1. Please review the complete instructions
2. Use the exemplar as guide
3. Use the provided template to complete the assignment
4. Review the grading rubric.
5. Use APA 7
Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
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
· You will be assigned to a specific case study for this Case Study Assignment. (See below the case study)
· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. (see exemplar as a guide and the template to use)
· Regarding the case study, you were assigned:
· 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.
CASE STUDY 2: Focused Throat Exam
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.
The Assignment
1. Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study.
2. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.
3. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
4. You are required to include at least five evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses.
5. Be sure to use correct APA 7th edition formatting.
Assignment 1: Case Study Assignment: Assessing the Head, Eyes,
Ears, Nose, and Throat
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 an
d 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 coll
ected from the patients, what physical
exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several
possible conditions.
To Prepare
·
Y
ou will be assigned to a specific case study for this Case
Study Assignment.
(See below the
case study)
·
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format
rather than the traditional narrative style forma
t.
(see
exemplar
as a guide and t
he
template
to
use
)
·
Regarding
the case
study,
you were assigned:
·
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 diffe
rential diagnosis
for the patient.
CASE STUDY 2: Focused Thro
at Exam
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.
The Assignment
1.
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the
patient in the case study
.
2.
Provide evidence from the literature to support diagnostic tests that would be appropriate for
each case.
3.
List five different possible conditions for the patient’s differential diagnosis and justify why you
selected each.
Assignment 1: Case Study Assignment: Assessing the Head, Eyes,
Ears, Nose, and Throat
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
You will be assigned to a specific case study for this Case Study Assignment. (See below the
case study)
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format
rather than the traditional narrative style format. (see exemplar as a guide and the template to
use)
Regarding the case study, you were assigned:
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.
CASE STUDY 2: Focused Throat Exam
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.
The Assignment
1. Use the Episodic/Focused SOAP Template and create an episodic/focused note about the
patient in the case study.
2. Provide evidence from the literature to support diagnostic tests that would be appropriate for
each case.
3. List five different possible conditions for the patient’s differential diagnosis and justify why you
selected each.
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 was “headache”, the LOCATES for the HPI might look like the following example:
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: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies 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 5 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 five 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 7th edition formatting.
© 2021 Walden University, LLC
Page 1 of 3
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
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
© 2021 Walden University LLC
Page 2 of 2
© 2021 Walden University
Page 1 of 2
9/27/21, 10:27 PM Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559590_1 1/5
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Excellent Good Fair Poor
Name: NURS_6512_Week_5_Assignment_1_Rubric EXIT
Grid View List View
9/27/21, 10:27 PM Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559590_1 2/5
Excellent Good Fair Poor
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.
45 (45%) – 50
(50%)
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.
39 (39%) – 44
(44%)
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.
33 (33%) – 38
(38%)
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.
0 (0%) – 32
(32%)
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.
9/27/21, 10:27 PM Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559590_1 3/5
Excellent Good Fair Poor
· List �ve
di�erent
possible
conditions for
the patient’s
di�erential
diagnosis, and
justify why you
selected each.
30 (30%) – 35
(35%)
The response
lists �ve
distinctly
di�erent and
detailed
possible
conditions for
a di�erential
diagnosis of
the patient in
the assigned
case study, and
provides a
thorough,
accurate, and
detailed
justi�cation for
each of the �ve
conditions
selected.
24 (24%) – 29
(29%)
The
response
lists four or
�ve di�erent
possible
conditions
for a
di�erential
diagnosis of
the patient
in the
assigned
case study
and
provides an
accurate
justi�cation
for each of
the �ve
conditions
selected.
18 (18%) – 23
(23%)
The
response
lists three to
�ve possible
conditions
for a
di�erential
diagnosis of
the patient
in the
assigned
case study,
with some
vagueness
and/or
inaccuracy in
the
conditions
and/or
justi�cation
for each.
0 (0%) – 17
(17%)
The response
lists two or
fewer, or is
missing,
possible
conditions for
a di�erential
diagnosis of
the patient in
the assigned
case study,
with inaccurate
or missing
justi�cation for
each condition
selected.
9/27/21, 10:27 PM Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559590_1 4/5
Excellent Good Fair Poor
Written
Expression and
Formatting –
Paragraph
Development
and
Organization:
Paragraphs
make clear
points that
support well-
developed ideas,
�ow 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 (5%) – 5 (5%)
Paragraphs
and sentences
follow writing
standards for
�ow,
continuity, and
clarity. A clear
and
comprehensive
purpose
statement,
introduction,
and conclusion
are provided
that delineate
all required
criteria.
4 (4%) – 4
(4%)
Paragraphs
and
sentences
follow
writing
standards
for �ow,
continuity,
and clarity
80% of the
time.
Purpose,
introduction,
and
conclusion
of the
assignment
are stated,
yet are brief
and not
descriptive.
3 (3%) – 3
(3%)
Paragraphs
and
sentences
follow
writing
standards
for �ow,
continuity,
and clarity
60%–79% of
the time.
Purpose,
introduction,
and
conclusion
of the
assignment
are vague or
o� topic.
0 (0%) – 2 (2%)
Paragraphs
and sentences
follow writing
standards for
�ow,
continuity, and
clarity < 60% of
the time. No
purpose
statement,
introduction,
or conclusion
were provided.
Written
Expression and
Formatting -
English writing
standards:
Correct
grammar,
mechanics, and
proper
punctuation
5 (5%) - 5 (5%)
Uses correct
grammar,
spelling, and
punctuation
with no errors.
4 (4%) - 4
(4%)
Contains a
few (1 or 2)
grammar,
spelling, and
punctuation
errors.
3 (3%) - 3
(3%)
Contains
several (3 or
4) grammar,
spelling, and
punctuation
errors.
0 (0%) - 2 (2%)
Contains many
(≥ 5) grammar,
spelling, and
punctuation
errors that
interfere with
the reader’s
understanding.
9/27/21, 10:27 PM Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16874433_1&rubric_id=_2559590_1 5/5
Excellent Good Fair Poor
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 (5%) - 5 (5%)
Uses correct
APA format
with no errors.
4 (4%) - 4
(4%)
Contains a
few (1 or 2)
APA format
errors.
3 (3%) - 3
(3%)
Contains
several (3 or
4) APA
format
errors.
0 (0%) - 2 (2%)
Contains many
(≥ 5) APA
format errors.
Total Points: 100
Name: NURS_6512_Week_5_Assignment_1_Rubric
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