NURS 550 Midterm Latest Update Graded A+

NURS 550 Midterm Latest Update Graded A+ Differential Diagnosis • In deciding which disease to include in the differential, consider: - What's the most life-threatening disease the patient could have? - Could this be a common disease presenting with unusual features? - What diseases present with misleading symptoms? - What rare diseases could be causing these signs and symptoms? Develop a Complete, Framed Differential Diagnosis (Hypothesis) • Not all diagnoses in a given differential are: - equally likely - equally important • You must select: - a leading (working) hypothesis - a must not miss hypothesis - An active alternative hypothesis SOAP stands for: • Subjective • Objective • Assessment • Plan Subjective The subjective section is what the patient tells you about their current condition and past conditions. Chief Complaint • What brought the patient to the office • Example: Sore throat for 2 days History of Present Illness/Injury - Onset - When did the symptoms and/or signs begin, what was the mechanism of injury - Chronology - episodic, variable, constant, etc - Quality - sharp, dull, ache, sudden, insidious - Severity - pain rating, 0-10 pain scale, interferes with daily activities - Modifying factors - aggravating and alleviating factors - Additional symptoms - unrelated or significant symptoms - Treatment - medications, herbs, "home remedies", rest, activity, splint, etc - Use "OLDCART" to assist you (Onset, Location, Duration, Character , Aggravating factors, Relieving factors, Treatments" History Allergies - list of allergies to food, medication, and products with type of reaction - Medical - past and present medical conditions (i.e. asthma, hypertension, malaria, etc.) - Surgical - past surgeries (i.e. appendectomy, CABG, craniotomy, etc.) - Family - mother, father, siblings, etc. - Social - occupation, alcohol, drug, tobacco use, risky behavior - Immunizations - current and past received with dates - Screenings/Health Promotion - mammography, testicular exams, dental, vision - Review of Systems - systemic symptoms related to the current problem(s) including pertinent positives and negatives Review of Systems General - fever (subjective) with chills and sweats, denies fatigue, weakness, weight loss, or malaise - Skin - denies rashes, lesions, discolorations - HEENT - positive for generalized headache, sore throat, pain with swallowing and rhinorrhea. Denies difficulty swallowing saliva, earache, sinus congestion, sinus pain, visual or auditory aura - Neck - denies lump, pain, stiffness, or decreased range of motion - Cardiac - denies chest pain, pressure, tightness, palpitations - Pulmonary - denies cough, wheeze, hemoptysis - GI - denies nausea, vomiting, abdominal pain - GU - denies missed menses, urinary frequency, urgency or hematuria - MS - denies cramping, pain, - Neuro - denies unilateral weakness, numbness, tingling Review of Systems • Should elaborate on the chief complaint and HPI • Don't ask questions that the patient may not know Review of Systems