Allergic Rhinitis Nursing Discussion Board Post
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
Discussion board post instructions:
Using the course text access below, please complete the discussion board post as requested by the instructor using the case study provided. Please be extremely detailed in your responses using the attached case study information. The post should contain at least 3 references including the course text. The second attached file includes all of the case study details. Please pay special attention to the history section; this is what should be used to answer the discussion post.
Discussion board Question:
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.
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.
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.
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.
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.
Course Text and assigned reading for this assignment:
Refer your course textbook, Bates’ Pocket Guide to Physical Examination and History Taking.
From the textbook, Advanced Assessment, read:
- Assessment and Clinical Decision-Making: An overview
- An overview of genetic assessment
- Pediatric Patients
From your course textbook, Bates’ Guide to Physical Examination and History Taking, read the following:
- Overview: Physical Examination and History Taking
- Clinical Reasoning, Assessment and Recording your findings
- Interviewing and Health History
- Beginning the Physical examination: General Survey, Vital Signs and Pain
Below is the assessment data and history to answer discussion questions.
You are working in Dr. Wilson’s office. The first patient of the morning is Mr. Frank Dennison.
As you and Dr. Wilson open the electronic medical record, you note past visits by Mr. Dennison for allergic rhinitis and refills of various antihistamines and nasal sprays. Then you look at today’s encounter which gives the following information:
Reason for visit: Cough for two months.
Vital signs:
- Temperature:2 degrees Fahrenheit
- Heart rate:80 beats/minute
- Respiratory rate:16 breaths/minute
- Oxygen saturation:97%
- Blood pressure:118/68 mmHg
- Height:5′ 8″
- Weight:190 lbs
- Body Mass Index (BMI):9 kg/m2
Dr. Wilson asks you to “do a focused history, then let me know what you find.”
Medical History:
You introduce yourself, and begin by asking:
“How may we help you today?”
Mr. Dennison responds, “I’ve had this nagging cough for two months.”
“Tell me more about your cough.”
“I don’t have a fever so I don’t think I have an infection. The cough is worse at night. In fact, I wake up some nights with coughing spells. Eventually, I cough up some clear mucous, and then I feel better. Sometimes I notice that my breathing gets noisy.”
“What kind of noise do you make when you are breathing?”
“It’s kind of a musical, whistling sound, especially when I breathe out.”
“How often do you notice this noisy breathing?”
“On one or two nights of the week, I will wake up coughing and get that noisy breathing at the same time. When I cough up some clear mucous, I feel better. I have never had the noisy breathing during the day. In fact, when I jog or bicycle, my breathing is fine.”
“Do you get any chest tightness or chest pain?”
“No.”
I see that you have a history of allergic rhinitis. How is that going?”
“My allergies were doing OK, but I have been having trouble the past three to four months. I’m sneezing a lot and congested in the nose a lot. I have a lot of clear drainage; occasionally there is a light yellow tinge to the drainage.”
“What medications do you take for this?”
“I’m supposed to take cetirizine and fluticasone nasal spray every day. But, to be honest, I only take them about two-thirds of the time. Sometimes, I get too busy and forget them. I’m also supposed to get allergy shots regularly, but I haven’t received one in several months.”
“Why haven’t you been receiving your allergy shots regularly?”
“I’ve been struggling to get to my appointments to receive the shots due to my new job schedule.”
“Let’s discuss some options to help you take your medications and receive your shots.”
“OK.”
Through these questions, you realize Mr. Dennison’s allergic rhinitis in not under ideal control. You wonder if treating his allergic rhinitis would help control his cough and wheezing.
Next, you wish to see if he has an underlying sinusitis, since that also is a co-morbid condition of asthma that could explain some of his symptoms.
In an early paper, Williams described hallmark symptoms of acute sinusitis to include a history of colored nasal drainage, a limited response to decongestants, a maxillary toothache, purulent secretions observed on physical examination and an abnormal transillumination of the sinuses, when he reported validation of a clinical rule predicting the probability of acute sinusitis in 1992.
In a more recent review of the evidence, the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNS) updated guidelines (2015) define acute sinusitis as having purulent or colored nasal drainage, along with either nasal congestion/blockage and/or facial pain/pressure for a duration of less than four weeks. These guidelines also describe other diagnostic criteria of acute sinusitis including the failure to improve after 10 days or the development of fever. Finally, they also note that some patients with acute sinusitis may describe improving after a typical viral upper respiratory infection and then feeling worse again (“double-worsening” sign).
Physical Assessment:
After you and Dr. Wilson have discussed which parts of the exam to focus on, you knock on the door to make sure he is ready for you and re-enter the room to examine Mr. Dennison.
You find:
Physical Exam
Vital Signs:
- Temperature: 98.2 degrees Fahrenheit
- Heart rate:80 beats/minute
- Respiratory rate: 16 breaths/minute
- Oxygen saturation:97% on room air
- Blood pressure: 118/68 mmHg
- Height: 5′ 8″
- Weight: 190 lbs.
- Body Mass Index (BMI): 28.9 kg/m2
Eyes: Normal sclerae and conjunctivae. No discharge or “allergic shiners” are present.
Ears: Tympanic membranes are normal.
Nose: Swelling of the inferior turbinates, pallor of the nasal mucosa with some clear drainage present.
Sinuses: No frontal or maxillary sinus tenderness.
Throat: Normal appearing; no signs of postnasal drainage.
Neck: No jugular venous distension with the head of the exam table elevated to 45 degrees; normal carotid pulses; normal thyroid; no lymph nodes.
Chest: No respiratory distress; normal, symmetrical expansion of the lungs; all areas resonant to percussion; mild scattered wheezes heard throughout.
Cardiovascular: Normal S1 and S2 without murmurs. No S3 or S4 heard.
Skin – No skin lesions. No areas of eczema seen.
Extremities: No clubbing, cyanosis or edema.
Mental status: Oriented to time, place and situation. Appropriate range of affect.
After concluding the physical examination, you inform Mr. Dennison that you will present your findings to Dr. Wilson. You ask him to remain in his gown because when you return with Dr. Wilson, he will want to confirm your physical exam findings.
When you find Dr. Wilson, you present your physical exam findings to him. He asks you what you are currently thinking about for a differential diagnosis.
Diagnosis
Most Likely Diagnosis
Based on spirometry findings of obstructive lung disease and improvement following treatment with inhaled bronchodilator, asthma is the most likely diagnosis.
The National Asthma Education and Prevention Program defines reversibility as an increase in the FEV1 value of > 200 mL and an increase > 12 % from baseline or an increase > 10% of the percent predicted FEV1.
Reversible obstructive findings on spirometry is the distinctive diagnostic abnormality in patients with asthma, especially early in the course. Patients with chronic, severe asthma may have less or no reversibility of their obstructive findings, very similar to patients with chronic obstructive pulmonary disease.
Less Likely Diagnoses
- Patients with nonasthmatic eosinophilic bronchitis will respond to inhaled corticosteroids like patients with asthma, but they will have a normal spirometry and normal chest x-ray. The diagnostic finding for this condition is sputum eosinophilia on induced sputum or bronchial wash obtained at bronchoscopy.
- Patients with vocal cord dysfunction may have flattening of the inspiratory loop on spirometry, but do not typically have reversible obstructive findings on spirometry like patients with asthma. The diagnostic finding of this condition is visualizing abnormal vocal cord movement during an episode of wheezing.
- Symptoms of chronic obstructive pulmonary disease, like those of asthma, should improve following treatment with bronchodilators and inhaled corticosteroids. Obstructive findings seen on spirometry with this condition, however, should not be reversible.
- Patients with gastroesophageal reflux disease typically present with either heartburn symptoms or findings of esophagitis on upper endoscopy. Even if asymptomatic, reflux can trigger bronchoconstriction and serve as an exacerbating factor for patients with asthma. If a patient with asthma fails to improve with standard treatment, it is reasonable to consider whether gastroesophageal reflux is present.
RUBRIC
QUALITY OF RESPONSE NO RESPONSE POOR / UNSATISFACTORY SATISFACTORY GOOD EXCELLENT Content (worth a maximum of 50% of the total points) Zero points: Student failed to submit the final paper. 20 points out of 50: The essay illustrates poor understanding of the relevant material by failing to address or incorrectly addressing the relevant content; failing to identify or inaccurately explaining/defining key concepts/ideas; ignoring or incorrectly explaining key points/claims and the reasoning behind them; and/or incorrectly or inappropriately using terminology; and elements of the response are lacking. 30 points out of 50: The essay illustrates a rudimentary understanding of the relevant material by mentioning but not full explaining the relevant content; identifying some of the key concepts/ideas though failing to fully or accurately explain many of them; using terminology, though sometimes inaccurately or inappropriately; and/or incorporating some key claims/points but failing to explain the reasoning behind them or doing so inaccurately. Elements of the required response may also be lacking. 40 points out of 50: The essay illustrates solid understanding of the relevant material by correctly addressing most of the relevant content; identifying and explaining most of the key concepts/ideas; using correct terminology; explaining the reasoning behind most of the key points/claims; and/or where necessary or useful, substantiating some points with accurate examples. The answer is complete. 50 points: The essay illustrates exemplary understanding of the relevant material by thoroughly and correctly addressing the relevant content; identifying and explaining all of the key concepts/ideas; using correct terminology explaining the reasoning behind key points/claims and substantiating, as necessary/useful, points with several accurate and illuminating examples. No aspects of the required answer are missing. Use of Sources (worth a maximum of 20% of the total points). 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