E-BOOK: Advanced Health Assessment & Clinical Diagnosis in Primary Care, 5th Edition
BASED ON ORDER # 80614 ANSWER TO 2 PEERS USING THE RICE MODEL
Physical Examination and Health Assessment
PLEASE RESPOND TO DISCUSSION PROMPT WEEK 2 AT LEAST 2 REFERENCES CITED AT THE END OF EACH PROMT,1 PAGE PER PROMPT REFERENCES SHOULD BE NO OLDER THAN 5 YEARS PLEASE USE THE E BOOK AS 1 OF REFERENCE . DO NOT POST NOTHING THROUGH CANVAS WEBSITE.
Please respond to the discussion prompt 1 AND 2 Week 2: Jarvis, chapters 1â€“7, 10â€“11
Dains, chapters 1 and 3
A 52-year-old woman complains that she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night. She denies other health problems, medication, or environmental allergies.
- Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
- In SOAP format, list:
- Pertinent positive and negative information
- Differential and working diagnosis
- Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
- Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
PROMPT 1 MOS
- With the case study provided, the information is divided into four different categories with the SOAP method.
- This case study had plenty of subjective information from the patient. She stated that she is missing days of work almost every week, neglecting her family, sleeping during the day, and not sleeping at night. In addition to that, she denied any other health problems, medication history, or environmental allergies.
- There is only one objective information that was described in this case study, which was that the patient is a 52 year old woman. To further assess for more objective information, I would want to focus on three types of information I can draw from by talking with the patient. First, focusing on her appearance would provide good information about the patient, specifically looking at her posture, body movements, dress, grooming, and hygiene (Jarvis & et al., 2020). Second, I would focus on her behavioral cues like her facial expression, speech, mood, and affect. Third, I would assess her cognition by asking about facts of herself like her birthday, name, and the date.
- In order to properly assess the patient, I would first take her vital signs: blood pressure, heart rate, temperature, and oxygen saturation. After that, I would take a listen to her heart and lungs.
- Once this part of the assessment is completed, I would ask some more questions regarding her new symptoms she is coming in for. The method I would use is the acronym COLDSPA, which stands for character, onset, location, duration, severity, pattern, and associated factors (Dains & et al., 2020). This would help in determining what other symptoms she may be having.
- In addition to asking about her new symptoms, I would do an assessment focusing on her health history and her functional status. First, with her health history, I would ask about her present health, past health concerns, her current and past medications, and history about her family (Dains & et al., 2020). Second, for her functional assessment, I would try to gather information to learn more about the environmental factors in her life that may contribute with her health, which include economic status, home environment, health promotion, and interpersonal relationships (Dains & et al., 2020).
- After this assessment and looking at her overall health history and environmental influences, I would be able to determine some problems that this patient may be having. One of the problems that I noticed is that the patient may be at risk for depression or another mental health disorder. The next step would be to plan care individualized to this patient.
- To address the concerns and problems seen with this patient, I would plan to assess her even further with some diagnostic tests. I would plan to draw her blood and get a complete blood count, hemoglobin A1c, a basal metabolic panel, and electrolyte levels. This can help to address where some of the problems may be originating from. Another diagnostic test I would do is a mental health test to determine whether or not the patient has any mental health disorder. An example of this is a depression screening. In addition to these diagnostic tests, I would recommend some non-pharmacological interventions to help with sleep like not utilizing electronic devices prior to sleeping, drinking tea, and trying some fragrances. In regard to pharmacological interventions, I would not prescribe anything specifically until all the diagnostic tests have been done. And, to end the session with this patient, I would set a follow up appointment.
PROMPT 2 ALY
Considering our patients age we should think about if this patient is going through menopause or not. Most women enter menopause between the ages of 49 and 52 years, and the average age among women in the United States is 51 years (Koothirezhi, 2020). She complains of missing days of work every week, neglecting her family and sleeping during the day. This warrants immediate attention and makes me want to ask questions about her mental health. The health concerns among menopausal women are mainly related to vasomotor symptoms, urogenital atrophy, osteoporosis, cardiovascular disease, cancer, psychiatric symptoms, cognitive decline, and sexual problems (Koothirezhi, 2020). I would use the PHQ-2 screening tool as it measures the severity of depression. If the patient answers several days or highs then PHQ-9 should be used (Jarvis, 2015). I would first start the interview process asking the patient how they are feeling today and then focus the questions on her mental health and reproductive health. I would ask at what age did she start her period, when was her last period and what is her flow like. After questions about her reproductive health then discuss her mental health. I would ask questions directly from the PHQ-2/PHQ-9. I would also ask if she has any stress in her life and how she copes with that. Is she on any medication? Does she have a social support? Does she have any diseases or conditions? Does she have a history or mental health issues or does any one in the family have mental health issues? I would want a lab work drawn up of CBC, thyroid function, vitamin B, folate, basic metabolic and urine sample to rule out any other underlying issues.
- Pertinent positive: she has been missing days of work almost every week, she states she is neglecting her family, and she is sleeping during the day but cannot sleep at night.
- negative information: denies other health problems, medication, or environmental allergies.
- Differential and working diagnosis: Major depressive disorder, postmenopausal syndrome
- Treatment plan, including: Hormone replacement therapy, SSRI, Psychotherapy
- Labs: CBC, thyroid function, vitamin B, folate, basic metabolic and urine sample
- health education: Discuss with patient that the antidepressants can take a couple of weeks to work. Discuss adverse side effects and what to look for. If patient does not like side effects can switch to another medication.
- lifestyle changes: Increase exercise, maintain healthy diet, modify sleep pattern
- follow-up with patient in 4-6 weeks and refer patient psychotherapy