NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
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.
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.
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. Applied Sciences homework help
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To Prepare
- By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. (See case study below)
- Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to the Episodic/Focused SOAP Template (Attached) in the Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
With regard to 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 5 possible conditions that may be considered in a differential diagnosis for the patient
The Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each. Applied Sciences homework help
Case study
A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinate’s, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.
Episodic Note
Focused SOAP for a patient with throat pain
S.
CC: Throat pain
HPI: the patient is thirteen years old male who developed sudden onset of pain while swallowing which began yesterday. The pain is described as “really bad sore throat” and is rated two out of four. The pain gets worse with swallowing. The patient reports feeling very tired. Tonsil stones are located on the right side and there is presence of white patches on his tongue. The patient tried Motrin with minimal relief of his symptoms.
Current Medications: children’s Motrin
Allergies: food-none, environmental-none, PCN-rash
PMHx: covid-19 vaccine on 22/23/2021
Soc Hx: Negative for tobacco use currently or previously, likes swimming, stable family status
Fam Hx: No history of asthma in first degree relatives. Father is a smoker
ROS:
- General- positive for fever, tiredness and chills. Denies weight loss
- Head: reports onset of headaches, blurred vision and drainage
- EENT-reports a sore throat, cough and difficulty while swallowing, denies running or congested nose, denies double vision, reports no ear pain
- Skin-presence of skin rash
- Pulmonary- positive for cough
- Gastrointestinal- positive for nausea without vomiting, negative for diarrhea, abdominal pains, reports loss of appetite
- Respiratory- denies shortness of breath, cough or sputum. Reports intermittent cough. Applied Sciences homework help
O.
Gastrointestinal: There is no distention in the belly, and bowel movements are in all locations.
Pulmonary: Both lungs are open to percussion.
Diagnostic results:
CDC influenza SARS-Cov-19 multiple assay- to distinguish covid-19 from influenza virus (Ovchinnikov et al., 2020)
WBC with differential shows an elevation (14000cubic millimeters)- to confirm infection (Karam et al., 2019) .
Differential diagnoses
Bacterial pharyngitis- this due to the presence of cough, pain while swallowing and fever.
Covid-19- due to the presence of fever and cough
Croup- due to coughing, fever, tiredness and sore throat (Karam et al., 2019)
Measles- due to the skin rash, sore throat and fever
Common cold- due to the presence of fever, throat irritation and cough
The physical diagnostics will using a lit device to examine the throat and possibly enlarged glands. Include using a lit device to examine the throat and possibly enlarged glands (Prescott et al., 2019). The results will be used to rule out other diseases to arrive at the main illness.
References
Karam, M., Victor, R., & Singh, H. (2019). Fungal Infections in Ear, Nose and Throat: A Clinical Study. Annals Of International Medical And Dental Research, 4(3). https://doi.org/10.21276/aimdr.2018.4.3.en1
Ovchinnikov, A., Miroshnichenko, N., & Nikolaeva, Y. (2020). Sore throat. Recent trends in treatment. Vestnik Otorinolaringologii, 85(4), 35. https://doi.org/10.17116/otorino20208504135
Prescott, K., Mahida, N., & Boswell, T. (2019). Healthcare worker screening in Streptococcus pyogenes outbreaks using throat and perineal swabs. Journal Of Hospital Infection, 101(4), 485-486. https://doi.org/10.1016/j.jhin.2019.01.010 Applied Sciences homework help
