Unit 4Focused vs. Comprehensive Assessment discussion. 1000w essay due 3-25.23. 4 references.
Instructions:
Discussion post for this week, please take the following descriptive information and place it with the appropriate categories listed. This section is already completed… please include in essay.
- Based on the descriptive information, would this be a focused or comprehensive assessment and, if focused, what system or systems would you want to assess and why? This section needs to be completed…
Categories
- Chief Complaint
- History of Present Illness
- Past Medical History
- Personal and Social History
- Review of Symptoms
Please be sure to validate your opinions and ideas with citations and references in APA format
Descriptions
- Presents with c/o headache
- Pain is a ‘4’ on a scale of 1-10
- Scoliosis corrected with Charleston brace, broken toe
- No cold/sinus symptoms
- Eye exam 2 years ago
- No medications, NKDA
- No hospitalizations
- No tobacco use, wine once monthly, no recreational drug use
- Single, lives alone
- Traveled to UK, Caribbean in past 3 months
- Throbbing for past 2 hours, can feel pulse in temple
- Sports-induced asthma
- No fever, no changes in vision
Already completed… please include in essay.
Chief Complaint:
- Presents with c/o headache
History of Present Illness:
- Pain is a ‘4’ on a scale of 1-10
- Throbbing for past 2 hours, can feel pulse in temple
Past Medical History:
- Sports-induced asthma
- Scoliosis corrected with Charleston brace, broken toe
- Eye exam 2 years ago
- No medications, NKDA
- No hospitalizations
Personal and Social History:
- No tobacco use, wine once monthly, no recreational drug use
- Single, lives alone
- Traveled to UK, Caribbean in past 3 months
Review of Symptoms:
- No cold/sinus symptoms
- No fever, no changes in vision
Redo the section/ essay below the assessment is a focused one…use the health assessment book attached.
- In this section of the essay state the specific system that would be assessed and why.
- State difference between focused and comprehensive health assessment.
- Speak on structure, function, and data you would analyze/ diagnostic reasoning.
- Who would you refer the patient to or coordinate with for the patient and why?
Sample essay……………….
With the information above, this is a focused assessment which is a detailed assessment specific
to a body system(s)related to the presenting complaint(s) or concern(s). A focused assessment is
more problem directed and allow for selection of appropriate treatment for the concerns. With
the information about the patient above, there are few additional systems I would assess to.
Neurological System Assessment: neuro assessment is important for this patient especially with
the description of the headache as throbbing with palpable pulse in the temple, as this may be
signs of serious life-threatening condition such as temporal arteritis, TIA, tension headache
(Ameer et al., 2021). Assessment should therefore be geared toward obtaining a detailed account
of the current headache, a full neurological exam and a description of any prior headache
disorder or headache history, as well as any other associated symptoms such as nausea, vomiting,
and hypersensitivity should be gathered. Likewise, assessment of the level of consciousness,
mood, affect should be done, so findings can guide treatment plans to an additional testing or
emergent therapy” (Baraness& Baker, 2021).
Cardiovascular System Assessment: there is an established link between headache and
cardiovascular disorder especially stroke. Most times, headache is the initial presenting feature of
an ischemic stroke and sometimes precedes the development of stroke (Ahmadi Aghangar et al.,
2015). It is therefore important to have a detailed cardiovascular assessment to rule out any
impending development of stroke. The assessment should include questions about chest pain,
palpitation, dyspnea, SOB, assessing the arterial pulse, measuring blood pressure, palpating any
thrills on the chest, and palpating for the point of maximal impulse, as well as auscultating for
heart sounds (Malik & Goyal, 2021).
References
Ahmadi Aghangar, A., Bazoyar, B., Mortazavi, R., & Jalali, M. (2015). Prevalence of headache
at the initial stage of stroke and its relation with site of vascular involvement: A clinical
study. Caspian journal of internal medicine, 6(3), 156–160.
Ameer, M. A, Peterfy, R. J, Bansal P, and Khazaeni, B. (2021). Temporal Arteritis.
https://www.ncbi.nlm.nih.gov/books/NBK459376/
Baraness, L. and Baker, A. M. (2021). Acute Headache.
https://www.ncbi.nlm.nih.gov/books/NBK554510/
Malik, M. B & Goyal, A. (2021). Cardiac Exam.
https://www.ncbi.nlm.nih.gov/books/NBK553078/
Headache also known as cephalalgia is a common discomfort in the head that interferes to carry
out normal daily activities. While most headaches are benign and innocuous in causes, it can be a
sign to many serious and life-threatening conditions such as brain tumor or intracranial
bleeding. The cause of headache varies from “direct mechanical, chemical, or inflammatory
stimulation of pain-generating structures to less well-characterized events as evident in primary
headache disorders” (Cutrer and O’Donnell, 2004). While the pathophysiology of secondary
headache depends on the underlying process that of a primary headache is not well understood.
Although “routine laboratory testing and imaging may not really be helpful in diagnosing
primary headaches, differential diagnosis and serious etiologies of secondary headache can be
ruled out or in with CT, MRI, and EEG” (McCance & Huether, 2015). In this case study, it is
important that focus health assessment with history taking, and physical examination is
thoroughly done. History should be geared toward obtaining a detailed account of the current
headache, a full review of systems, and a description of any prior headache disorder or headache
history, includes family history, precipitating factors, any other symptoms that happen with or
before the headache, such as nausea, vomiting, and hypersensitivity. In addition, “specific
questions relating to any possible life-threatening causes of secondary headache should be asked,
as the answers, along with any examination findings, will direct additional testing or emergent
therapy” (Baraness and Baker,2021).
This
Based on the information provided, this exam would be a focused health assessment. A focused
assessment is a more flexible or problem oriented exam (Bickley & Md, 2020). This type of exam
addresses specific concerns or symptoms and is often used for established patients or in an urgent care
situation such as visits concerning acute pain. The exam methods are relevant to the specific problem in
order to assess it as thoroughly as possible. Some systems that would require assessment include the
neurological system, the cardiovascular system, and peripheral vascular system. These systems need to
be thoroughly examined to rule out more serious conditions that can cause secondary headaches such
as a neoplasm, aneurysm rupture, venous sinus thrombosis, and intracranial pressure. A neurological
exam that shows abnormal findings, triples the odds of finding a significant intracranial abnormality
(Micieli & Kingston, 2019). Headaches can be secondary to brain tumors, encephalitis, and bleeding on
the brain. A headache is the most common presenting symptom of idiopathic intracranial hypertension
(Micieli & Kingston, 2019). Headaches have been associated with myocardial infarction, hemorrhagic
stroke, and in some instances with peripheral artery disease (Micieli & Kingston, 2019). Headaches that
are severe and have a sudden onset can also be a sign of meningitis. When assessing a headache, the
exam should attempt to elicit red flags or worrisome clinical features that may indicate the presence of
an underlying pathological condition disease (Micieli & Kingston, 2019).
References
Bickley, L. S., & Md, R. S. P. (2020). Bates’ Guide To Physical Examination and History Taking (Lippincott
Connect) (13th ed.). Wolters Kluwer Health.
This
