The purpose of the case analyses is to assist in learning the key components from the assigned reading and other adjunct learning tools. Case analyses will focus on a variety of topics incorporating assessment across the lifespan (pediatric, geriatric, obstetric, etc.). Read each case analysis and choose two to complete: P. W., a 23 yearold recent immigrant, has come to the health care center complaining of night sweats, recent weight loss, and a decrease in energy level. Sputum is blood tinged. S. B. has come for his first physical in several years. History includes the use of one or two packs of cigarettes a day for 20 years. Examination reveals increased anteroposterior diameter, decreased tactile fremitus, hyperresonance on percussion, and decreased breath sounds. J. V., a 24yearold man, is admitted to the emergency department after a motorcycle accident. He is having trouble in breathing and is very upset. The rescue personnel tell you that his breath sounds are absent on the right side, his chest expands unequally, and that there is tracheal shift toward the left. There is a large contusion on his right rib cage. G. E., a 52yearold social worker, has been treated for a deep vein thrombosis for two days. He calls the nurse to come to his room right away. When the nurse arrives, she sees that he is apprehensive, restless, diaphoretic, and extremely anxious. His PaO2 is 82% (previously had been 97% on room air), his heart rate is 116 beats per minute and his blood pressure is 100/56 mm Hg. He is complaining of a sharp chest pain that gets worse when he breathes in and has shortness of breath. Choose two cases from the list above and complete the following: 5 review of systems (ROS) questions 5 physical assessment techniques that would be conducted in a focused physical exam Each case is worth 10 points Each case must include 5 ROS questions and 5 physical assessment techniques for full credit PLEASE FOLLOW THE INSTRUCTIONS HERE IS THE MODEL TO FOLLOW .D. is an 18 month old, Caucasian, male toddler brought to the health practitioner by his mother. He appears listless as he is leaning into his mother’s shoulder, while she supports him with both her arms, laying her chin upon his head. Practitioner speaks to P.D.’s mother, “Good afternoon Mrs. D I am Mrs. W., how long has P.D. been like this?” Parental bonding is being demonstrated positively by this child and parent. “Parental bonding, the child’s interactions with the parents, show mutual response and are warm and affectionate, appropriate to the child’s condition.” (Jarvis, 2011, p. 143) Communication with a toddler P.D.’s age consists of, “nonverbal communication as the primary method, since older infants have anxiety toward strangers. They are more cooperative when the parent is kept in view.” (Jarvis, 2011, p. 39) As P.D. progresses through Erickson’s theory of psychosocial development he should be nearing the end of “trust verse mistrust stage and beginning the autonomy verse shame and doubt stage”. (About.com, 2012) This may be difficult to assess at this time due to current illness and listlessness of the toddler. Practitioner continues with questioning the mother regarding P.D.’s current illness, past medical and postnatal history. At completion of obtaining health history the toddler is assessed on the mother’s lap. Subjective questions asked in a review of systems would include: 1. Has he had any fever and when did it start? 2. Has he had any nasal congestion, runny nose or cough? 3. How much is he drinking and eating, compared to his normal intake? 4. How many times has he urinated, had a bowel movement or vomited in the last 12 hours? Please describe the consistency of the stool, color or the urine and quantity of emesis. 5. Did you notice P.D. in any pain, pulling at his ears or any rashes on his body? Assessment techniques that would be conducted in a focused physical exam would include the following: 1. Inspection: “Begin by greeting the child and the accompanying parent by name, but focus more on the parent”, to allow the child time to warm up to you. (Jarvis, 2011, p. 123) Keep the child dressed for as long as you can and have the parent undress the child one part at a time. (Jarvis, 2011, p. 124) Looking at the child for visible skin moisture, color and rashes. 2. Measurements: Obtain respiratory rate for full minute, first, while listening to the parent, this is to ensure accurate respiratory rate while allowing time for the child to remain calm. Remember to watch for use of accessory muscles and nasal flaring. Followed by the heart rate, using a brachial pulse for 30 seconds x 2, tympanic temperature, length, weight and head circumference. Leaving the more invasive procedures for last. 3. Auscultation: Listen to the child’s lungs and heart with stethoscope while the child sits on the mother’s lap. The practitioner should listen in a Z pattern taking care to listen to all areas of the heart auscultating for murmurs, extra beats and any other abnormalities. 4. Examination: Assess the child’s mouth, throat and ears with otoscope/ophthalmoscope while the child is sitting on his mother’s lap. Gently pulling the top of the ear upward for best view of the tympanic membrane. Unless he becomes uncooperative then lay child on the examination table while the mother assists in keeping child still. Keeping safety in mind at all times. 5. Focused Assessment: Assess the child for dehydration. Check skin turgor and mobility over the abdomen by slightly pinching the skin and observing the skin retraction time, assess mucus membranes and tear production when crying. Also refer back to the subjective response from his mother in regards to oral intake and urination pattern. (Jarvis, 2011) Note: For grading purposes, please be sure that ROS and PE are pertinent to the case study. For the review of systems, do not list singly: pain assessment, aggravatoring factors, rating, medications, etc. This is one question as PQRSTU. For the physical assessment, do not include diagnostic/laboratory testing. Points will be deducted.
