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NSG6020 Week 2 exam review

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1a) Identify two (2) additional questions that were not asked in the case study and should have been? What allergies do you have? Do you exercise?1b) Explain your rationale for asking these two additional questions. It is important to know what the patient is allergic to, so it can be avoided, as well as noted in the medical record. It is also essential to know what kind of lifestyle the patient is living for health promotion reasons. Daily exercise is imperative, and we need to know if the patients symptoms get better or worse with exercise. 1c) Describe what the two (2) additional questions might reveal about the patient's health. It will help determine if the patients symptoms coinside with being around something the patient is allergic to. If the patient’s cough got worse with exercise (or if he exhibited cardiac symptoms such as chest pain, or shortness of breath), then a cardiac workup may be needed. DOMAIN: PHYSICAL EXAM For each system examined in this case; 2a) Explain the reason the provider examined each system. The provider examines the systems to get a generalized understanding of the patient’s health status. Once a patient history, review of systems and assessment have been completed, differential diagnoses can be made. 2b) Describe how the exam findings would be abnormal based on the information in this case. Nose: Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage present. Lungs: mild scattered wheezes heard throughout. Patient states he wakes up coughing several times a week, has been experiencing these symptoms for months, therefore, it is a chronic issue. 2c) Describe the normal findings for each system. General: The patient appears well with an appropriate range of affect. HEENT: All unremarkable. Eyes: Normal sclerae and conjunctivae. No discharge or "allergic shiners" are present. Ears: Tympanic membranes are normal. Sinuses: No frontal or maxillary sinus tenderness. Throat: Normal appearing; no signs of postnasal drainage. Neck: No jugular venous distension with the head of the exam table elevated to 45 degrees; normal carotid pulses; normal thyroid; no lymph nodes. Respiratory: No respiratory distress; normal, symmetrical expansion of the lungs; all areas resonant to percussion. No clubbing or cyanosis to extremities. Cardiovascular: Normal S1 and S2 without murmurs. No S3 or S4 heard. Skin: No skin lesions. No areas of eczema seen. Neurological: Alert and oriented to person, place, and time. Appropriate affect. 2d) Identify the various diagnostic instruments you would need to use to examine this patient. Stethoscope, blood pressure cuff, otoscope, ophthalmoscope, tuning fork, tongue depressor, gloves, thermometer, and penlight. DOMAIN: ASSESSMENT (Medical Diagnosis) Discuss the pathophysiology of the: 3a) Diagnosis: Asthma; a chronic inflammatory disease of the airways that involve a variety of cells including mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells. Chronic inflammation leads to airway hyperresponsiveness and limitation of airway flow. The persistence of inflammation can lead to airway edema. Long term inflammation can lead to airway remodeling and permanent loss of lung function (Marino & Lal, 2020)

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