iscussion Peer/Participation Prompt Due Sunday by 11:59 pm
Instructions:
Please respond to at least 2 of your peer’s posts. To ensure that your responses are substantive, use at least two of these prompts:
Do you agree with your peers’ assessment?
Take an opposing view to a peer and present a logical argument supporting an alternate opinion.
Share your thoughts on how you support their opinion and explain why.
Present new references that support your opinions.
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.
Please review the rubric to ensure that your response meets the criteria.
Estimated time to complete: 2 hours
PLEASE USE UPDATED REFERENCE FOR BOTH PEER RESPONSE I WILL PROVIDE EACH POSTBELOW:
Deborah Martin
MondayNov 22 at 12:34pm
Initial Discussion Post
Organization
Chief Complaint
Presents with C/O headache
History of Present Illness
Pain is a 4/10
No cold/sinus symptoms
Throbbing for past 2 hours, can feel pulse in temple
No fever, no changes in vision
Past Medical History
Scoliosis corrected with Charleston brace
Broken toe
Eye exam 2 years ago
No medications
NKDA
No hospitalizations
Sports-induced asthma
Personal and Social History
No tobacco use, wine once monthly, no recreational drug use
Single, lives alone
Traveled to UK, Caribbean in past 3 months
Review of Symptoms
No cold/sinus symptoms
Throbbing for past 2 hours, can feel pulse in temple
No fever, no changes in vision
Focused vs. Comprehensive
I believe this would be a focused assessment because it primarily focuses on focused concerns and specific body systems (Bickley, 2021). With the information provided, the assessment includes chief complaint, symptoms of the complaint, pertinent negatives, and previous medical history. Some of the information I placed in multiple categories because I thought they were pertinent to both. For example, I placed the no fever or changes in vision in both histories of present illness and review of symptoms. This is important for HPI due to pertinent negatives of the patient’s condition. This is also important for the review of symptoms because the patient expressed more details on his HEENT exam.
Other Systems to Assess
Other systems I would assess are HEENT, cardiovascular, respiratory, and neurological. In regard to cardiovascular and respiratory, it is important to address these systems for every visit and assessment. Any changes in these two systems could indicate immediate issues or complications. I would also review the neurological system due to the location and severity of the patient’s pain. I would especially want to address the patient’s neurological status such as her alertness and orientation, reflexes, and movement. I would also ask additional questions such as “when did these symptoms start?” and “What helps alleviate the pain?” Another important aspect to research is the patient’s travel experience. She may have gotten ill due to some type of bacterial or viral exposure on the trip.
Reference
Bickley, L.S. (2021). Overview: Physical examination and history taking. Bates’ guide to physical examination and history-taking, 13th ed. New York: Lippincott, Williams, & Wilkins. ISN-13:9781496398178
Reply
PEER #2
Chief Complaint – Presents with c/o headache
History of Present Illness – Pain is a ‘4’ on a scale of 1-10, No cold/sinus symptoms, throbbing for past 2 hours, can feel pulse in temple
Past Medical History – Scoliosis corrected with Charleston brace, broken toe, Eye exam 2 years ago, No hospitalizations
Personal and Social History – No medications, NKDA, No tobacco use, wine once monthly, no recreational drug use, Single, lives alone, Traveled to UK, Caribbean in past 3 months
Review of Symptoms – A focused assessment is used to gather relevant information pertaining to the current chief complaint of the patient. Headache is due to activation of pain-sensitive structures in or around the brain, skull, face, sinuses, or teeth (Merck Manuals, n.d.) This is typically performed in emergency situations or acute symptom development in a patient. In this scenario, the provider must approach the condition with a focused neurological assessment.
First, the HPI needs to include location, duration, severity, onset, quality. Continuing to the ROS, systems that should be assessed are:
Vision & visual field deficits
Airway patency & sinus pain
Musculoskeletal – to ensure proper balance and body function
Cardiovascular system – to assess blood pressure and profusion
Cerebral Nervous System – to assess for seizure, intracranial pressure, brain mass or mass lesion.
Reference
Merck Manuals. (n.d.). Approach to the Patient With Headache. Merck Manuals Professional Edition. https://www.merckmanuals.com/professional/neurologic-disorders/headache/approach-to-the-patient-with-headache
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