Assignment 1: case study assignment: assessing the head, eyes, ears,

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.

Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.

In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

To Prepare

· You will be assigned to a specific case study for this Case Study Assignment. (See below the case study)

· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. (see exemplar as a guide and the template to use)

· Regarding the case study, you were assigned:

· Consider what history would be necessary to collect from the patient.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

CASE STUDY 2: Focused Throat Exam

Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, Lily figured she shouldn’t take her 3-day sore throat lightly. Your clinic has treated a few cases similar to Lily’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn’t sound congested.

The Assignment

1. Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study.

2. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.

3. L

Episodic/Focused SOAP Note Template

 

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing

Episodic/Focused SOAP Note Exemplar

Focused SOAP Note for a patient with chest pain

S.

CC: “Chest pain” 

HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.

Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg

PMH: Positive history of GERD and hypertension is controlled

FH: Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives.

SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years 

Allergies: PCN-rash; food-none; environmental- none

Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna

ROS   
General–Negative for fevers, chills, fatigue
Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema 
Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis  

O.

VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

General–Pt appears diaphoretic and anxious

Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the

second right inter-costal space which radiates to the neck.

A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.

Gastrointestinal–The abdomen is symmetrical without distention; bowel

sounds are normal in quality and intensity in all areas; a

bruit is heard in the right para-umbilical area. No masses or

splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.

Pulmonary— Lungs are clear to auscultation and percussion bilaterally

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)

A.

Differential Diagnosis:

1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

2) Angina (provide supportive documentation with evidence based guidelines).

3) Costochondritis (provide supportive documentation with evidence based guidelines).

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

A.

Differential Diagno

9/27/21, 10:27 PM Rubric Detail – Blackboard Learn

https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559590_1 1/5

Rubric Detail
Select Grid View or List View to change the rubric’s layout.

  Excellent Good Fair Poor

Name: NURS_6512_Week_5_Assignment_1_Rubric EXIT

Grid View List View

9/27/21, 10:27 PM Rubric Detail – Blackboard Learn

https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559590_1 2/5

  Excellent Good Fair Poor

Using the
Episodic/Focused
SOAP Template:
· Create
documentation
or an
episodic/focused
note in SOAP
format about the
patient in the
case study to
which you were
assigned.

·  Provide
evidence from
the literature to
support
diagnostic tests
that would be
appropriate for
your case.

45 (45%) – 50
(50%)

The response
clearly,
accurately, and
thoroughly
follows the
SOAP format
to document
the patient in
the assigned
case study. The
response
thoroughly and
accurately
provides
detailed
evidence from
the literature
to support
diagnostic
tests that
would be
appropriate for
the patient in
the assigned
case study.

39 (39%) – 44
(44%)

The
response
accurately
follows the
SOAP format
to document
the patient
in the
assigned
case study.
The
response
accurately
provides
detailed
evidence
from the
literature to
support
diagnostic
tests that
would be
appropriate
for the
patient in
the assigned
case study.

33 (33%) – 38
(38%)

The
response
follows the
SOAP format
to document
the patient
in the
assigned
case study,
with some
vagueness
and
inaccuracy.
The
response
provides
evidence
from the
literature to
support
diagnostic
tests that
would be
appropriate
for the
patient in
the assigned
case study,
with some
vagueness
or
inaccuracy in
the evidence
selected.

0 (0%) – 32
(32%)

The response
incompletely
and
inaccurately
follows the
SOAP format
to document
the patient in
the assigned
case study.
The response
provides
incomplete,
inaccurate,
and/or missing
evidence from
the literature
to support
diagnostic
tests that
would be
appropriate
for the patient
in the assigned
case study.

9/27/21, 10:27 PM Rubric Detail – Blackboard Learn

https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559590_1 3/5

  Excellent Good Fair Poor

·   List �ve
di�erent
possible
conditions for
the patient’s
di�erential
diagnosis, and
justify why you
selected each.

30 (30%) – 35
(35%)

The response
lists �ve
distinctly
di�erent and
detailed
possible
conditions for
a di�erential
diagnosis of
the patient in
the assigned
case study, and
provides a
thorough,
accurate, and
detailed
justi�cation for
each of the �ve
con

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