acute epididymitis (Bickley, 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.       

There was a case of skipped question regarding genital sores or discharges during the interview. Avoiding such question is not an option since through receiving an answer to it would it be possible to detect the sexually transmitted illness, for instance syphilis, chlamydia or gonorrhea. Despite Mr. Baldwin’s statement that he has kept up a monogamous relationship for the past two decades, I had no options but for asking him the particular question. (Bickley, 2017). Patients suffering from sexually transmitted diseases commonly suffer and complain about such symptoms as irregular genital discharge, possible nausea and fever, genital itching, vomiting, etc.

There was another question that I skipped during the interview with Mr. Baldwin, which was regarding the feeling of itching or insensitivity in his leg. Since he previously expressed complaints about the painful feelings down his scrotum and groin, asking such question would have allowed to better understand the cause. 

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.

            Failure to properly auscultate the entire area around the heart was my initial mistake during the physical exam. Goolsby and Grubbs (2015) believe that every specific sound or distortion could be heard better in the concrete location only.

Another mistake I have committed was failure to differentiate the abdominal sounds for a long enough period of time. Examining each area of the patient’s body for the proper amount of time is very important for successful research. To avoid skipping any areas of the abdomen, it is a must to carefully auscultate each quadrant for the distortions. (Bickley, 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.

As a result of my physical exam, one key finding was elevated blood pressure. The blood pressure should be measured in both arms while patient is lying, sitting and standing. Upper and lower extremities should be compared to look for coarctation. It is important to determine whether there is a medical history or family history of hypertension. The heart should be examined for an S3 or S4, indicating decrease compliance of the left ventricle and ventricular hypertrophy. (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.

I failed to determine the tenderness of the left groin as well as induration and scrotal edema. This would lead the practitioner to think better about the diagnosis of incarcerated hernia, in this case, it needs surgery as soon as possible. After checking on the feedback, and that which is required, I was able to identify that, I was not selecting the correct problem that was needed to be addressed which include, diaphoresis, and tachycardia also. This enabled to realize that, I needed to do all the activities in a protocol manner (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 used specific references from your text to support the inclusion of the diagnosis for this client.

An incorrect or missed different diagnosis that I did fail to add was kidney calculi. This condition is associated with matters such as the inability to find a comfortable position, variable radiation to the lower abdomen, and gross hematuria (Goolsby & Grubbs 2015). On physical and historical collection, Mr. Baldwin reported severe pain but I failed to identify any characteristic of hematuria effect. Thus I did not consider adding this differential diagnosis. Those who show kidney calculi sometimes experience hypertension as well.