Assignment 1: Case Study
Assignment: Assessing the Head,
Eyes, Ears, Nose, and Throat
Photo Credit: Getty Images/Blend Images
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
•By Day 1 of this week, you will be assigned to a specific case study for
this Case Study Assignment. Please see the “Course Announcements”
section of the classroom for your assignment from your Instructor.
• Also, your Case Study Assignment should be in the Episodic/Focused
SOAP Note format rather than the traditional narrative style format.
Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP
Template in the Week 5 Learning 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:
• Review this week's Learning Resources and consider the insights they
provide.
• 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.
The Assignment
1,
, 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 Week 5 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.
By Day 6 of Week 5
Assignment 1: Case Study Assignment: Assessing the Head, Eyes,
Ears, Nose, and Throat
Case Study 1: Focused Ear Exam (Student last name A-M)
Amy, a 3 year old girl is brought to your office by her mother because she
has a fever and complains that her ear hurts. She has no significant medical
history. The child is not pleased to be in the provider's office and has been
crying. Her mother explains that she developed a “cold” about 3 days ago
with sniffles. As she cries she continues to cough and has yellowish nasal
discharge.
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
1,
Assignment: Assessing the Head,
Eyes, Ears, Nose, and Throat
Photo Credit: Getty Images/Blend Images
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
•By Day 1 of this week, you will be assigned to a specific case study for
this Case Study Assignment. Please see the “Course Announcements”
section of the classroom for your assignment from your Instructor.
• Also, your Case Study Assignment should be in the Episodic/Focused
SOAP Note format rather than the traditional narrative style format.
Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP
Template in the Week 5 Learning 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:
• Review this week's Learning Resources and consider the insights they
provide.
• 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.
The Assignment
1,
, 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 Week 5 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.
By Day 6 of Week 5
Assignment 1: Case Study Assignment: Assessing the Head, Eyes,
Ears, Nose, and Throat
Case Study 1: Focused Ear Exam (Student last name A-M)
Amy, a 3 year old girl is brought to your office by her mother because she
has a fever and complains that her ear hurts. She has no significant medical
history. The child is not pleased to be in the provider's office and has been
crying. Her mother explains that she developed a “cold” about 3 days ago
with sniffles. As she cries she continues to cough and has yellowish nasal
discharge.
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
1,
