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

NURS 6512

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.

 

TO PREPARE

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  • 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.

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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 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

Submit your Assignment.

SUBMISSION INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

  1. To submit your completed assignment, save your Assignment as WK5Assgn1+last name+first initial.
  2. Then, click on Start Assignmentnear the top of the page.
  3. Next, click on Upload Fileand select Submit Assignment for review.

 

RESOURCES

Be sure to review the Learning Resources before completing this activity.

Click the weekly resources link to access the resources.

WEEKLY RESOURCES

LEARNING RESOURCES

Required Readings

  • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach(9th ed.). St. Louis, MO: Elsevier Mosby.
  • Chapter 11, “Head and Neck”
  • This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.
  • Chapter 12, “Eyes”
  • In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.
  • Chapter 13, “Ears, Nose, and Throat”
  • The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.
  • Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care(6th ed.). St. Louis, MO: Elsevier Mosby.
  • Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
  • Chapter 15, “Earache”
  • Download Chapter 15, “Earache”
  • This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.
  • Chapter 21, “Hoarseness”
  • Download Chapter 21, “Hoarseness”
  • This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.
  • Chapter 25, “Nasal Symptoms and Sinus Congestion”
  • Download Chapter 25, “Nasal Symptoms and Sinus Congestion”
  • In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.
  • Chapter 30, “Red Eye”
  • Download Chapter 30, “Red Eye”
  • The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.
  • Chapter 32, “Sore Throat”
  • Download Chapter 32, “Sore Throat”
  • A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.
  • Chapter 38, “Vision Loss”
  • Download Chapter 38, “Vision Loss”
  • This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.
  • Note:Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.
  • Document: Episodic/Focused SOAP Note Exemplar
  • Download Episodic/Focused SOAP Note Exemplar
  • (Word document)
  • Document: Episodic/Focused SOAP Note Template
  • Download Episodic/Focused SOAP Note Template
  • (Word document)
  • Document:Midterm Exam Review
  • Download Midterm Exam Review
  • (Word document)

Shadow Health Support and Orientation Resources

 

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Required Media

Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 (29m)

 

Online media for Seidel’s Guide to Physical Examination

It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 10, 11, and 12 that relate to the assessment of the head, neck, eyes, ears, nose, and throat. Refer to the Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.

  • Geeky Medics. (2020, June 5).Fundoscopy (Ophthalmoscopy)
  • Links to an external site.
  • – OSCE guide [Video]. YouTube. https://www.youtube.com/watch?v=SVuP5Td23AQ&feature=youtu.be
  • Health4TheWorld Academy Videos Channel. (2020, February 15).Paranasal sinus imaging
  • Links to an external site.
  • [Video]. YouTube. https://www.youtube.com/watch?v=8TQBtdbEY-I
  • University of Iowa Ophthalmology. (2016, December 19).Fluorescein staining of the cornea
  • Links to an external site.
  • . Retrieved from https://vimeo.com/198695974
  • Credit Line: University of Iowa Ophthalmology. (n.d.). Fluorescein staining of the cornea [Video file]. Retrieved from https://vimeo.com/198695974. The author(s) and publishers acknowledge the University of Iowa and EyeRounds.org for permission to reproduce this copyrighted material.
  • Note: Approximate length of this media program is 25 seconds.

Optional Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:

LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.

  • Chapter 7, “The Head and Neck”
  • This chapter describes head and neck examinations that can be made with general clinical resources. Also, the authors detail syndromes of common head and neck conditions.

 

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 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

 

  1. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

 

 

Also read related assignments:

  1. NURS 6512 WEEK 5 ASSIGNMENT 1: Case Study Assignment
  2. Academic clinical SOAP Pancreatitis
  3. NURS 6512 Week 6: Assessment of the Abdomen and Gastrointestinal System
  4. NURS 6051 Healthcare Information Technology Trends

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