NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache

NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache

NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache

Patient Identifying Data

Mike is a 32 year old white Male who presents to the clinic with complaints of headache for 4 weeks

Problem List: Headache onset 16/11/2017. (No previous medical problems and active problems)

Subjective

Mike visits the clinic and states “I’ve had a headache for 4 weeks, and it’s still there.”

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Differential Diagnosis Rationale

Headache (ICD-9 code 784.00): Specifically, Mike is suffering from a tension headache caused by the abrasive relationship with his girlfriend. Mikes originates from a family characterized by issues of violence and mistreatment; therefore, the heated tension in his family has stressed him all along. (DiTommaso, Hoffman, Lucas, Dikmen, Temkin, and Bell (2014) suggests family conflicts, sour relationships cause stress, which consequently leads one to contract tension headache. NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache.

Brain Tumor: Mike has had headache for 4 weeks, which could be a symptom of tumor. Ideally, headache is the first symptom for ¾ of patients with brain tumor (Bauer, Wiest, Nolte, and Reyes, 2013).

HPI:

Mike is 21 years old and describes his headache as dull and pounding. On a scale of 1 to 10, he rates the pain between 3 and 8 and suggests it doesn’t get worse or better. The pain starts at the back and then migrates to the top. In addition, the condition causes him to feel dizzy but denies photophobia. NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache. He can relate the condition to a provocative factor because he suggests he is always in heated arguments with his girlfriend and one of such arguments escalated to a physical fight where he tripped and fell with his back head. Ever since he has been taking ibuprofen.

Social History: Mike is not a smoker and neither is he alcoholic.

Medical history: None

ROC: Above information

DOE: Normal condition

NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache

Pertinent positives and Negatives

Tension Headache: The headache is band like, which is typical for a tension headache, however it is not bilateral

Brain Tumor: This diagnosis is unlikely because the S&S began after falling down and remains at back of the head

Objective

Vital Signs: Weight 179lbs, temperature 99.2 orally, Resp 20, height 65 inches, BP 114/72

Physical Exam:  No hematomas, cooperative, appropriate language and speech, no tenderness to palpation, atraumatic, and head normocephalic, visual fields full to confrontation, gag reflex and tongue movement is intact and full, tympanic membrane visualized, reflexes 2+ throughout and Romberg testing negative. NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache.

Assessment Plan:

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Genogram:

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NSG 6020 Week 1 Discussion HISTORY Collection Paper

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

This week’s case study was quite insightful for me.  There were definitely several questions that I regretfully missed the opportunity to ask my patient.  One question I should have asked Rachael was “Do you have any swollen lymph nodes?” Breast cancer can spread to lymph nodes, so her lymph nodes might be affected. “Malignant cells from a breast cancer may spread directly to the infraclavicular nodes or into the internal mammary chain of lymph nodes within the chest” (Bates, Szilagyi, & Hoffman, 2017, p. 422). Another question I should have asked was “Is the lump movable?” as lumps that are movable are often benign. “Hard irregular poorly circumscribed nodules, fixed to the skin or underlying tissues, strongly suggest cancer” (Bates, Szilagyi, & Hoffman, 2017, p. 438).

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

In my assessment of Rachael, I failed to note the consistency of the lumps in her breast.  It is important to note the consistency of any lumps and determine if they are soft, firm, or hard (Bates, et al., 2017).   I also failed to note delimitation. NSG 6020 Week 1 Discussion HISTORY Collection Paper. Delimitation is describing the boundaries of the lumps.  Noting whether the lumps are well circumscribed or not is another important detail in the breast assessment.  “Assess and describe the characteristics of any nodule: location, size, shape, consistency, delimitation, tenderness, and mobility” (Bates, et al., 2017, p. 438).

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text. NSG 6020 Week 1 Discussion HISTORY collection.

One key finding in my physical assessment was a one centimeter right axillary lymph node that was firm but mobile.  To further evaluate this finding, I can completely examine the axillary area.  The text explains exactly how to examine for lymph nodes: “To examine the left axilla, ask the patient to relax with the left arm down and warn the patient that the examination may be uncomfortable. Support the patient’s left wrist or hand with your left hand. Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla. Place your fingers directly behind the pectoral muscles, pointing toward the midclavicle. Now press your fingers in toward the chest wall and slide them downward, trying to palpate the central nodes against the chest wall. Of the axillary nodes, the central nodes are most likely to be palpable. One or more soft, small (<1 cm), nontender nodes are frequently felt” (Bates, et al., p. 440). If any of the centrally located nodes are large, tender, or hard, or if there is a concerning lesion in the axillary nodes drainage areas, palpate for the other groups of axillary lymph nodes in the pectoral, lateral, and subscapular nodes, as well as re-examine the infraclavicular and supraclavicular nodes (Bates, et al., p. 441.) NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

A missed category that I missed was the unintentional weight loss experienced by Rachael.  Malignancy is linked to unexplained weight loss Gannavarapu, et al., 2018).  Unintentional weight loss should therefore always be investigated further.  As this patient has hypothyroidism, which is generally associated with weight gain, rather than weight loss, this weight loss is of even greater concern.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client

One diagnosis I missed was fat necrosis.  Upon exam, if breast dimpling or retraction is seen, this suggests underlying cancer.  Cancer can cause fibrous strands to be attached to the skin and fascia which lie over the pectoral muscles.  This may cause dimpling inward of the skin during contraction of the muscle.  Sometimes, this sign may signify a benign condition such as fat necrosis, but it should always be evaluated further to be sure (Bates, et al., 2014, p. 436.) NSG 6020 Week 1 Discussion HISTORY Collection Paper.

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Discussion 2

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

The first question I missed was does your breast problem come and go? To assist a patient in describing a complaint, a nurse practitioner must know how to ask salient and focused questions to draw out necessary information. It is important to know the particular symptoms that  brought the patient to seek medical help.

The second question I missed was when did the problems of your breast start? It is important to ask this history question because identifying when the problem first started and  how it has changed or progressed since the onset helps in the assessment, evaluation and diagnosis process.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings incorrect assessment of this client.

My first error was I did not auscultate required respiratory locations, which would have better identified the patient’s lung pathology. Auscultating the lungs for adventitious sounds, particularly crackles at the bases, which might indicate heart failure while other adventitious sounds could indicate a respiratory rather than cardiac cause. NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache.

My second error was I did not auscultate lung in the correct order. To get a correct assessment of a patient lung field auscultation needs to be done in the correct order because breath sounds vary in intensity, volume and duration depending from each base of the lung to another.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

One key finding is breast lumps found in the right breast through breast examination of the patient. This is a physical exam I will perform at the point of care.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

One missed category in my assessment was breast mass/lump, neoplastic. In Rachael’s case, the presence of multiple masses excludes nearly all other diagnoses, Rachael’s family history, and the presence of an axillary lymph node is a must-not-miss

It is important to arrive at the correct differential diagnoses for this client because this client’s history meets specific criteria for being  high risk for breast cancer which includes of her age, family history, (first degree relative with breast cancer), personal history (history of ductal hyperplasia), present history, and surgical history (breast biopsy) (16, Goolsby, Grubbs, 2015).

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.

Breast abscess was of the one incorrect diagnosis. It contradicts the fact that Rachael experienced no pain and suffered no trauma also with the breast examination. NSG 6020 Soap Note and Genogram Wk 1 Ass 1 – Post-traumatic Headache.

Rachael had no pain, breasts were not red, or warm to touch, and breasts had no swelling, which are general symptoms of breast abscess. The patient also did not have a high temperature or feel unwell. Although any breast mass should be carefully evaluated and usually warrants further testing like biopsy and mammogram (17 Bickley, 2016).