Description
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Hello!
Select the Week 3 Discussion link above and create a thread to post the initial substantive response to the Discussion Question. The initial response must address all aspects of the Discussion Question and contain at least two citations (within the last 5 years) with corresponding references.
Instructions:
1. Complete all of the readings up to and including Week 3.
2. Identify a realistic CC related to one of the systems covered up to this week or from the list below. Post your topic in the discussion thread. DO NOT REPEAT TOPICS! If you have a CC that you want to use that is not on the list, please email the instructor for approval.
3. Complete a History and Physical (H&P) on a patient with this “CC”.
- Sore throat
- Wheezing
- Hoarseness
- Earache
- Ringing in ear
- Ear drainage
- Nasal symptoms and congestion
- Difficulty swallowing
- Red eye
- Eye drainage
- Rash (there are MANY – look up types of rashes)
- Skin lesion (there are MANY – look up types of skin lesions)
- Purple hands/cold hands/feet
- Cellulitis
- Pain in sinuses/face pain
- Cough
- Bloody phlegm
- Green phlegm
- Difficulty swallowing
4. Document subjective data: (Include Identifying data – age, gender)
- Chief complaint (CC)- always in the patients own words – use quotation marks
- History of Present Illness (HPI) Include symptom analysis using OLDCART – follow the acronym to ask about onset, location, duration, characteristics, associated symptoms, relief measures, and time. You may list use the acronym OLDCART for clarity and practice.
- Past Medical History (including date of diagnosis)
- Past Surgical History (include date of surgery and any complication)
- Family History (FH): Include only the FH that would contribute to the development of the differential diagnoses for the CC.
- Social History (SH): Include only those components that will contribute to the development of the differential diagnoses for the CC. Be sure to include employment, type of dwelling, and whom the patient lives with
- Medications, OTC, supplements
- Allergies (medications, food, other) and reaction
- Review of Systems (ROS): Include systems related to CC as well as constitutional ie nausea, vomiting, diarrhea, weight loss, and weight gain. Follow ROS template provided. Remember, ROS is NOT the same as PE. If there are any positive findings in any system, you must inquire using OLDCART and document.
- Explanatory Model: Use BATHE Technique
5. Document objective data to include:
- Vital signs:
- General Survey:
- PE: Examine only those organ systems that are pertinent to the CC but always assess the respiratory and cardiac systems of all patients. The PE is not the same as ROS; is a hands-on head-to-toe assessment performed by the provider. You will not be performing a genitourinary examination for this assignment. Use textbook – follow proper written documentation. Use the IPPA process (Inspection, Percussion, Palpation, Auscultation) and document your findings in this order as a chart-worthy document.
6. Pick one possible diagnosis for the CC.
7. Identify one diagnostic study (lab, x-ray or maneuver) that will help to confirm the diagnosis you have chosen. Cite and reference your work using a clinical guideline, peer-reviewed article, textbook, or other reputable sources as evidence from the literature. Look for the gold standard diagnostic study to confirm the diagnosis.
