Week 5 Case Study Assignment

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Week 5 Case Study Assignment

Patient Information:

Initials: L.L. Age: 20 Years Sex: Female Race: Caucasian

CC (chief complaint): The patient came in complaining of a sore throat, difficulty in swallowing, loss of appetite, and headache for a period of three days.

HPI: The patient is a 20 year-old Caucasian female who comes in with sore throat, headache, loss of appetite, and dysphagia. She denies a history of having these symptoms before. The symptoms are located in her head, throat, and nose. The onset of the symptoms was three days before coming to the hospital. The throat is painful and the headache is pounding with pressure around the temples. The associated symptoms are loss of appetite dysphagia, hoarseness of the voice, and a runny nose. These symptoms do not have specific timing but have been present all through since they started three days before. The sore throat is made a little better by drinking chamomile tea and the headache is relieved for a while by taking paracetamol. The patient rates the severity of the sore throat at 6/10 and that of the headache at 7/10. Week 5 Case Study Assignment

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Current Medications:

Chamomile tea 250 ml three times daily (homeopathic, used for three days)
Paracetamol 1,000 mg prn (OTC, used for three days)

Allergies:

NKDA
No known allergies to food or food products
No known allergies to environmental irritants
No history of intolerance or reaction to any allergens
No history of angioedema or anaphylaxis

PMHx:

Patient L.L. has received all the immunizations that she is supposed to have got by her age. The last Tdp was given to her in 2019. She also received her pneumococcal and influenza vaccines at the beginning of 2020, in February. She was admitted as a child with streptococcal sore throat which was successfully treated. She also got admitted in 2012 with infectious gastroenteritis and dehydration. She does not have any significant surgical history. Her LMP was two weeks before the hospital visit.
Soc Hx:

Patient L.L. is a student and still lives with her family. She has a boyfriend with whom they attend the same college. Her hobbies include partying, clubbing, picnicking, and travelling. She admits to taking etoh regularly when clubbing and during house parties but only smokes occasionally. Her father is a smoker and also drinks regularly but her mother neither smokes nor drinks. They live in a middle class neighborhood with sufficient public amenities including regular garbage collection. There is a park where residents can engage in physical activity in the neighborhood. In her family, they have always been taught never to be in a moving car without fastening the seatbelt and never to use a phone while driving. They do not have smoke detectors at home. She has a robust social support system in the form of her parents, her elder sister and older brother.

Fam Hx:

Her father is hypertensive and diabetic (type II diabetes mellitus). Her mother is obese and hypertensive. None of her siblings have any significant health problems. Both her maternal and paternal grandparents are still alive. Her paternal grandfather is hypertensive and has hypercholesterolemia. Patient L.L. does not have a child.

ROS:

GENERAL: Reports fatigue and occasional chills/ fever, but denies weight loss.

HEENT: Reports intermittent headaches. Eyes: On and off tearing for the past three days. She denies double vision, blurring or visual loss. Ears, Nose, Throat: Denies tinnitus, otorrhea, or hearing loss. She does not use any hearing aids. Also denies sneezing but reports rhinorrhea and a sore throat with dysphagia.

SKIN: Denies any rash or itching.

CARDIOVASCULAR: Denies any chest tightness, pressure, discomfort, or pain. Also denies having any palpitations or experiencing peripheral edema.

RESPIRATORY: Denies difficulty in breathing or coughing.

GASTROINTESTINAL: Denies having nausea, anorexia, vomiting, or diarrhea. Reports normal bowel movements with the latest one being on the morning of the visit. Denies abdominal discomfort or pain. Denies melena or hematochezia.

GENITOURINARY: Denies pain on micturition or frequency. Patient is heterosexual. LMP was 12/12/2020.

NEUROLOGICAL: Reports on and off headache in the last three days. Denies fainting attacks, difficulties with movement, or paraesthesia in the extremities. Also denies loss of either bladder or bowel control.

MUSCULOSKELETAL: Denies arthralgia, myalgia, or back pain/ join stiffness.

HEMATOLOGIC: Denies any history of clotting problems or blood disorders. Denies bruising or bleeding.

LYMPHATICS: Denies splenectomy or lymphadenopathy.

PSYCHIATRIC: Denies a history of mental illness such as anxiety or depression.

ENDOCRINOLOGIC: Denies excessive diaphoresis or heat intolerance. Also denies excessive thirst or excessive drinking of water.

ALLERGIES: Denies any history of asthma, allergic rhinitis, hives, or eczema.

Physical Examination:

GENERAL: A&O x 3. She is well groomed and dressed appropriately for the weather and time of the day. No ataxia or gait disturbance. Vital signs: T 99.14°F; BP 125/75 mmHg; RR 16/ min; PR 78 b/m; BMI 29.2 kg/m².Week 5 Case Study Assignment

HEENT: The head is atraumatic and normocephalic. Slight lacrimation but PERRLA. EOMI. No fluid levels on otoscopy bilaterally. Tympanic membranes intact with no fluid levels visible bilaterally. No nasal polyps but nasal turbinates inflamed. Evidence of watery discharge from the nose (rhinorrhea). The throat is mildly erythematous and shows signs of inflammation. There is no exudate however.

CARDIOVASCULAR: S1 and S2 audible and RRR. No murmurs and no bruit.

RESPIRATORY: Lung fields clear. No rales, wheezing, rhonchi, or crepitations.

Diagnostic results:

Laboratory: CRP 50 mg/L; WBC 13,500 x 10⁹/L (leucocytosis)
Radiological: CXR (AP) clear.
SpO₂ 96%

Differential Diagnoses

SARS-CoV-2 (covid-19 infection): This is the most likely diagnosis given the presentation of patient L.L. and the fact that many colleagues at the college had presented with the same symptoms (AMBOSS, 2020). Covid-19 is a current global pandemic ravaging populations and groups of people staying together such as in colleges are very susceptible.
Influenza: The symptomatology of covid-19 and influenza is almost indistinguishable. Influenza also causes sore throat, a runny nose, and malaise (Hammer & McPhee, 2018). This makes influenza the second most likely diagnosis.
Bacterial pneumonia: because of the leucocytosis and the mild fever, there is a small chance that the infection could be bacterial pneumonia such as Streptococcus pneumoniae pneumonia (Hammer & McPhee, 2018). There is also a chance this may be comorbid with covid-19.
Human rhinovirus (Hammer & McPhee, 2018).
Respiratory syncytial virus (Hammer & McPhee, 2018).

References

AMBOSS (2020). COVID-19 (coronavirus disease 2019). https://www.amboss.com/us/knowledge/COVID-19_(coronavirus_disease_2019)

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9^th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12^th ed. Wolters Kluwer.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8^th ed. McGraw-Hill Education.

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

Emily, age 15, is brought to your clinic complaining of chills, aches, and a sore throat. Without any testing, consider all of the possible diagnoses. It could be a cold, the flu, bronchitis, or even something more serious, such as meningitis or mononucleosis. Assessing the actual cause will involve much more than simple visual inspection. Some conditions are so subtle that they require the use of special instruments and tests in addition to a trained eye and ear.

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This week, you will explore how to assess the head, neck, eyes, ears, nose, and throat. Whether dealing with a detached retina, sinusitis, meningitis, or even cough, advanced practice nurses need to know the proper assessment techniques in order to form accurate diagnoses.

Learning Objectives

Students will:

Apply assessment skills to diagnose eye, ear, and throat conditions

Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat

Learning Resources

Required Readings (click to expand/reduce)

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”

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”

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”

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”

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”

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”

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.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.

Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

Chapter 71, “Visual Function Evaluation: Snellen, Illiterate E, Pictorial

This section explains the procedural knowledge needed to perform eyes, ears, nose, and mouth procedures.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1, 3, 4, and 5)

Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in clinical examination. Vision Research 90, 32–37. doi:10.1016/j.visres.2013.02.001. Retrieved from https://www.sciencedirect.com/science/article/pii/S0042698913000217

Rubin, G. S. (2013). Measuring reading performance. Vision Research, 90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from http://www.sciencedirect.com/science/article/pii/S0042698913000436

Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment. American Family Physicians, 88(7), 435–440.

Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html

This website provides medical images of sinusitis, including X-rays, CT scans, and MRIs (magnetic resonance imaging).

Document: Episodic/Focused SOAP Note Exemplar (Word document)

Document: Episodic/Focused SOAP Note Template (Word document)

Document: Midterm Exam Review (Word document)

Shadow Health Support and Orientation Resources

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Student Acknowledgement Form (Word document)

Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.

Document: DCE (Shadow Health) Documentation Template for Focused Exam: Cough (Word document)

Use this template to complete your Assignment 2 for this week.

Optional Resource

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. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.Week 5 Case Study Assignment

Chapter 7, “The Head and Neck” (pp. 178–301)

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.

Required Media (click to expand/reduce)

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.

Case Study Assigned is:

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 does not sound congested.

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.Week 5 Case Study Assignment

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.

Please include text book below in the reference and add 2 more peer reviewed references with 5 years

Required Text

Seidel’s Guide to Physical Examination: An Inter professional Approach 9TH 19

Author: Ball, Jane W.

ISBN-13: 978-0-323-48195-3

ISBN-10: 0-323-48195-7

Edition/Copyright: 9TH 19

Publisher: C.V. Mosby Co.

Week 5 Case Study Assignment

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