The Complete Guide to Physical Examination and History Taking

Question One 

Do you feel any pain or symptoms that are connected to your pain? 

The client hinted that they had a cough and had pain when breathing. One must ask if there is any pain that is associated with their coughing. If a cough lasts more than three weeks, then it is classified as acute while sub-acute, it will last for three weeks. However, if a cough goes up to eight weeks, it is said to be chronic (Goolsby & Grubbs, 2014). 

Have you experienced any chest pains before? 

A doctor must determine if the client's chest has any discomfort. Connectedly, one must find out if the discomfort has been persistent, or it is a new symptom. Determining the severity of the pain is essential, and the doctor must note the level of pain. It is imperative that the doctor through the help of the client locates the exact location of the pain and ascertain if there are any location radiation and its relation to the patient's respiration (Goolsby & Grubbs, 2014). 

Question Two 

Administering a pain stimulus to conscious client 

It is wrong to give a pain medication stimulus to a patient who can describe their condition. It is essential to use the available scales that can be used to ascertain the level of pain a client is experiencing. 

Not inspecting the eye during the HEENT exercise 

According to Goolsby and Grubbs (2014), investigating the eyes is the central technique that was not conducted. It is crucial that an expert examines the eyelid, such as looking at the ptosis while also looking at the location of an eyelid. 

Question Three 

I conducted an auscultated examination on the client’s lungs using a stethoscope from the posterior section going to the anterior side. From the analysis, the patients had a harsh and highly pitched breath that the normal one of bronchovesicular or vesicular parts of lungs (Ramsingh et al., 2016). A physician or caregiver should examine whether replacing air-filled lungs by consolidated tissues is possible (Bickely, 2017). 

Question Four 

One omission conducted was not taking the orthostatic blood pressure, both the systolic and diastolic pressures. It is crucial to ascertain the client's orthostatic blood pressure by considering the pressure at the supine and standing position (Bickley, 2017). 

Question Five 

Listing pneumocystis as a diagnosis was an incorrect diagnosis, which should instead have been community-acquired pneumonia. Community-acquired pneumonia has symptoms such as cough, fever, and chest discomfort (Goolsby & Grubbs, 2014). It was possible to if it was necessary to admit the client in the ward Using the CURB-65. The tool is able to measure breathing rate and blood pressure, among others of the patient. A patient should be hospitalized if the total value is between 3 and 5 (Goolsby & Grubbs, 2014). 

References 

Bickley, L. S. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). [South University]. Retrieved from digitalbookshelf.southuniversity.edu/#/books/9781496354709/ 

Goolsby, J. M., & Grubbs, L. (2014). Advanced Assessment: Interpreting Findings and Formulating Differential Diagnoses (3rd ed.). [South University]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9780803645011/ 

Ramsingh, D., Frank, E., Haughton, R., Schilling, J., Gimenez, K. M., Banh, E., ... & Cannesson, M. (2016). Auscultation versus Point-of-care Ultrasound to Determine Endotracheal versus Bronchial IntubationA Diagnostic Accuracy Study. Anesthesiology: The Journal of the American Society of Anesthesiologists, 124(5), 1012-1020.