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.
Mr. Jose Martin is a 54-year-old Hispanic patient who comes to the office for a routine checkup. Although Mr. Martin is asymptomatic, he has elevated blood pressure. According to Bickley (2016), arterial hypertension is defined as blood pressure greater than or equal to 140/90 mm Hg. Arterial hypertension is a multifactorial disease, so the interview should focus on risk factors for developing hypertension, especially those that can be modified, contributing to disease control. It’s also crucial to inquire about symptoms related to endocrine disorders that were omitted in the interview. I think that I missed two essential questions:
1.How often do you exercise? As indicate by Goolsby & Grubbs (2015), physical inactivity is a factor that contributes to the development of primary hypertension.
- Do you have increased sensitivity to cold, dry skin, sluggishness, constipation, or hair loss?
Some endocrine disorders, such as hypothyroidism, hyperthyroidism, pheochromocytoma, and primary aldosteronism, can cause secondary hypertension (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.
In the physical examination performed on Mr. Martin, I did not complete the skin assessment. Systemic illnesses that are causes of hypertension have many associated skin findings. Some common examples are:
Chronic renal disease: Pallor, xerosis, uremic frost, pruritus, calciphylaxis.
Diabetes Mellitus: Acanthosis nigricans, Candidiasis, Neuropathic ulcers.
Hypothyroidism: Dry, rough and pale skin. Myxedema, skin cool to touch.
Hyperthyroidism: Warm, moist, soft velvety skin. Hyperpigmentation.
Cushing disease: Striae, atrophy, purpuras, telangiectasias, buffalo hump, hypertrichosis.
Dyslipidemias: Xanthomas, xanthelasma.
(Bickley, 2016).
In the physical examination of the patient, I also omitted the assessment of the carotid pulse. It is essential as it provides information about cardiac function, specifically aortic valve stenosis and regurgitation. The carotid pulse should be inspected and palpated for the amplitude and contour of the pulse wave. The carotid pulse is small, filiform, or weak in cardiogenic shock. It’s bounding in aortic regurgitation. I must auscultate the carotid pulse to look for thrills and bruits that indicate aortic stenosis or carotid artery disease (Bickley, 2016).
The two coronary arteries should not be palpated simultaneously, as it causes decreased blood flow to the brain and syncope. Pressure on the carotid sinus can cause reflex bradycardia or a drop in blood pressure (Bickley, 2016).
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.
In the physical exam performed on Ms. Martin, I included the cardiac examination. The inspection and palpation are relevant in making a diagnosis. However, the auscultation of heart sounds and murmurs leads directly to important clinical diagnoses.
The Nurse Practitioner should auscultate with the patient’s chest and head elevated at 30 degrees. Auscultate first with the diaphragm of the stethoscope and then with the bell, starting at the apex and moving to the base. I must auscultate the patient in the left lateral decubitus position to diagnose mitral stenosis. To diagnose aortic regurgitation, I must tell the patient to sit down, lean forward, thoroughly exalt, and stop breathing briefly.
The main auscultation findings are:
- Heart sounds: They are brief and transitory sounds due to the heart valve’s closing and opening. They are systolic or diastolic.
- Murmurs: indicate turbulence of blood flow. They can be diastolic, systolic, or continuous according to their intensity, location, and location concerning the cardiac cycle moment. The intensity varies on a scale from 1 to 6.
(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.
A missed category, which I consider essential in the differential diagnosis are the complications of arterial hypertension. These complications contribute to uncontrolled blood pressure. Mr. Martin has not been checked for ten years; therefore, it is very likely that he has suffered hypertension for a long time and already has some target organs affected. I consider it necessary to have assessed kidney function. The assessment does not describe the patient’s facies or subcutaneous cellular tissue characteristics. I should have asked how the patient is urinating if have hematuria, nausea, or vomiting (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.
A missing differential diagnosis is a metabolic syndrome or syndrome X. According to Goolsby & Grubbs (2015), lack of physical activity and poor eating habits lead to obesity and insulin resistance. The syndrome characteristics are hypertension, central obesity, hyperlipidemia, and glucose intolerance with hyperinsulinemia. This syndrome increases the risk of type 2 diabetes and cardiovascular disease.
Ms. Martin is overweight due to his poor dietary habits and lack of exercise. It is likely to be the cause of hypertension. I should have done a symptom and sign assessment to rule out diabetes and cardiovascular disease.
References
Bickley, L. (2016). Bates’ guide to physical examination and history taking. F.A. Lippincott, William & Wilkins.
Goolsby, M. J., & Grubbs, L. (2015). Advanced assessment: Interpreting findings and formulating differential diagnoses. F.A. Davis.
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