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Art, Essay, Pages: 2

Unit 4 Journal: HEENT and Chest Exam

Unit 4 Journal: HEENT and Chest Exam

Unit 4/Module 2 Journal NU552
Date                   Student Name

 

 
OBJECTIVE
GENERAL APPEARANCE

The patient is awake, alert, and oriented x3 and appears fatigued with mild dyspnea at rest. He also has mild respiratory distress and frequent dry coughs during the exam: Unit 4 Journal: HEENT and Chest Exam
HEENT

Head: Atraumatic, normal shape and size

Eyes: Conjunctivae reddish, sclerae reddish

Ears: Clean pinna, clean bilaterally, no exudate

Nose: Nasal mucosa reddened bilaterally, moist without congestion, mild clear exudate noted. Mild pain rated 3/10 upon sinus palpation.

Throat: Oropharynx mildly erythematous, tongue freely mobile, no lesions noted, no enlarged tonsils noted upon palpation

Neck: No palpable lymph nodes, no enlarged thyroid noted upon palpation, the entire neck area is non-tender, trachea midline
CARDIOVASCULAR

92bpm RR, S1 and S2 present, no murmurs, rubs, or gallops. Capillary refill <2 seconds.
LUNGS

25R, chest symmetrical with normal expansion. Noted diminished breath sounds bilaterally, expiratory wheezes, and coarse rhonchi in bilateral lower lobes upon auscultation. No crackles.

No dullness to percussion. Breathing was labored, and mild accessory muscle use was noted.
SKIN

Natural in color, warm, smooth, dry, and intact. Good skin turgor, no lesions, rashes, no nail clubbing.
How might diagnostic reasoning and clinical judgment be used to move toward a diagnosis in one of these systems? Include 2-3 evidence based resources, at least one of which is a clinical guideline for a condition that may be a differential. Word count 75-100
The diagnosis of conditions based on cough as a symptom can be complicated as it is a non-specific symptom in most pulmonary and extrapulmonary conditions without any specific underlying cause or as a refractory condition to therapies (Chung et al., 2022). Clinical reasoning helps physicians to develop early hypotheses of conditions during patient encounters and compare their hypotheses with results from clinical assessments (Kourtidis et al., 2022).

This helps NPs to arrive at sound judgments on the conditions to make timely and correct diagnoses (Smith et al., 2022).

In the case of George, clinical reasoning can be applied to compare presented symptoms, including worsening cough over two weeks and a history of conditions such as HTN, COPD, and DM2 (Global Initiative for Chronic Obstructive Lung Disease, 2024), to develop possible differentials such as acute exacerbation of chronic obstructive pulmonary disease and heart failure.

This can narrow down lab testing and move down to a diagnosis.

 References

Chung, K. F., McGarvey, L., Song, W. J., Chang, A. B., Lai, K., Canning, B. J., Birring, S. S., Smith, J. A., & Mazzone, S. B. (2022). Cough hypersensitivity and chronic cough. Nature Reviews Disease Primers, 8(1), 1–21. https://doi.org/10.1038/S41572-022-00370-W;SUBJMETA=153,1785,308,692,699;KWRD=DRUG+DEVELOPMENT,RESPIRATORY+TRACT+DISEASES

Global Initiative for Chronic Obstructive Lung Disease. (2024). Pocket guide to COPD diagnosis, management and prevention: A guide for healthcare professionals. Global Initiative for Chronic Obstructive Lung Disease – GOLD. https://goldcopd.org/wp-content/uploads/2024/02/POCKET-GUIDE-GOLD-2024-ver-1.2-11Jan2024_WMV.pdf#page=9.33

Kourtidis, P., Nurek, M., Delaney, B., & Kostopoulou, O. (2022). Influences of early diagnostic suggestions on clinical reasoning. Cognitive Research: Principles and Implications, 7(1), 1–17. https://doi.org/10.1186/S41235-022-00453-Y/METRICS

Smith, S. K., Benbenek, M. M., Bakker, C. J., & Bockwoldt, D. (2022). Scoping review: Diagnostic reasoning as a component of clinical reasoning in the U.S. primary care nurse practitioner education. Journal of Advanced Nursing, 78(12), 3869–3896. https://doi.org/10.1111/JAN.15414;WGROUP:STRING:PUBLICATION

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Question 

Explore the process of assessment skills, diagnostic reasoning, and appropriate techniques necessary for a focused patient physical examination of the head, ears, eyes, nose, throat (HEENT) and chest across the lifespan.

HEENT and Chest Exam
In this competency assessment you will submit a Kaltura video and objective note, demonstrating your skill in completing this portion of an objective assessment. Use this Journal Template (ATTACHED).
You will use a live person volunteer, not a patient, and conduct the physical examination as a professional medical provider. During your examination you should verbalize for the evaluator what you are doing and why.
“Assessing Lung fields” “Auscultating heart sounds for murmur.” Your comments are your choice, demonstrating your understanding of the assessment and the purpose.
Be sure to read the required readings and watch the videos assigned in the readings. Your final production video should be about 5 minutes. It should not exceed 6 minutes; so your preparation and succinctness in the process and moving the patient through the exam is important. Consider how you will divide your time as you begin to prepare and practice.
Your communication should be clear and concise; smoothly transitioning.
Follow the pattern and process for the HEENT and Chest/ Thorax exam. This is a focused exam of the HEENT and Chest/Thorax area due to cough. Some of the content has been obtained for you. See the Unit 4 Journal Documentation Template.

Unit 4 Journal: HEENT and Chest Exam

Unit 4 Journal: HEENT and Chest Exam

Be sure to use appropriate techniques addressed in the text. You will have to practice several times to be sure your skills are honed, smooth, and that you are not looking at directions during video recording. Demonstrate professional communication with your patient.
Complete the exam and the documentation in a systematic way.
Include 3 evidence-based resources, at least one of which is a clinical guideline or evidence-based support for a condition that may be a differential for this case. Comment on how diagnostic reasoning and clinical judgment would be used to move toward a diagnosis.
Client Notes:
I will record the Kaltura Video.
The interview mock person’s details that I created
Hello George
My name is X I am a NP.
I will be assessing your lung fields and listening to your heart sound for murmurs.
This is George, a 35-year-old African American male.
You had been having a cough that was getting worse in the last two weeks
No allergy
Hx: HTN, COPD, DM2
Requirements
  • Two page
  • APA format
  • Citations after every paragraph