Assignment 1: Case Study Assignment

Injuries, infections, underlying severe health conditions, and structural abnormalities cause symptoms to the head, neck, eyes, ears, nose, and throat. Manifestations that occur in these body regions can be imprecise. Thus, a focused examination that includes a physical exam and diagnostic tests is needed to acquire accurate, relevant data to identify the diagnosis correctly. This week’s discussion explores how to assess the head, neck, eyes, ears, nose, and throat to reach an accurate diagnosis. The focused SOAP note format will be utilized for the case study, which involves the patient’s symptoms needing an assessment of the throat. Assignment 1: Case Study Assignment

Case Overview

Scenario: 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 over the past two weeks, Lily thought that she should not take her three-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 slight hoarseness in her voice but does not sound congested.

Patient Information: Name: Lily       Age: 20 years old.        Sex: Female

Subjective.

Chief Complaint: Lily reported having a sore throat for the past three days. Associated symptoms are headache, pain with swallowing, and decreased appetite. Lily is worried that her symptoms are interrelated to a recent outbreak of flu in her school.

HPI: Lily is a 20-year-old female Caucasian patient who presents to the clinic with complaints of a sore throat for the past three days. As per the patient, she was taking her sore throat lightly.  An outbreak of flu in her school, which happened two weeks ago, concerns her that her symptoms may be associated with it. She reported having episodes of a headache, decreased appetite, and pain with swallowing. Lily says that some of her classmates have similar symptoms. The patient denies a history of fever or chills. She did not take any medications for her symptoms.

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Current Medications: The patient is on multivitamins daily (One Tablet-A-Day multivitamins) for the past six months.

Allergies: lily reports being allergic to bee stings – hives

PMH: The patient does not have a history of previous hospitalization or any health condition requiring medical care. Immunization history showed that she received the flu vaccine in October 2017

Social Hx: Lily is a college student at a community college. She lives with her parents and younger brother. She refutes the use of recreational drugs, alcohol, and cigarette smoking.

Fam Hx: There is no history of health conditions affecting the family or causing deaths among the first-degree relatives.

Review of Systems:

GENERAL:  The patient is alert and oriented to time, place, person, and situation. She is pleasant and cooperative. No acute distress was noted. She denies any weight loss, weakness, fever, or fatigue.

HEENT:  patient reports headache, pain with swallowing, runny nose, and sore throat for three days. However, there is no visual loss, and she does not use eyeglasses. No hearing difficulties were noted.

SKIN:  No rash nor itching.

CARDIOVASCULAR:  No chest pain, chest discomfort, or chest pressure. No palpitations were noted.

Respiratory:  The patient has a runny nose and sore throat. No complaints of difficulty in breathing, shortness of breath, congestion, or cough. Assignment 1: Case Study Assignment

Gastrointestinal:  Poor appetite noted. She denies abdominal pain or change in bowel patterns.

GENITOURINARY:  No change in urinary voiding, nor any urinary pattern change. Last menstrual period, 11-12-2020.

NEUROLOGICAL:  Complaints of intermittent headache for the past three days with intensity ranging from four to 5 out of 10. No reports of dizziness or syncope.

MUSCULOSKELETAL:  No muscle, joint pain, back pain, or stiffness.

HEMATOLOGIC:  No bleeding, anemia, or bruising.

LYMPHATICS:  No enlarged lymph nodes. No cervical lymphadenopathy.

PSYCHIATRIC:  No history of anxiety or depression.

ENDOCRINOLOGIC:  No reports of cold or heat intolerance or sweating. No polydipsia or polyuria.

ALLERGIES:  Bee sting – hives.

Objective.

Physical exam: Vital signs: Blood Pressure 112/68mmHg, Pulse 64 beats/min (strong and regular); Temperature 98.8ºF axillary; RR 21 breaths/min; non-labored; SpO2: 99% room air; Weight: 122 lbs.; Height: 5’3

General: Alert, oriented x4, pleasant, and cooperative. Not in acute distress.

HEENT: Normocephalic and atraumatic. The sclera is anicteric, pupils are equal, round, and reactive to light, oropharynx is red, and mucous membranes are moist. No facial drooping. Rhinorrhea with mild dysphonia was noted. There are visible red and swollen tonsils, no exudates. Uvula hangs at the midline.

Neck: No pain, tenderness, swelling, or palpable nodules.

Chest and Lungs: No wheezes, rhonchi, or congestion. Bilateral lung sounds are clear on auscultation.

Heart and Peripheral Vasculature: Regular heart rate and rhythm noted. No murmurs were heard on auscultation. No palpitation.

ABD: Soft, non-tender, non-distended. Bowel sounds present in all four quadrants.

Genital and Rectal: There is the continence of the bladder and bowel.

Musculoskeletal: Normal range of motion of joints. Average muscle mass for age. No joint deformities or swelling.

Neuro: Patient is alert and oriented x4. Strength and are intact.

Skin and Lymph Nodes: No cervical lymphadenopathy. No erythema rashes.

Diagnostic results

Laboratory studies: Complete Blood Count – WBC 7.8; H/H: 12.7/37.6; PLT: 202; RBC: 4.8

Throat swab culture: Final results are pending. Preliminary findings are negative for Group A Streptococcus bacteria.

Nasopharyngeal Swab: preliminary result shows that patient is negative for influenza

Assessment.

Differential Diagnoses:

Acute laryngitis: Acute pharyngitis is a self-limiting condition caused by a viral infection, postnasal drainage secondary to poorly treated allergic rhinitis, environmental irritants, or voice overuse. Symptoms of laryngitis include sore throat, voice hoarseness, dry cough, and a weak voice (Ruppert et al., 2015).

Influenza: Every year, influenza, also known as “the flu,” spreads across college campuses nationwide, probably due to shared restrooms and close living quarters. The many social activities among campus students make them more likely to catch the flu. The flu is a contagious respiratory illness caused by influenza viruses.  Symptoms include fever, runny nose, cough, sore throat, headache, muscle or body ache, and fatigue.

Acute pharyngitis: This is an infection of tonsils or posterior pharynx caused by microorganisms such as group A beta-hemolytic streptococci, Mycoplasma pneumonia, Neisseria gonorrhea.  Associated symptoms include sore throat, fever, dysphagia, malaise, foul breath, and headache. Acute epiglottitis is another differential diagnosis (Ruppert et al., 2015). Acute epiglottis is a severe and rapidly developing condition with sore throat symptoms, hoarseness, and dyspnea.  This infection is commonly associated with the infection of Haemophilus influenza (Meadows, 2020). Assignment 1: Case Study Assignment

Postnasal drip: Postnasal drip is mucus accumulation in the throat or dripping from the back of the nose. Excessively thick secretions, swallowing disorders, or throat muscle problems cause this condition (Patel et al., 2019). Another differential diagnosis is infectious mononucleosis, which is caused by the Epstein-Barr virus that occurs most often in teens and young adults.  Symptoms of infectious mononucleosis include sore throat, fever, and swollen lymph nodes (Rostgaard et al., 2019).

Plan.  

A complete physical examination with attention to the ear, nose, and throat exam is necessary to assess other findings related to Lily’s symptoms. Due to the recent exposure to the influenza virus, it is essential to check if the patient had acquired the infection by taking a nasopharyngeal swab. Tests for throat culture will be necessary to check for microorganisms that can cause acute epiglottitis, acute pharyngitis, and infectious mononucleosis (Mantzourani et al., 2019) If voice hoarseness or sore throat are persistent, laryngoscopy may be necessary to examine the laryngeal structure. A serious underlying cause of prolonged vocal change and sore throat will necessitate the laryngeal structure’s visualization (Meadows, 2020).

References

Mantzourani, E., Hicks, R., Evans, A., Williams, E., Way, C., & Deslandes, R. (2019). Community Pharmacist Views On The Early Stages Of Implementation Of A Pathfinder Sore Throat Test And Treat Service In Wales: An Exploratory Study. Integrated Pharmacy Research & Practice, 8, 105.

Meadows, M. (2020). Sore Throat. The Family Nurse Practitioner: Clinical Case Studies, 85-87.

Patel, C., & Ponda, P. (2019). Perennial Rhinitis and Post Nasal Drip. In Pediatric Allergy (pp. 33-36). Springer, Cham

Rostgaard, K., Balfour Jr, H. H., Jarrett, R., Erikstrup, C., Pedersen, O., Ullum, H., & Hjalgrim, H. (2019). Primary Epstein-Barr virus infection with and without infectious mononucleosis. PloS one, 14(12), e0226436.

Ruppert, S. D., & Fay, V. P. (2015). Pharyngitis: soothing the sore throat. The Nurse Practitioner, 40(7), 18-25.

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”.

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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: Assignment 1: Case Study Assignment

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:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Assignment 1: Case Study Assignment

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

P.

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

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6^th edition formatting.

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. Assignment 1: Case Study Assignment

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

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.

Case Study

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.     Assignment 1: Case Study Assignment