Differentiating Components of Health Assessment

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Topic 1: Differentiating Components of Health Assessment

Accurate documentation of subjective and objective findings is necessary to establish an appropriate plan of care. Access the Differentiating Components Health Assessment and use critical thinking and diagnostic reasoning skills to differentiate components of health assessment.

Topic 2:

Case and Discussion: Headache

A 35-year-old woman comes to your office to discuss her “bad headaches,” which started after having her first child 2 years ago. The headaches sometimes awaken her from sleep and at times can be disabling and occasionally require her to take Tylenol and rest in a dark room. Sometimes she vomits during an attack. Over the past 6 months, her headaches have become more severe and frequent, prompting her visit today.

  • What additional questions would you ask to learn more about her headaches?
  • How do you classify headaches?
  • How can you determine if this is an old headache or a new headache/s? Is this a chronic or episodic condition?
  • Can you make a definite diagnosis through an open-ended history followed by focused questions?
  • How can you use the patient history to distinguish between benign headaches and serious ones that require urgent attention?
  • What diagnostic tests do you want to include to help you with your diagnosis?
  • Create a differential diagnosis flow sheet for this patient for this patient and include the diagnostics related to the differentials.

APA 6th edition

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Unit 5 Differentiating Components of Health Assessment Please review the following data and differentiate subjective, objective, assessment, and plan data. Place the data under the appropriate component of the assessment. Submit the completed chart to the discussion forum by Friday at 11:59 p.m. 1. Bilateral breath sounds clear to auscultation 2. Consumes 75% of meals 3. Pneumonia 4. Fine needle aspiration of thyroid gland 5. Refer to pulmonology 6. Chronic bronchitis 7. “My throat is sore and I’m hoarse” 8. Hemoglobin 25 9. Sister with breast cancer 10. Relieve of chest pain with Tylenol 11. Back pain score 8/10 with radiation to legs 12. Skin warm and dry 13. “My head hurts” 14. Potassium 3.8 15. Refer to oncology 16. COPD 17. Left mastitis 18. Lateral curvature of thoracic spine 19. Productive cough x 10 days of green yellow sputum 20. Chest pain associated with activity Subjective Data Objective Data Assessment (medical diagnosis) Plan (orders)
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Subjective Data

Objective Data

Assessment (medical
diagnosis)
Left mastitis

Plan (orders)

“My throat is sore and I’m
hoarse”

Chest pain associated with
activity

“My head hurts”

Lateral curvature of the thoracic
spine

COPD

Relieve of chest pain with
Tylenol

Sister with breast cancer

Skin warm and dry

Pneumonia

Potassium 3.8

Consumes 75% of meals

Bilateral breath sounds clear to
auscultation
Back pain score 8/10 with
radiation to legs

Chronic bronchitis

Refer to pulmonology

Hemoglobin 25

Fine needle aspiration of the
thyroid gland

Productive cough x 10 days of
green yellow sputum

Refer to oncology


Running head: Headache Case Study

1

Headache Case Study
Name
University

Headache Case Study

2
Headache Case Study

Introduction
Headaches are symptoms of pain in the head or neck area of a person caused by sleep
deprivation, hormonal imbalances, head injuries among others. There are more than 150 types of
headaches with varied symptoms classified into primary and secondary headaches (Andree,
2015). Some of these are harmless but others can be life-threatening and one should visit a health
care provider for treatment during an episod...


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