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DOMAIN: HISTORY
1a) Identify two (2) additional questions that were not asked in the case study and should have been?
1.
"Do you have a history of chronic medical conditions, such as diabetes or hypertension?"
2.
"Have you had any recent significant life changes or stressful events that could impact your
overall health?"
1b) Explain your rationale for asking these two additional questions.
The rationale for asking these two additional questions is critical in obtaining a comprehensive patient
history. First, inquiring about a history of chronic medical conditions such as diabetes or hypertension is
vital, as these conditions significantly impact overall health and may require ongoing management.
Research shows that individuals with chronic diseases like diabetes have an increased risk of various
health complications, making assessing and managing these aspects crucial (Silva et al., 2018). Secondly,
understanding recent life changes or stressful events is essential, as research highlights the profound
influence of stress on physical and mental health (Yaribeygi et al., 2017). Stress can contribute to various
health issues, from cardiovascular problems to mental health disorders, and therefore, this information
is invaluable for a holistic assessment and effective healthcare planning.
1c) Describe what the two (2) additional questions might reveal about the patient's health.
1.
Asking about chronic conditions uncovers potential underlying health issues and guides
treatment strategies. A positive response may indicate disease management needs.
2.
Inquiring about recent life changes assesses stressors' impact, unveiling links between stress and
health problems, enabling early intervention, and holistic patient care.
DOMAIN: PHYSICAL EXAM
For each system examined in this case
,
2a) Explain the reason the provider examined each system.
The provider examined each system for specific reasons critical to comprehensive patient care. The
HEENT examination assessed the patient's sensory organs for potential daily life issues. Evaluating the
neck is crucial to detect thyroid abnormalities and ensure normal breathing. Cardiovascular examination
checks for heart health, which is vital for long-term well-being. The respiratory system assessment
ensures proper oxygenation and detects respiratory issues. Musculoskeletal examination identifies
musculoskeletal problems crucial for mobility. Neurologic evaluation assesses the patient's cognitive and
motor function. Each system examination aims to detect potential problems and provide holistic patient
care by addressing issues affecting overall health and quality of life.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a
wellness visit, based on the patient's age, describe what exam findings could be abnormal.
In a wellness visit for a 45-year-old cisgender female, several abnormal exam findings could be detected.
Firstly, in the HEENT examination, any abnormalities in the eyes, such as signs of cataracts or glaucoma,
could be concerning at this age. Additionally, if the patient had nodules or other abnormalities in the
neck during the neck examination, it might signal thyroid issues or lymph node problems. In the
cardiovascular assessment, murmurs, irregular heart sounds, or significantly high blood pressure could
be considered abnormal for a patient of this age. For respiratory health, wheezing, shortness of breath,
or abnormal lung sounds could indicate underlying respiratory conditions. A limited range of motion or
signs of joint inflammation in the musculoskeletal examination might suggest musculoskeletal issues.
Neurologically, abnormal findings could encompass weakness, altered sensation, or abnormal reflexes,
pointing to neurological problems.
2c) Describe the normal findings for each system.
In the HEENT examination, normal findings consist of unremarkable eyes, ears, nose, and throat, without
signs of cataracts or glaucoma in the eyes. The neck should exhibit a normal-sized thyroid with no
nodules, and the trachea should be in the midline. Cardiovascularly, normal S1 and S2 heart sounds
should be present with no murmurs, gallops, or rubs. Pulses should be palpable and equal throughout.
Clear breath sounds with good respiratory excursions are expected in the respiratory assessment.
Normal musculoskeletal findings entail good muscle development and a full range of joint motion.
Neurologically, normal findings involve intact cranial nerves, normal strength, sensation, equal and
symmetrical reflexes, and a normal gait, reflecting overall health and well-being.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.
To examine this patient, diagnostic instruments such as a blood pressure cuff and stethoscope are
essential for assessing cardiovascular health. A penlight, nasal speculum, otoscope, and ophthalmoscope
aid in examining the eyes, ears, and nose. A percussion hammer helps assess reflexes, while a
thermometer monitors body temperature. The sphygmomanometer is used to measure blood pressure.
Additionally, a tuning fork can be utilized for sensory assessments. For breast cancer screening,
mammography is the primary tool, proven to detect early-stage disease.
DOMAIN: ASSESSMENT (Medical Diagnosis)
'Not Applicable'
DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
1.
Pap Smear Follow-Up:
Given Mrs. Payne's previous ASC-US (Atypical Squamous Cells of
Undetermined Significance) result, it is essential to monitor her cervical health. A retest is
recommended in 3 years due to the negative HPV co-testing. This follow-up test helps detect any
cervical abnormalities or potential HPV-related issues early.
2.
Complete Blood Count (CBC):
A CBC is a fundamental blood test that provides valuable
information about the patient's overall health. It includes measures of red blood cells, white
blood cells, and platelets.
3.
Lipid Profile:
A lipid profile assesses cholesterol levels, including LDL (low-density lipoprotein)
and HDL (high-density lipoprotein) cholesterol. It helps evaluate cardiovascular health and
identify the risk of heart disease or atherosclerosis, which is crucial as Mrs Payne's age makes
her susceptible to heart-related issues.
4.
Fasting Glucose Test:
This test measures blood sugar levels after fasting. It is essential for
screening for diabetes or prediabetes. Given Mrs. Payne's age and the mention of her weight,
monitoring glucose levels is vital to detect early signs of diabetes or glucose metabolism
abnormalities.
4b) Discuss what lab results would be abnormal.
1.
Abnormal Pap smear findings (e.g., ASC-H or LSIL).
2.
Elevated LDL cholesterol levels.
3.
Reduced HDL cholesterol levels.
4.
Elevated total cholesterol levels.
5.
High triglyceride levels.
6.
Abnormal fasting glucose levels.
7.
Abnormal complete blood count (e.g., low hemoglobin or high white blood cell count).
4c) Discuss what the abnormal lab values indicate.
Abnormal lab values can have specific clinical implications. Abnormal Pap smear findings, such as ASC-H
or LSIL, suggest abnormalities in cervical cells, possibly indicating precancerous or cancerous changes, as
supported by the American Cancer Society. In addition, elevated LDL cholesterol levels are a significant
risk factor for atherosclerotic cardiovascular disease, with extensive research indicating its association
with heart disease, according to the American Heart Association. Reduced HDL cholesterol, high total
cholesterol, and elevated triglycerides are markers of an unfavorable lipid profile, increasing the risk of
cardiovascular events. Moreover, elevated fasting glucose levels may indicate impaired glucose
metabolism, a precursor to diabetes (American Diabetes Association, n.d.). An abnormal complete blood
count, such as low hemoglobin or a high white blood cell count, could suggest anemia or an underlying
infection (National Heart, Lung, and Blood Institute, 2022). These abnormal values serve as early warning
signs, guiding further assessment and intervention to address underlying health issues effectively.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
There are no diagnostic procedures to order at this time
4e) If this is a wellness visit, discuss what the
U.S. Preventive Taskforce
recommends for patients in
this age group.
The U.S. Preventive Services Task Force (USPSTF) recommends several vital preventive measures for a
wellness visit in this age group. In adults aged 45 to 49, the USPSTF advises screening for colorectal
cancer. Additionally, between ages 30 and 65, they suggest HPV (human papillomavirus) screening,
which can be performed every five years with high-risk HPV (hrHPV) testing alone, every five years with
contesting (hrHPV and cytology), or every three years with cytology alone (U.S. Preventive Taskforce,
2018).
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References
U.S. Preventive Taskforce. (2018). A and B Recommendations | United States Preventive Services
Taskforce. Www.uspreventiveservicestaskforce.org.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-
recommendations#:~:text=The%20USPSTF%20recommends%20screening%20for%20colorectal
%20cancer%20in%20adults%20aged
American Diabetes Association. (n.d.).
Diagnosis | ADA
. Diabetes.org.
https://diabetes.org/about-
diabetes/diagnosis
National Heart, Lung, and Blood Institute. (2022, March 24). Anemia - What Is Anemia? | NHLBI, NIH.
Www.nhlbi.nih.gov.
https://www.nhlbi.nih.gov/health/anemia
Silva, J. A. da, Souza, E. C. F. de, Echazú Böschemeier, A. G., Costa, C. C. M. da, Bezerra, H. S., & Feitosa, E.
E. L. C. (2018). Diagnosis of diabetes mellitus and living with a chronic condition: participatory study.
BMC Public Health
,
18
(1).
https://doi.org/10.1186/s12889-018-5637-9
Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body
function: A review. EXCLI Journal, 16(1), 1057–1072.
https://doi.org/10.17179/excli2017-480
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Patient’s Name: P.B.S.
Birthdate: 08/05/1990
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Height (cm): 148 cm
BMI:27.21 kg/m^2
Religion: Roman Catholic
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