Advanced Physical Examination Essay
Advanced Physical Examination Essay
Introduction
A focused history taking and physical examination enable the healthcare provider to make a definitive diagnosis and plan for the appropriate treatment modality. A conclusive history taking involves detailed patient’s particulars, the chief complaints, the history of presenting illness, past medical history, the review of systems, and personal social-economic history. The care provider can make an impression of the patient’s complaint to act as a guide when performing a physical examination. Physical examination involves general examination, vitals, and systemic examination. When performing a systemic examination, the clinician focuses on the most affected body system and then proceeds to the others. A complete assessment of the subjective and objective data determines the appropriate diagnostic investigations to do. This paper describes Brian, an adult male who presents with chest pain for an unspecified time.
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Subjective Data
Subjective data entails the information obtained from the patient or the informant. This includes a detailed patient’s particulars, the chief complaints, the history of presenting illness, past medical history, the review of systems, and personal social-economic history (Butt, M. F., et al, 2020). For this case, the patient’s particulars are name, age, gender, and ethnicity (Brian, adult male, and no specified ethnic group). The chief complaint is chest pain for an undefined period. Advanced Physical Examination Essay
History Of Presenting Complaint
The history of presenting the complaint entails expounding on the patient’s symptoms (Butt, M. F., et al, 2020). In this case, the clinician should ask the site, the onset of pain, the character of the pain, radiation of the pain, relieving and aggravating factors of the pain, the timing factor of the pain, and the severity (Aygun, et al, 2020). The cause determines the site of the pain. For example, cardiovascular-related pain is usually on the left side of the chest. Pain caused by respiratory illness is centrally located or diffuse. Gastro-intestinal-related pain is at the sternum or central region. Defining the character of the pain helps identify the cause of the pain. The pain character can be described as stabbing in nature, very sharp or pinpoints, and burning sensation. For example, pain caused by respiratory illness is stabbing, cardiovascular pain is sharp pinpoints, and gastrointestinal-related chest pain is of burning sensation.
The direction of pain radiation determines the affected system. Often, cardiovascular chest pain radiates to the left side of the neck, the jaw, or the left arm. Pain-related to the gastrointestinal system radiates to the back, right upper quadrant, left upper quadrant, or the epigastric region. Aggravating factors are the activities that trigger the pain, for example, exertion, feeding, or coughing. Relieving factors can be rest or taking pain medication. The clinician should note any history of trauma to the chest. It is also necessary to include the associating factors. For example, in the respiratory system, the patient may present with a productive cough, shortness of breath, or wheezing.
Associating symptoms in the cardiovascular system can be syncope, orthopnea, paroxysmal nocturnal dyspnea, and palpitations. For example, a patient may complain of chest pain all over the lung zones whose onset was acute. The character was a stabbing pain that did not radiate. The pain was aggravated by cold air or dust and slightly relieved by inhaling Ventolin. The pain was associated with difficulties in breathing, a productive cough, and wheezing. The history of presenting complaints should exhaust all the symptoms in the affected system.
The Review Of Systems
The clinician should then review other systems like cardiovascular, respiratory system, gastrointestinal system, musculoskeletal system, and the nervous system. The patient’s past medical history entails previous admissions, chronic illnesses, surgical procedures, current medication, food and drug allergy, and blood transfusion. Personal, family, and social-economic details help define the patient’s behavior, activities, relationship, and risks of illnesses. For example, an asthmatic patient who smokes, works at a timber yard, and his parents are asthmatic is at risk of developing frequent attacks because of the three risk factors; dust from the timber yard, smoke, and a positive family history of asthma (Friesen, M. C., et al, 2019). Advanced Physical Examination Essay
Objective Data
Objective data is the information obtained by the clinician after performing a physical examination. According to Jarvis, C. (2018), physical examination starts from the gait or posture of the patient and physical appearance. For example, the patient came in a wheelchair, well-groomed, and distress. The clinician needs to check the basic vitals; blood pressure, temperature, and oxygen circulation. The clinician should proceed to the systemic examination by inspecting, auscultating, percussing, and palpating. Inspection of the chest is observing for movement, scars, and masses. A stethoscope auscultates the chest for breath sounds and heart sounds. Palpation of the chest determines the functions of the heart valves and masses on the chest wall. Percussion determines the size, consistency, and borders of body organs (Jarvis, C. 2018). Percussing means tapping the chest wall using fingers or a small instrument. For example, physical examination findings of a patient with an acute asthmatic attack are obvious respiratory distress, intercostal muscle resection, symmetrical chest expansion bilaterally, resonant note on percussion, and wheezing or rhonchi on auscultation.
Differential Diagnosis
The differential diagnosis for this patient can be acute asthma, pneumonia, pulmonary embolism, gastrointestinal reflux, pericarditis, myocardial infarction, or acute thorax dissection because acute chest pain is the common complaint (Reamy, et al, 2017). However, the nurse should evaluate the risk factors, diagnostic investigations, and examination findings before making a diagnosis. Advanced Physical Examination Essay
Plan Of Care Individualized To Findings
Plan of care involves diagnostic investigations and treatment methods. For this patient, I would do a complete blood count to determine if there is an allergic reaction, bacteria, or viral infection. I would also do a chest X-ray to view the lungs and the heart. I would give the patient pain medication such as Tylenol tablets. An individualized care plan enables the clinician to critically think about what is needed to achieve and the desired outcome of the treatment. For one to establish an individualized care plan, they have to assess the patient, have a working diagnosis, plan for the outcome, implement and evaluate (McAllister, et al, 2018). Individualized care is achieved through effective communication, inter-professional collaboration, patient-centered care, and compliance. For instance, a patient newly diagnosed to have an acute asthmatic attack will have an individualized care plan that has actual treatment for acute asthma (nebulization with salbutamol 2.5mcg), the patient should be reviewed by the physician, the patient needs to be educated about the causes of asthma and how to prevent frequent attacks, and the patient will need a follow-up plan to ensure a good prognosis.
Conclusion
The patient’s diagnosis and treatment is difficult to determine without the laboratory results and the imaging. As the nurse on duty, I would treat patient conservatively depending on the severity of the pain and the physical findings. Advanced Physical Examination Essay
Assignment Instructions: For this 4-5 page assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Brian, an adult who is complaining of chest pain. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. Submission Parameters: For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s).
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Introduction (including purpose statement) Focus of the assessment Describe the focus of this particular assessment on the patient complaining of chest pain Subjective Component Describe the ROS, PMH, and other relevant data in this section. Objective Component Describe the physical examination findings including techniques of examination Documented evidence to support clinical reasoning Describe the list of differential diagnoses Plan of care Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment. Conclusion References (use primary and/or reliable electronic sources) In regards to APA format, please use the following as a guide: Include a cover page and running head (this is not part of the 4-5 pages limit) Include transitions in your paper (i.e. headings or subheadings) Use in-text references throughout the paper Use double space, 12 point Times New Roman font Apply appropriate spelling, grammar, and organization Include a reference list (this is not part of the 4-5 pages limit) Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP) Bickley, L, Szilagyi, P. (2017). Bates’ Guide to Physical Examination and history taking. (12th ed.). Advanced Physical Examination Essay
References
Aygun, E., Aygun, S. T., Uysal, T., Aygun, F., Dursun, H., & Irdem, A. (2020). Aetiological evaluation of chest pain in childhood and adolescence. Cardiology in the Young, 30(5), 617-623.
Butt, M. F., Choudhury, R. R., M Al-Jabir, H., & El Mahdi, E. (2020). History-taking in general practice: guidance for medical students. Education for Primary Care, 31(2), 122-124.
Friesen, M. C., Humann, M., Stefaniak, A. B., Stanton, M. L., Liang, X., … & Virji, M. A. (2019). Clustering asthma symptoms and cleaning and disinfecting activities and evaluating their associations among healthcare workers. International journal of hygiene and environmental health, 222(5), 873-883. practice. Journal of pediatric nursing, 43, 88-96.
Jarvis, C. (2018). Physical Examination and Health Assessment-Canadian E-Book. Elsevier Health Sciences.
McAllister, J. W., Keehn, R. M., Rodgers, R., & Lock, T. M. (2018). Care coordination using a shared plan of care approach
Reamy, B. V., Williams, P. M., & Odom, M. R. (2017). Pleuritic chest pain: sorting through the differential diagnosis. American family physician, 96(5), 306-312. Advanced Physical Examination Essay
