Mr. Martin denies any history of hypertension
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.
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.
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.
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.
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.
|PATIENT CHART: HISTORY – MR. JOSE MARTIN|
|Past Medical HistoryMr. Martin denies any history of hypertension, hypercholesterolemia, or diabetes. He denies any history of kidney disease, eye problems, peripheral vascular disease, heart disease, or strokes. No history of gout or arthritis. His last vaccinations were over 10 years ago, and he has not had any preventive services for his age. He denies other medical problems.MedicationsNone. Denies use of complementary or herbal remedies.Past Surgical HistoryNone.Social HistoryMr. Martin speaks English and Spanish. He is married to his wife and has one daughter, age 16. He and his family moved here from the Dominican Republic 10 years ago. He works as a taxi driver for 12-hour shifts, six days a week. His wife works as a seamstress. They are both uninsured. His daughter gets her medical care in her high school clinic. He and his family live in a two-bedroom apartment near the clinic. He is sexually active with his wife only. He does not drink alcohol or use recreational drugs. He does not smoke. The patient has good emotional support from his family and friends. He admits to occasional financial stressors, but his family is never short of food or clothing. However, his daughter may be going to college soon and his rent continues to increase annually, which worries him.Diet HistoryMr. Martin states that he eats a lot of fast food during his long and busy taxi shifts. He eats better when he is at home. His wife makes “chicken without the skin, rice, beans, plantains, yuca, and the occasional marinated pork.”Family HistoryHis mother, age 73, has high cholesterol and diabetes. His father passed away of a heart attack at age 64. He has no siblings.ROS:ConstitutionalMr. Martin reports that he has gained 20 pounds in the past five years. He denies malaise or fatigue.Head, Ears, Eyes, Nose, and ThroatHe denies headaches or vision problems.LungsHe denies shortness of breath or other breathing problems.HeartHe denies any chest pain, palpitations, fainting, or murmurs.AbdomenHe denies any abdominal concerns.GenitourinaryHe denies any urinary problems or erectile dysfunction.ExtremitiesHe denies leg swelling, pain or cramping, or varicose veins.NeurologicHe denies any weakness, tremors, or other neurologic concerns.|