Build Health History and Diagnosis.
ANSWER
In general, when building a health history, you should consider the following:
- Subjective Data:
- Presenting Complaint: What are the patient’s main symptoms or concerns?
- History of Present Illness: Details about the symptoms, when they started, their progression, and any exacerbating or alleviating factors.
- Past Medical History: Existing medical conditions, surgeries, and chronic illnesses.
- Medications: A list of current medications, dosages, and frequency.
- Allergies: Any known drug allergies or allergies to substances.
- Family History: Information about the patient’s family’s health history.
- Social History: Lifestyle factors such as smoking, alcohol consumption, diet, and exercise.
- Review of Systems: A systematic review of various body systems to identify any other symptoms the patient might be experiencing.
- Objective Findings:
- Physical Examination: A detailed physical assessment of the patient, including vital signs (e.g., blood pressure, heart rate), general appearance, and specific organ systems.
- Laboratory Tests: Any relevant lab results, such as blood tests, urine tests, imaging studies, and biopsies.
- Diagnostic Exams:
- Based on the patient’s symptoms and initial assessment, you may order diagnostic exams such as X-rays, CT scans, MRI, ultrasound, or specific blood tests (e.g., complete blood count, chemistry panel) to help confirm or rule out specific conditions.
- Differential Diagnoses:
- Based on the information gathered, consider three possible diagnoses that could explain the patient’s symptoms. These should be ranked in order of likelihood.
- Rationales for Differential Diagnoses:
- Explain why you’ve chosen each of the three differential diagnoses, providing reasons based on the patient’s history, symptoms, and findings. Consider the most common and relevant conditions that match the patient’s presentation.
- Teaching:
- Educate the patient about their condition, the proposed diagnostic tests, and the differential diagnoses. Provide information on treatment options, potential outcomes, and self-care measures.
Once you have the specific case details, you can apply the above framework to build a comprehensive health history and clinical plan. Please provide the case number and any additional information for a more detailed discussion.
QUESTION
Description
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
Once you received your case number, answer the following questions:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
- What teachings will you provide?
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