CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT NURS 6512

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NURS 6512 CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT

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Week 5: Assessment of Head, Neck, Eyes, Ears, Nose and Throat

Episodic/Focused SOAP Note

Patient Information:

D.R. 8 years old male, Hispanic Initials, Age, Sex, Race

S.

CC (chief complaint) “I have been coughing for five days, feeling sick and fatigued due to lack of sleep.”

HPI:  The eight-year-old presents with a cough that started some five days ago, and the cough becomes worse at night. The nighttime cough causes the patient to have fatigue due to a lack of sleep. Even though the sputum is clear, the cough is watery and gurgly. Even though the cough does not aggravate with activity, the patient coughs every few minutes. The patient reports pain in the throat and right year with scales of 3/10 and 2/10, respectively. The mother administered some over-the-counter yellow cough syrup for treatment which gave temporary relief.

Current Medications: unknown over-the-counter cough syrup to suppress the cough and daily intake of vitamins.

Allergies: Denies any seasonal, food, or medication allergies

PMHx: The patient has no history of hospitalizations or past surgical history. He was treated for pneumonia in the past year and had had recurrent ear infections.

 

Fam Hx: The father had a history of asthma as a child, and the father currently smokes cigarettes; hence the patient is exposed to secondhand smoke

ROS:

General: The patient denies night sweats, chills, or fevers. No changes in normal activities or appetite. However, the patient admits to enhanced fatigue.

Skin: Denies any skin changes or rashes.

HEENT: No headaches, denies blurred vision or vision changes. Reports pain in the right ear as a 3/10. Denies any hearing changes, vertigo, or tinnitus. Has throat pain as a 2/10.

Respiratory: Admits to coughing that commenced five days ago and worsening at night. Denies wheezing or shortness of breath. No history of asthma.

Cardiovascular: Denies palpitations, chest tightness, or pain.

Gastrointestinal: normal appetite, denies abdominal pain, constipation, diarrhea, or vomiting.

O.

Physical exam:

General: The boy appears fatigued but stable, good eye contact during the exam, appropriately dressed

Skin: The skin is intact with no visible rashes, lesions, or wounds

Head: Normocephalic and atraumatic

Eyes: No conjunctival discharge, the conjunctiva is pink and moist. The sclera is white. The eyes are dull in appearance.

Ears: The right tympanic membrane is inflamed and red. No noticeable visible findings like perforations, bulging, or fluid. The left auditory canal looks pink, and the tympanic membrane is pearly gray.

Nose: The mucus membrane has a clear discharge and is moist.

Throat: cobblestoning and redness observed in the throat back

Lymph nodes: The right cervical lymph node appears bigger, and tenderness also observed upon palpation

Respiratory: There is an increased respiratory rate, but no acute distress was observed. No bronchophony and adventitious breath sounds were observed. The breath sounds are clear. The chest wall is resonant to percussion. Productive cough even though the sputum is clear, expected fremitus.

Spirometry: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%)

A.

Differential Diagnoses

From the observation and the physical assessment accomplished, the following differential diagnoses apply.

  1. Common cold: This diagnosis is highly likely as indicated from the symptoms described by the patient including running nose cough and sore throat. From the physical examination, the patient’s lymph nodes were also observed to be swollen
  2. Strep throat- The condition is also likely due to the sore throat and the condition is also common among children. However the patient had no fever, headache, rash, vomiting or nausea.
  • Rhinitis: Rhinitis is another condition that is likely for this patient. Various symptoms could point to it. Some of the symptoms include stuffy nose, itchy throat, and clear nose drainage. Ear infections that keep on coming back
  1. Asthma and allergies: Asthma and allergies are also a possibility, even though the patient denies any history of allergic reactions. The patients has had coughs which is a major symptom of cough. However, there was no shortness of breath, chest tightness or pain or wheezing.

Primary Diagnosis/Presumptive Diagnosis: Common cold

Additional tests and referrals should be made to help confirm or rule out certain suggested conditions. The patient should do an allergy test to help rule out the possibilities of allergies. A rapid strep test should also be conducted to help eliminate strep throat through a Strep culture (Bickley et al., 2020). Another assessment is necessary to identify a possible bacterial infection. The patient should be offered medication as guided by the outcomes of the rapid strep test.  An RX antitussive therapy at bedtime or OTC should be introduced for ten days. Education is key for the management of this patient.

The patient and the family members should be educated on how to avoid possible allergens which can aggravate the situation or trigger a new attack (Sexton et al., 2019). The family members are also to be advised to maintain cleanliness by washing the child’s bedsheets weekly. The father smokes, and this could be an aggravating factor. Therefore, the parents should be advised to smoke away from the house, away from the patient. Some of the indicated referrals and consultations include allergy tests to rule out allergies and lung function tests to help rule out asthma.

In terms of follow-ups, the patient needs to visit the facility in a fortnight for review and assessments. However, they should seek medical attention immediately in case other symptoms such as fainting, chest pain, dizziness, shortness of breath, and high fever appear.

 

 

 

 

 

 

 

References

Brooker, C. (2021). Cough and cold: The perils of the season. AJP: The Australian Journal of Pharmacy102(1206). Doi: 10.3316/informit.789777137910856

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2020). Bates’ pocket guide to physical examination and history taking. Lippincott Williams & Wilkins.

 

Rubric

NURS_6512_Week_5_Assignment_1_Rubric
NURS_6512_Week_5_Assignment_1_Rubric
Criteria Ratings Pts

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.

50 to >44.0 pts

Excellent
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.

44 to >38.0 pts

Good
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.

38 to >32.0 pts

Fair
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.

32 to >0 pts

Poor
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.
50 pts

·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.

35 to >29.0 pts

Excellent
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected.

29 to >23.0 pts

Good
The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.

23 to >17.0 pts

Fair
The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

17 to >0 pts

Poor
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
35 pts

Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 pts

Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts

Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts

Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts

Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
5 pts

Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts

Excellent
Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts

Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts

Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts

Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

5 to >4.0 pts

Excellent
Uses correct APA format with no errors.

4 to >3.0 pts

Good
Contains a few (1 or 2) APA format errors.

3 to >2.0 pts

Fair
Contains several (3 or 4) APA format errors.

2 to >0 pts

Poor
Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100