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MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 1 Discussion

Complete both of the Discussion Topics and Submit by the Due Date.

1) Obtaining a comprehensive health history can be difficult in a variety of situations. In this discussion, choose one type of patient scenarios and describe how you would approach interview and obtain the history. Each student must reply to at least one other student in discussion of the scenario.

A) The Angry Patient who has been waiting a long time for an appointment and is disgusted with health care in general.

B) The Internet Patient who obtains all his health information from the Internet and has self -diagnosed his problem.

C) The Unfocused Patient with a 3 inch health record she has brought with her to get a second opinion.

D) The Terminal Patient who has end-stage uterine metastatic cancer who has refused treatment.

Instructions:

A. Make your initial post by 11:59pm EST Wednesday of Week 1.

B. Respond to one other classmate posts by 23:59 EST Saturday of Week 1.

2. There are both a comprehensive history and physical exam and a focused history and physical exam. Discuss the circumstances and components for each type of history/exam. This discussion DOES NOT require another student response.

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 2 Discussion

Case Study 2A

C.C. M.A. is a 6 year old female who presents for a sick episodic visit who is accompanied with her mother for sore throat, fever and rash.

HPI: Her mother states M.A..has been sick for about 4 days which started with a headache. Then she developed a sore throat and runny nose. M.A..now appears feverish and doesn’t feel like eating much.

She normally attends pre-school, but mom has kept her home yesterday and today since she felt feverish. Now, this morning, she has this rash. The rash is “a little itchy”. Mom denies changing laundry detergents, foods, soaps and there has been no known exposure to anyone else with a rash or illness.

M.A. has never had a rash previously.

PMH: Growth percentiles within normal limits on previous visits

Immunizations Record:

DPT given at: 2 mos 4mos 6 mos 18 mos 5 yr

OPV given at: 2 mos 4 mos 18 mos 5 yr

MMR: given at: 13 mos 5 yr

Hib given at: 2 mos 4 mos 6 mos 18 mos

FH:

Relationship Mortality Age Health Problems Relationship Mortality Age Health Problems

Mother Alive 27 None Father Alive 27 None

MGM Alive 51 HTN/DM MGF Alive 48 HLN

PGM Alive 45 None PGF Alive 52 Prostate CA

SH: Lives with mother but spends every other weekend with father who lives in a suburban area 15 miles away. Mother is an elementary school teacher and Father is an social worker. Parents have been divorced for 2 years. M.A. is doing well in the first grade without social or behavioral problems.

Meds: Children’s Tylenol 1 dose last pm Allergies: None

ROS:

General: Mom denies weight loss, fatigue until the last 3 days, generally eats well

Skin: Mom denies birthmarks, scars, no previous rashes

HEENT: Denies dizziness, head trauma, vision trouble, does not wear glasses, has about 3 colds/year, denies swallowing problems, nasal congestion, Admits to sore throat, difficulty swallowing, but drinking fluids as normal

Neck: Denies lumps, pain, stiffness

Resp: Denies dyspnea or pain, admits to rare non-productive cough for 48 hours

Cardiac: Denies chest pain, irregular heart rate, or edema

Gastrointestinal: Denies nausea, vomiting, diarrhea or abdominal pain

PE:

Vital Signs: Temp: 100.6 Rest: 26 Pulse: 98 Ht: 50” Wt: 45 lbs

General: Well developed, well-nourished 6 yo female in no acute distress (NAD)

Skin: confluent, maculopapular rash, no pustules, no desquamation covering trunk, with 6 non-linear vesicles on lower trunk about 10 cm apart.

HEENT: Normocephalic, without masses, lesions, alopecia, conjunctiva pink, PERRL, EOM intact, nares patent without redness, throat with erythema and vesicles scattered in pharynx, tonsils +1 enlargement without exudate, no petechiae on palate or uvula, uvula and tongue is midline , dentition good with missing upper front teeth, TM slightly dull but mobile

Neck: Supple without thyromegaly, + mildly tender anterior cervical lymph palpable

Lungs: clear to auscultation and percussion, tactile fremitus bilaterally equal and normal

1) What are your pertinent positives and associated differential diagnoses?

Answers: Headache, Fever, Sore Throat, Anorexia, itchy, confluent, maculopapular rash with vesicles

Differential Diagnoses for Rash, Sore Throat and Fever:

2) What diagnostic tests would you order and why?

3) Write your assessment summary statement:

4) Health promotion: Given her age what recommendations should you give at this time?

5) What would you prescribe to treat this condition?

6) What would your follow up consist of?

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 3 Discussion

Diagnostic Reasoning and Advanced Physical Assessment

MODULE 3 CASE STUDY

BJ is a 10 yr old female of Hispanic origin who presents to your exam room with an adult Hispanic male that identifies himself as her uncle. He states that BJ has hurt her Right arm after falling down the steps the day before. He states she did NOT loss consciousness or injury her head. The providers asks BJ, “How did you fall down the steps?” BJ looks down and softly states, “I just tripped and feel:. Both speak with broken English.

PMI: No hospitalization or Surgeries. Immunization History is unknown.

Medications: None Allergies: None

FH: Parents Living Mother age 24 Father age 30, No Siblings

SH: Both parents work cleaning in the hotel industry. BJ is “home schooled” by her aunt.

ROS:

General: NEG weight loss or gain NEG fatigue, NEG fever

HEENT: NEG for headache, congestion, nasal drainage, vision problems, throat pain

Cardiac: NEG for chest pain, palpitations, swelling, loss of consciousness

Resp: NEG Dyspnea, Neg for cough, wheezing, NEG PND

GI: NEG Nausea, Neg for Vomiting, Diarrhea, dysphagia, pain, anorexia

MS: + R Shoulder Joint pain, +Joint Swelling, + for falls

HEME: + for bruising NEG for bleeding, Neg night sweats

ENDO: Neg for thirst, heat or cold intolerance

NEURO: NEG dizziness, Neg for confusion, numbness, aphasia

PSYCH: NEG for memory loss, Neg for nervousness, suicidal ideation

PE:

General: thin, small for stated age, unkempt but clean in appearance, sitting on exam cradling her R arm in her lap. She winces in pain with any body movement.

HEENT: Normocephalic, long tangled black hair with thin patches of hair loss in occipital area. R Pinnae with purple bruising. TM clear.NEG Weber and Rinne Test. Brown Eyes symmetrical, PERRL, Normal Light Reflex, Normal EOM and Convergence. Nose centered, nares clear with pale, bloody turbinate’s. Throat with clear pharynx, normal tonsils, uvula midline, poor dentition with missing teeth,

NECK: No JVD, Trachea Midline, No Adenopathy, FROM, + Pain with Lateral movement

CHEST: symmetrical, COR: Reg S1S2, No murmurs, rubs, gallops

RESP: CTA with equal bilateral expansion. Significant ecchymosis R sternomastoid muscle into R sub clavicular and post scapular areas

ABD: Ecchymosis in RUQ with tenderness to light palpation. Possible liver enlargement. Bowel Sounds x 4 quadrants

GU: ecchymosis of perineum with vaginal spotting noted on underpants

EXT: No clubbing, cyanosis, pale, sluggish capillary refill in R phalanges nail beds. FROM in LUE & bilateral LE, Severe pain with attempts to abduct RUE. +3 pedal, femoral, brachial, radial pulses

Psych: Alert, Oriented to Place and Time. Quiet, withdrawn mood, Flat affect, avoids eye contact

Vital Signs: HT: 53 inches WT: 60 TEMP: 99 BP: 100/50 HR: 90 RESP 30 O2SAT: 95%

Discussion Questions: What diagnostic tests would you order and why? What referrals would you request? How else can you document/validate your physical findings? What would you do if uncle refused the testing or treatment? Although this is a case of child, this could easily be an elderly 75 year old brought in by a family member. What would you do differently if this an adult?

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 4 Discussion

Diagnostic Reasoning and Advanced Physical Assessment

Module 4 Case Study

K.H. is a 16 year old male who presents to your exam room with recurrent episodes of dyspnea. His mother is with him and reports he has been in his usual good health until this past fall football season ( 4 months ago), when she noticed him wheezing after activities. Usually the wheezing would resolve spontaneously after a couple of minutes of rest. When you ask K.H. how often he feels SOB, he states it has gotten worse and now even walking up a flight of steps causes wheezing and coughing. He also admits to increased fatigue with decreased exercise tolerance.

PMH: Croup as an infant. Recurrent URIs as a child. Immunizations are Up To Date.

Surgical History includes PE tubes at age 3 for chronic OTM (Otitis Media)

Medications: None Allergies: Amoxicillin (hives)

SH: Breast fed x 6 month. Normal Developmental Milestones.Currently in grade 10 at local high school. Active in sports (football, baseball) Grades: As and Bs. + Smoking 3-4 cigs per day x 1 year. Neg for ETOH (alcohol)

Denies illegal drugs. Lives at home with both parents and sister

FH: Mother living @ age 36 with Hypertension and Hypothyroidism – Asthma, – Pneumonia – Smoking

Father living @ age 40 with GERDS -Asthma -Pneumonia + Smoking 1 ppd x 10 years

Siblings: 1 Sister age 13 with recurrent URIs

ROS:

General: No weight changes, fever, chills

Head: No trauma, headaches, hair loss

EENT: No vision changes, earaches, no hearing loss, no congestion, nosebleeds, sore throat or hoarseness

Neck: No dysphagia, swollen glands or stiffness

PUL: + SOB, + Wheezing, + Cough No sputum or sneezing

CAR: + chest pain, worse with deep breaths, No palpitations, swelling. Sleeping sitting up x 1 week.

GI: Not eating well x 1 week. No N/V/D/ Constipation

GU: No urinary frequency, pain or incontinence, or discharge

PVD: No leg pains, numbness or tingling

HEME: No bruising or bleeding

PSYCH: Alert, Oriented, Cooperative. Appropriate thought content and process.

WT: 150 lb s HT: 5’5 BMI: BP: 135/90 HR: 1000 Resp.24 O2 Sats: 88%

PE: K.H. is a 16 year old male who appears stated age, well groomed with tachypnea and appears anxious.

HEENT: Normocephalic, Atraumatic. Hair is evenly distributed.

Eyes: Symmetrical, sclera and conjunctiva normal color PERRL

Ears: Auricles equally symmetrical, non-tender. TMs clear with normal structures. Weber: Equal lateralization

Rinne: AC> BC bilaterally. Nares patent. Turbinates pale. Pharynx: Clear. Good dentitian. Uvula midline. Tonsils pink without enlargement

Neck: Trachea midline Neg for Thyromegaly or nodules. Neg: Carotid Bruits Neg: JVD + Lymphadenopathy

Lungs: Inspiratory/expiratory wheezes 2/3 lobes with decreased breath sounds @ bases. Cough induced with deep inspiration. Hyper-resonance with percussion. Fremitus decreased at the bases. Mild anterior retractions noted.

Cardiac: Reg S1S2 with early systolic murmur @3-4 ICS (intercostal space) MCL (Mid clavicular line).PMI @ 4th MCL w/o thrills

Abd: soft, non-tender, BS x quads. No masses, No scars Neghepatomegaly Neg Splenomegaly

Ext: Diaphoretic, Pale, Neg Clubbing, Pale, sluggish capillary refills .FROM (Full Range of Motion) all extremities

Psych: Anxious, frequently looking at mom to help with answers and during the exam. Alert, Cooperative, Oriented x 4. Subdued Mood.

What other historical information would you like to ask? What are the initial H & P “red flags” are cause for concern? What diagnostic tests/interventions would you perform? What would you include in your differential?

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 5 Discussion

Case Study 5

CC: J.D. is a 32 year old male presents to your office for a complete physical exam as a new patient. He c/o intermittent episodes of diarrhea, abdominal discomfort, bloating and occasional constipation.

HPI: J.D. states he often eats a meal and within 10 minutes, he feels bloated and “gassy”. He frequently has periods of nausea, urgent watery diarrhea. This is embarrassing for him as he is not always near a bathroom. This has become progressively worse over the last years and occurs almost daily. He first realized he was having bowel problems when he was in high school when he played on the football team. Diarrhea always seemed to get worse on game day. He denies vomiting or laxative use.

PMH: No hospitalizations or surgeries. His childhood immunizations were all completed and he had a tetanus booster 5 years ago. Only health problem has been his abdominal bloating and “bowel problems”. He was treated for strep throat and a sinus infection 5 years ago with Amoxicillin.

FH: Relationship Mortality Age Health Problems

Mother Alive 54 None

Father Alive 56 Arthritis

MGM Alive 70 HTN, Rheumatoid Arthritis, HLN

PGM Alive 66 Breast CA, Pacemaker

PGF Alive 67 None

MGF Deceased 65 CVA

SH: He is a graduate student at the university studying Psychology. He lives in an apartment with his girlfriend.

He drank heavily in high school, but may have 1 glass of wine weekly. Denies smoking cigs/marijuana or IV drug use. He exercises regularly but his diet is “awful” and depends on how hectic his schedule is. He is currently working full time as a bank teller.

Meds: None Allergies: None

ROS:

General: Fair appetite with no weight loss, Denies fatigue, fever, chills, blood transfusion

Skin: Denies rashes, lesions, scars

HEENT: Denies dizziness, headaches, head trauma, vision or hearing difficulties, Sees dentist annually, Denies allergies, nasal congestion, sinus problems, dysphagia

Neck: Denies lumps, pain, stiffness

Cardiac: Denies chest pain, dyspnea on exertion, palpitations

Resp: Denies dyspnea, cough, wheezing

Gastrointestinal: See HPI

Genitourinary: Denies dysuria, frequency, hematuria, penile discharge, heterosexual but libido is low as he frequently just does not feel well.

Musculoskeletal: Denies joint pain, swelling, arthritis, myalgia

Endocrine: Denies skin or hair changes, temperature intolerances, excessive thirst or urination

Neurological: Denies weakness, seizures,

Psychological: Denies depression, but admits he sometimes gets “anxious” with graduate school and work.

Nutritional: Admits he eats 1 meal/day usually in the evening when “life has quieted down”. This meal consists of some meat/potato. Salads causes bloating. Snacks can cause cramping and diarrhea in the afternoon-so I just don’t eat. Milk products do not seem to bother him.

Physical Exam:

Vital Signs: Temperature 98 Pulse: 76 b/min Resp: 16/mi BP: 120/80 HT: 5’11 WT: 174 BMI: _____

General Appearance: Well developed, well nourished, appropriately groomed and appears his stated age

Skin: Smooth, soft, w/o lesions, rashes, scars. Tattoo of an eagle on his chest.

HEENT: Normocephalic with evenly distributed hair. No redness or lesions of his eyes, extraocular movements (EOM) intact.

Ophthalmic Exam: Red reflex intact bilaterally. Optic Disc is round creamy yellow with clear margins. Retinal vessels are bright red without exudate, edema, and wool spots. Macula is positive for foveal light reflex.

Otoscopic Exam: No ear discharge, TM grey and intact, crisp cone of light

Nose: patent nasal airways, no exudates, turbinates pink without polyps

Mouth: Good dentition, no lesions, buccal tissue pick, tongue/uvula midline, pharynx unremarkable

Neck: No lymphadenopathy, thyromegaly, Has Full ROM, No JVD

Heart: Regular S1S2 w/o gallops, rubs, or murmurs, PMI @ 5ICS MCL

Lungs: Clear to auscultation bilaterally with equal excursion and normal tactile fremitus

Abdomen: soft, no masses, no HJR, no organomegaly, slight diffuse tenderness with light palpation in lower abdomen

Bowel sounds: hyperactive in 4 quads. Rectum: empty, no masses with normal tone. No hemorrhoids or fissures

Hemoccult: Negative

Genitourinary: No palpable inguinal nodes, circumcised penis without lesions, edema, erythema or discharge. Testes descended without masses or tenderness, negative for inguinal hernia

Peripheral Vascular: No edema with +2 palpable radial, popliteal, pedal pulses bilaterally

Musculoskeletal: FROM of all extremities, no joint swelling, pain in upper or lower extremities

Neurological: CN 2- 12 grossly intact

Psychological: Alert, pleasant but subdued. Cooperative and follows commands.Communicative with focused answers.

What are your pertinent positives and your differential diagnoses?

What diagnostic tests would you proceed to order?

Since this is a new patient, what anticipatory guidance would you recommend?

MSN610 Diagnostic Reasoning and Advanced Physical Assessment

Module 6 Discussion

Case Study 6

CC: 85 year old female presents to your exam room with “memory loss”

HPI: J.B. is brought in with her son who states his mom is forgetting to pay her bills over the last 4 months and “gets lost” in her own home. J.B. admits she sometimes gets “forgetful”. Her previous PCP retired 6 months ago and they have no medical records with them.

PMH: Total Abdominal Hysterectomy 20 years ago. G3P2 1 Miscarriage. No other surgeries or hospitalizations. Treated for HTN, A-fib

Medications: HCTZ 25 mg daily Allergies: None

Digoxin 0.25 mg daily

Coumadin 1 mg daily

Multivitamin daily

FH: Relationship Mortality Age Health Problems

Mother Deceased 54 Diabetes Mellitus II

Father Deceased 75 CAD

Daughter Deceased 20 MVA

Son Alive 45 None

ROS:

General: Denies weight loss, fatigue until the last 3 days, generally eats well

Skin: Denies birthmarks, scars, no previous rashes

HEENT: Denies dizziness, head trauma, vision trouble, does wear glasses, Had cataract surgery in L eye , denies swallowing problems, nasal congestion,

Neck: Denies lumps, pain, stiffness

Resp: Denies dyspnea or pain, cough, wheezing

Cardiac: Denies chest pain, or edema of extremities, Has had an irregular heart rhythm “for years”

Gastrointestinal: Denies nausea, vomiting, diarrhea or abdominal pain

Genitourinary: Denies hematuria, dysuria, or odor

Musculoskeletal: Denies back pains, Admits to knee pain with difficulty walking

Neurological: Denies seizures, limb weakness, headaches, loss of consciousness

Psychological: Denies depression/anxiety. No suicidal/homicidal ideations.

She likes to color and work on puzzles but sometimes “I loose pieces” that makes me angry.

PE: Vital Signs: Temp 98.6 HR: 84 RESP: 18 BP: 149/90

Constitutional: Thin, frail-looking, well-kempt 85 yo female in NAD (no acute distress)

HEENT: Normocephalic, atraumatic, with thinning grey hair. Eyes with small xanthoma R outer canthus, conjunctiva pale, white sclera, cloudy R cornea, L cornea normal size and color PERRL, EOM intact.Snellen 20/40 using both eyes with glasses

Ophthalmoscopic Exam: Optic Red reflex intact bilaterally. Optic Disc is round creamy yellow with blurry margins. Retinal vessels are bright red without exudate, edema, and wool spots. Macula is positive for foveal light reflex.

Otoscopic Exam: No ear discharge, TM grey and intact, with mild amount of cerumen, crisp cone of light, Whisper test 2/3 bilaterally

Nose: patent nasal airways, no exudates, turbinates pink without polyps

Mouth: Wearing Dentures, no lesions, palate rises symmetrically , tongue/uvula midline, pharynx unremarkable

Neck: Supple without lymphadenopathy, thyromegaly, or carotid bruits, Has Full ROM, No JVD

Heart: Irregular S1S2 w/o gallops, or rubs, Grade II/VI murmur heard at 4th ICS LBS, , PMI @ 5ICS MCL

Lungs: Clear to auscultation bilaterally with equal excursion and normal tactile fremitus

Abdomen: soft ,thin with little fat, no masses, no HJR, no hepatosplenomegaly, Hypoactive bowl sounds in 4 quads. Rectum: with brown stool, no masses with normal tone. Small external hemorrhoids or fissures. Stool guaiac: negative

Genitourinary: No palpable inguinal nodes, wearing incontinent pad with faint smell of urine. Perineum intact without discharge, edema or skin lesions. Pelvic Exam deferred

Peripheral Vascular: No edema or cyanosis, or clubbing with +2 palpable radial, popliteal, pedal pulses bilaterally

Musculoskeletal: FROM of all extremities, no joint swelling, pain in upper extremities. Bilateral knees with creaking with extension and mild tenderness with extension. Strength and sensation in upper/lower extremities are symmetrical

Neurological: CN 2- 12 grossly intact. Ambulates slowly without assistance

Psychological: Alert, pleasant but subdued. Cooperative and follows commands.Communicative with focused answers.

Previous labs found in local hospital lab records from 2 months prior:

WBC 4.6 Sodium 128 (L)

RBC 3.45 (L) Potassium 5.3

Hgb 10.13(L) Chloride 104

HCT 33.2 (L) Albumin 3.8 (L)

MCV 78.3 (L) Total protein 6.3 (L)

MCH 28.2 AlkPhos 100

MCHC 32.4 ALT 22

RDW 16.2 (H) AST 28

Platelets 221 LDH 134

Segs 66(H) T. Chol 252 (H)

Lymphocytes 21 (L) Calcium 8.4 (L)

Monocytes 8 FBS 130 (H)

Based on this information, what is your problem list?

What is the difference between delirium vs dementia?

What else is missing and you would need to know?

What additional diagnostic testing would you order?

What health promotion/maintenance measures would you consider?