TWO WEEK 6 DISCUSSION ADVANCED HEALTH AND PHYSICAL ASSESSMENT

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Colorado School of Mines *

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4100

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Nursing

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Nov 24, 2024

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docx

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1 Week 6 Discussion Student’s Name University Affiliation Course Date

2 Week 6 Discussion History Domain In healthcare, understanding a patient's health background is crucial because it determines the course of treatment. The obligation is on the patient to inform the doctor of any circumstances in his past that might be relevant to the diagnosis or treatment plan. One healthcare issue highlighted by the example is dealing with a patient who shows up with a swollen leg but does not have any history of trauma (Stevens et al., 2020). After experiencing a steady decline for three days, the patient finally made the decision to see a doctor. Before asking any further questions, keep in mind that he is a heavy smoker with a medical history of obesity, high blood pressure, diabetes type 2, and high cholesterol. These questions will arise from the client's medical history form. It is crucial to learn whether or not the client has ever experienced any form of cardiac distress, such as a heart attack, chest pain, or leg cramps. According to Shanley et al. (2019), hyperlipidemia is characterized by symptoms like cramping in the legs or chest and occurs when extra fat and lipids block blood vessels. The patient to emphasize that the client’s history of hyperlipidemia or other endocrine illnesses is most likely responsible for the inflammation within the patient’s leg could use this reaction. I would like to hear if Mr. Smith has tried to exercise regularly, and if so, how his body has responded to the new routine. Mr. Smith has noticed some soreness in his legs. The test subject's doctor has suggested that he start exercising regularly to help with his endocrine disorder symptoms and to boost his overall health. This is a fantastic plan to help him get in shape, in my opinion.

3 Physical Exam Domain After interviewing the patient in the case study, a physical examination should be conducted. Now is the time when the interviewee's responses can potentially influence the doctor's final prognosis. The diagnosis will likely rely heavily on the findings of the physical examination included in the assessment. For the cause of leg swelling to be identified, a complete physical examination is required. After two seconds of thumb touch with the swollen parts of the client's leg, the client's response was assessed, and an estimate of the time necessary for the skin to return to its normal structure was made. The client's left leg felt hot and swollen to the touch. This prompted the need for more research into the edema's root cause. The client's blood pressure and weight were also tracked to look for a causal relationship between the soreness in their leg and additional health problems. Blood tests, such as lipid profiles, are required for comprehensive diagnostic assessments (Malayala et al., 2021). Hyperlipidemia, in which cholesterol molecules and fatty acids impede blood circulation, is evaluated by these tests; this disorder causes symptoms like inflammation and soreness in the legs. If the patient complains of leg muscle pain, a diagnostic test for cognitive impairments, like magnetic resonance imaging (MRI), can be utilized to look for fat deposits, vascular blockage, and other causes of poor leg health. Medical Diagnosis Domain The outcomes of the physician's physical examination play a critical role in arriving at the correct diagnosis. Correctly diagnosing major diseases will need to use the pathophysiology of the relevant diagnostic field for symptoms. Venous insufficiency (ICD 10 code I87.2)can have basic pathophysiological origins such as an overflow that does not drain back into the client's coronary arteries, or the evolution of a venous blood flow anomaly to the patient's heart.

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4 Smoking, being overweight, and a family medical history of hyperlipidemia are all risk factors for developing this disease. According to Kearon and Kahn (2020), lymphedema is a pathological condition with an ICD 10 code of I87, that results from the buildup of protein-rich fluid within the lymphatic system, obstructing blood flow to the extremities and other organs. When this happens, it causes discomfort and a decrease in blood flow. Another potential diagnosis that could be paralleled by the displayed symptomatology is pneumonia, which is classified as I26 in the ICD-10 classification system. The risk of atherosclerosis increases with smoking age, which is a major factor in its prevalence among the elderly. Laboratory and Diagnostic Tests It is crucial to make a list of all the possible diagnostic treatments and procedures that could be performed on the patient in the test case. Determining whether or not a client has inflamed legs requires looking at the patient's medical background and performing a physical evaluation of the legs. A combination of the patient's health history and the results of the physical examination point to venous insufficiency as the most likely source of the patient's symptoms. Vascular echocardiography would be carried out to verify the diagnosis. Ultrasonic waves within the vascular system can detect blockages in the arteries and veins of a client, as well as conditions like deep vein thrombosis (Abe et al., 2019). As a result of ruling out lymphedema and pulmonary embolism, the pattern of the veins and arteries on imaging would be useful in identifying venous insufficiency as the suspected ailment. The only way to find the blockage and figure out how to get rid of it is to draw a map of the damaged artery(s) and the path the blood takes. Wherever there is a blockage in the blood supply, it will be indicated on an image of the client's veins and arteries by an arrow. Mr. Smith is correct in his assessment that venous

5 insufficiency must be the cause of the patient's blood's inability to circulate back to the heart from the lower extremities. The result is swelling of both the legs and feet.

6 References Abe, K., Kuklina, E. V., Hooper, W. C., & Callaghan, W. M. (2019). Venous thromboembolism as a cause of severe maternal morbidity and mortality in the United States. Seminars in Perinatology, 43(4), 200–204. https://doi.org/10.1053/j.semperi.2019.03.004 Kearon, C., & Kahn, S. R. (2020). Long-term treatment of venous thromboembolism. Blood , 135(5), 317–325. https://doi.org/10.1182/blood.2019002364 Malayala, S. V., Mohan, G., Vasireddy, D., & Atluri, P. (2021). Purpuric rash and thrombocytopenia after the mRNA-1273 (Moderna) COVID-19 Vaccine. Cureus . https://doi.org/10.7759/cureus.14099 Shanley, J., Kanj, A., El Zein, S., Tabaja, H., Trzcinski, B., Horman, J., Salimnia, H., Fairfax, M., & Singh, M. (2019). Non-O1, non-O139 Vibrio cholerae bacteremia in an urban academic medical center in the United States. IDCases, 15, e00527. https://doi.org/10.1016/j.idcr.2019.e00527 Stevens, J. P., Brownell, J. N., Freeman, A. J., & Bashaw, H. (2020). COVID-19-Associated multisystem inflammatory syndrome in children presenting as acute pancreatitis. Journal of Pediatric Gastroenterology & Nutrition, Publish Ahead of Print . https://doi.org/10.1097/mpg.0000000000002860

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