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.

Discussion 1

 

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.

Missed questions: Any trauma to hands?  Is there a pattern to her abdominal pain?

I did ask about trauma through a different question and noted no trauma, but it did not check this question off the list.  It is important to find out about trauma as a cause of the swelling. According to the text, specific traumas to the hands are not addressed but reviewed in the history.  Mechanisms can be variable so treatment will be according to the trauma (Goolsby and Grubbs, 2015). This patient’s mother denied any trauma in general and this was taken as no trauma to the hands therefore the swelling in the patient’s hands was not due to traumatic causes.

Any pattern to her abdominal pain?  I did not ask the patient’s mother about the pattern of abdominal pain due to the patient’s difficulty in communication due to age.  The pattern of pain can tell a lot about the cause. For example, a constant ache can represent a different cause than a sharp intermittent type of pain.  Although pediatric assessment of patterns of abdominal pain can be difficult to interpret because, like with this patient, the lack of speaking complicates the interpretation. Goolsby and Grubbs (2015, p.251) describe three types of abdominal pain: visceral, somatoparietal, and referred.”  Although pain can be easily detected by facial expression and body language in a child, the type and pattern of pain are difficult to detect without words.

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.

Missed: cardiac auscultation- murmur early systolic; neurological- deep tendon reflexes.

Cardiac auscultation-murmur early systolic.  This finding can be innocent or pathological in children according to Goolsby and Grubbs (2015, p. 182). I misheard and mislabeled this murmur, which was difficult to differentiate on video recording.  This is an important finding in this child due to the increased swelling of her hands and feet and possible cause of the swelling. Cardiac complications with sickle cell disease include left ventricle failure, pulmonary hypertension, systolic ejection murmurs, and cardiomegaly which can complicate and increase the likelihood of swelling (Alrayyes et al., 2018).

Deep tendon reflexes.  Assessing deep tendon reflexes is important to determine neuromuscular function.  In some rare cases, muscular necrosis can occur due to occlusions of the vasculature with sickling (Rubio, Diez, Alvarez, & Munteis, 2015).  If not assessed, a child could lose function of his or her extremities.

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.

Test range of motion.  Range of motion is important in the function of joints in the musculoskeletal system.  “An injured or diseased joint will likely be painful on motion, and active ROM may be limited to a greater degree than passive ROM” (Goolsby & Grubbs, 2015, p. 407).  To test a patient’s range of motion in joints, one must passively flex and extend the joint, have the patient actively repeat the movement. All actions including pronation and supination at the elbows; and abduction and adduction at the hips and shoulders must be assessed passively and actively in order to thoroughly assess range of motion (Bickley, 2016).

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.

Splenomegaly.  This finding is important to the diagnosis of sickle cell disease (SCD).  SCD can cause ischemia to organs, including the spleen. Red blood cells and blood components accumulate in the spleen and cause an enlargement of the spleen and systemic anemia.  Organ ischemia can occur due to SCD, which can lead to the risk of infection in children who develop splenic infarction (Alrayyes et al., 2018).

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.

Juvenile rheumatoid arthritis.  Joint inflammation in large joints is key factors in juvenile rheumatoid arthritis, which is now known as Juvenile idiopathic arthritis (JIA).  JIA can start off as involving less than five joints (pauciarticular) or be systemic with a positive ANA (still disease). As McCance and Huether (2014, p. 1604) write, the pauciarticular disease can dissipate, while systemic disease with seropositive ANA may advance into adult rheumatoid arthritis.  JIA has the same goals as does SCD in symptomatic support and to minimize permanent damage (McCance & Huether, 2014).

 

 

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 history collection for Miya was difficult because the Mother does not know her family medical history, due to her being adopted.  Like the cases in the past I seemed to ask unnecessary questions trying to investigate her condition.  One of the questions that I failed to ask was, “Has she had any trauma to her feet?” Swelling of any body structure can be indicative of a potential trauma (Goolsby & Grubbs, 2015).  Skin conditions of several types can be associated with trauma, such as blisters, erythema, or edema (Goolsby & Grubbs, 2015).  The second question I failed to ask was, “Dose anything make the pain in her feet better or worse?”  I believe that I did not ask this question because the Mother had already informed me that she had been giving her Ibuprofen as needed for pain, and it had not been eliminating her pain.

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.

            During my physical exam of the patient I failed to palpate her extremities.  I believe I avoided this to prevent causing pain to the patient.  The Mother informed me during the interview that she had a lot of pain when her hands and feet were touched.  Palpation is necessary to measure the amount of edema that is present, and whether it is pitting or not (Goolsby & Grubbs, 2015).  Range of motion and visualization of gait were also omitted from this assessment, also in an attempt to minimize the patient’s discomfort.  General inspection of the patient’s musculoskeletal system is mostly visual exam, but for thorough understanding of the severity of the impairment ROM testing should be performed (Goolsby & Grubbs, 2015).

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.

            My list of key findings contained edema of hand and feet.  This is the point of the exam when I should have palpated the patient’s hands and feet to determine the severity of the edema.  The measurement of edema is obtained by pressing your thumb or finger into the edematous area, the depth of the depression is measured and rated 1+ through 4+, with 4+ being the most severe (Bickley, 2016).

            

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.

I failed to list abdominal distention in the key findings of the assessment, but I did list splenic enlargement.  Abdominal distention can occur as a result of many complications.  Constipation, bowel obstruction, organ enlargement, or mass could all result in different severities of abdominal distention.  Splenic enlargement is one of the key findings for patients with Sickle Cell Anemia this finding should definitely make a provider look more closely at this patient’s hematological studies (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.

            I did select rheumatoid arthritis, but did not indicate juvenile rheumatoid arthritis, as a differential diagnosis. Rheumatoid arthritis (RA) can cause joint swelling in of most major joints, it is commonly seen in hands, feet, knees, wrists, ankles, and elbows (Goolsby & Grubbs, 2015).  RA is a chronic condition that has intermittent exacerbations, which is consistent with our patient’s complaints (Goolsby & Grubbs, 2015).