Advanced Health Assessment and Clinical Reasoning Essay

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Learning Contract Student ID: Mentor:	Type of assessment Date:	Keys Steps Consider the process!	Evaluation How will you evaluate?	Reflection What have you gained? What went well? What would you do differently?	Final 6 Summative Assessments Achieved, A, Not achieved NA Mentor Signature
Complete health history Michael, 35 years old, widowed, has good cognitive ability, recalls information well, good attitude. Entire body is painful; started four months ago. Feels nervous because he does not have knowledge on the condition, better emotional and experiential readiness to learn, and does not sharing health information.	A ‘head-to-toe’ assessment of the taxi driver living in Corona County was used (Brooks, Connolly, & Chan, 2004); not social, no religious inclination. Chief complain of burning pain all over the body, non-specific, keeps changing, fatigue, does not perform chores normally, has been hospitalised. First experienced four months ago after he lost his wife through a road accident on the route he normally uses. Worsened by movement especially walking. Feels better when resting. The family has history of suicide. Occasional drinks alcohol and smokes cigarette. No allergic record. Eats a lot of carbohydrates.	After Interview, the patient was made to sit comfortable and relaxed. Screened for the existence of physical pain while closely observing and monitoring facial expression; pain existed defined as type, cause, intensity and specific sources to determine course of treatment (Kucia, & Quinn, 2009)	At 23 years he was treated of mental disorder. The family history indicates that his mother and younger brother had treatment histories, the father had suicide attempt. He has once considered committing suicide. Once accused of sexually abusing a cousin sister. Began using alcohol after accusation of sexually molesting the cousin, Poor appetite.	From the above examination, the patient mood swing showed psychiatric problem. He could not be suffering from any serious illness, only mentally disturbance. He seems to over indulge himself to alcoholism after accusation of sexual molestation probably to keep his m. He could be avoiding working for the fear of road accident that claimed him of a wife. Such patients’ needs close monitored.
Respiratory physical examination A 45 years old man. Without past medical history complains of mild chest pain with dyspnoea on exertion. Fainted two months ago after walking a short distance. Heart rate is 90/min, respiratory rate of 11/min, blood pressure is 90/70 mmHg, oxygen saturation of 87% on pulse oximetry. Cardiac examination is noted for a loud pulmonic component to the second heart sound and systolic murmur best appreciated at the lower sterna border. Distended neck veins, hepatomegaly, and lower extremity edema appreciated. Skin. Musculoskeletal normal. Chest X-ray reveals normal lung fields with cardiomegaly. Enlarged pulmonary vessels. Normal Pulmonary tests with diffusion capacity of 50%	Checked status of the respiratory system. Observed respiratory rate (inaudible respirations occurring between 12 and 20 times per minute). Duration of inspiration and expiration cycles were noted, the former should take about half the time interval taken by the latter (Alpert & Ewy, 2002). Labored breathing noted. Heart rate and blood pressure closely monitored. Watched for arrhythmias because of hypoxemia suspicion (Kim, 2010). Performed passive range of motion exercise and helped him perform motion exercise. Monitored arterial blood gas studies and pulse oximetry.	Airways were maintained. Placed in a prone position to improve chest wall compliance and drainage of bronchial secretions. Performed passive range of active exercise. Posture was closely noted during interview. Auscultated posterior chest, beginning with the regions above scapulae, then downwards in a stair step fashion. Findings compared with those obtained from the other side of the chest. Breathe sounds characters listened to. Normal vesicular breath over most lung field.	The duration of inspiration and expiration were compared, where expiration was expected to take twice the time taken by inspiration (Elling, & Elling, 2003). Difficulty in breathing could have been due to airway obstruction leading to characters of breath sounds. The patient had to labor while breathing and was supported. Auscultation checked for the heart sounds in case arrhythmias was suspected	Auscultation and recognition of abnormal breath sounds was difficult to note. Despite speculation that there could be murmurs asking the patient to roll partly onto the left side to help bring the left ventricles closer to the chest wall did not yield result (Tintinalli et al., 2003) differentiating the murmurs arising from the left and right side during breathing was not achieved
CardiacPhysical examination A gentle non alcoholic man aged 29 years responds to questions rather slowly. Has never had past medical history. The father died of heart failure three years ago. Chief complain of fatigue, rarely exercises and socially isolated. Likes fatty foods.	History, then Heart rate measured, respiratory rate, blood pressure, oxygen saturation. Auscultated. observed the neck veins, lower extremities for swelling, the skin and musculoskeletal system (Porth, 2007)	Head of bed elevated to 45^oand adjusted so as to see the jugular venous pulsation. Jugular pulsations observed and measured as the jugular venous pressure in relation to the sterna angle (MS et al., 2001). Carotid pulsations inspected for carotid bruits. Patient asked to roll partly onto the left side to listen to the apex and the lower sterna border. The location, magnitude, interval and diameter of the apical impulse were also noted as inspection and palpation of precordium for any visible pulsations, masses, scars, lesions and signs of trauma were done (Tintinalli et al., 2003). Then the patient was helped to roll back to the supine position to enabled listening of the entire heart. He was finally asked to sit, leaned forward while exhaling deeply. This enabled listening to the murmurs of the aortic regurgitation (Bickley, Szilagyi, & Bates, 2008).	Examination revealed that the jugular venous pressure was 1cm above the sterna angle when the examination head rose to about 35^o(Kozier et, al., 2004). The carotid upstroked briskly, without bruits. The apical impulse was discrete and tapping, barely palpable in the 4^thleft interspace, 7 cm lateral to the mid-sternal line. Good S₁, S₂. Neither S₃nor S₄was evidenced. An II/VI medium-pitched mid-systolic murmur at the second right interspace; which does not radiate to the neck was felt. No diastolic murmurs were evidenced (Barnard, 2009)	Examination of the heart beginning with auscultation followed with palpation and not the other way round more often yields good results as opposed to commencing with palpation (Bickley, Szilagyi, & Bates, 2008). Equally, patient leaning forward when detecting murmurs of the aortic regurgitation is dependent on the angle of inclination, good results obtained at roughly acute angle bent.
Abdominal physical examination John, aged 41 years old complains of abdominal distension, pain, nausea, vomiting, persistence coughing, inability to pass stool, fever, sputum production, and dyspnoea. Chest pain. Suffers insomnia and anorexia. More often has to maintain a certain posture to relieve pain. Condition started two weeks ago and has been progressing. .	After history, the patient was made to lie still while protecting the painful areas. A one hand method of deep palpation of the right upper quadrant, followed by a two handed method of deep palpation was used because there was muscle rigidity (Bickley, Szilagyi, & Bates, 2008). Percussion of the abdomen by placing the non-dominant hand on the patient’s abdomen with the middle finger hyperextended.	Lied down in a supine, still, comfortable manner head resting on a pillow. The four quadrants were palpated with light pressure, and then by deep pressure as the patient’s face monitored for discomfort expression. Areas of tenderness identified with palmar surfaces of finger (Barnard, 2009). Epigastrium palpated deeply to delineate the margins of aorta. Liver palpation done, hand on the right lower quadrant while pressing gently in and upward. Asked to take a series of deeper breath as the palpation continues upwards towards the right costal margin. Examination of the spleen was done with the right hand placed at the lower boarder of the rib cage; a gentle pressure was exerted upwards and towards the posterior. This examination was repeated when the patient was made to lied on his right side; the position enabled the gravity to bring the spleen forward and medially into an easily palpable position.	Upon palpation of the four quadrants, levels of distress noted to be on the upper right and upper left quadrants. Exhibited guarding of the abdomen. No rebound tenderness. Normal organs. No evident masses, scars, lesions nor signs of trauma. Absence of bowel sounds on auscultation could have been caused by vigorous palpation (Henderson, 1991).	Auscultation should have been done before percussion and palpation, vigorous touching the abdomen may have disturbed the intestines and altered their functioning as well as production of bowel sounds.
Focussed assessment on abdominal physical examination A 62 years old man has manifestation of sudden severe colicky abdominal pain, with distended abdomen. Recurrent episodes of nausea, vomiting and constipation persisted for three weeks. Diffused abdomen tenderness, abdominal distention tympany, palpable mass with cecal volvulus, peritoneal signs, fever, shock with bowel infarction. Rarely exercises. Diagnosed with duchenne muscular dystrophy three years ago.	Abdominal plain films X-ray was taken, to visualize distended colon. Barium enema and barium meal used to clearly visualize the intra abdominal outline (Bickley, Szilagyi, & Bates, 2008). Sigmoidoscopy done.	Shielded patient lies in supine position for radiography. Film covered top of the liver to pubic symphysis, ensuring the abdominal organs taken care of. A plain X-ray, followed with contrast radiography using Barium meal where X-ray films taken thereafter (Alpert & Ewy, 2002).	Plain and contrast radiography revealed intestine twistinglikely cause of throwing up. Profuse accumulation of its contents. Also suggested blocked intestines. These findings with the past condition of Duchenne muscular dystrophy suggested volvulus condition (Jcr, 2002).	Except for the associated condition mentioned, all the above retrieved signs, symptoms and assessments are shared in a number of medical conditions like Pneumonia, pyelonephritis, volvulus amongst others. Medical experience would therefore be instrumental in helping the clinician to decide which condition to narrow down into.
Focussed assessment on respiratory physical examination The 27 years old lady. Naomi is alcoholic, works as a cashier in a city supermarket complains of cough, chest pain, fatigue, fever, difficulty breathing, decreased thirst, convulsions and persistent vomiting. Has persisted for three months, taking antibiotics bought over the counter. Never been hospitalized, no past medical record.	Temperature noted. Dullness to percussion of the chest, crackles and rales on auscultation. Chest radiography done posteroanterior then lateral views to diagnose pneumonia (MS, et al., 2001). CT scan for lung abscess was carried out. Sputum sample cultured in a Clinical laboratory for the presence of Streptococcus pneumonia. Thoracentesis done by collecting pleural effusion with a needle for analysis of causative agents	Used non invasive breathing assistance in difficulty breathing. Sepsis and septic shock are potential complication of pneumonia these two occurs when bacteria enters blood stream (Alpert, & Ewy, 2002)	Rusty colored sputum examined selectively allowed growth of streptococcus pneumoniae,low blood pressure, high heart rate, low oxygen saturation noted are associated symptoms of community based pneumonia. Normal chest with decreased expansion. Auscultation revealed harsh breath sounds from the larger airways. Community acquired Pneumonia was suspected and a further biochemical tests recommended (porth, 2007).	A number of chest related diseases shares a lot of symptoms as well as physical examinations. Narrowing down to one specific microorganism would mostly yield doubted results (because there are chances of missing out on the pathogen in the growth media). It is therefore paramount that before deciding on which tests to do one should rule out a number of likely pathogens by elimination criteria.

A systematic reviewing of the collected medical history coupled with a general and specific assessment of the patients would more often give a face value diagnosis. However, with more work exposure and experience most clinicians would have identified the key issues under investigation at this stage. It has been elucidated that certain examination ought to be carried out prior to others. Auscultation must always come prior to palpation in certain body systems. History and physical examination should never be used to make a conclusive diagnosis upon which treatment would be based on.

References

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MS, N. et al. (2001). Guidelines for the management of adults with community acquired pneumonia. Diagnosis,assessment of severity, antimicrobial therapy and prevention. Am J Respir Crit Care Med., 163(7), 1730-54.

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