Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned
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.
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.
Case study 3:
Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past 2 days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he\’s been spending his summer, James responds that he\’s been spending a lot of time in the pool.
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
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Expert Answer and Explanation
Episodic/Focused SOAP Note
Patient Information:
James, 11-year old boy.
S.
CC The patient complains that he has had a mild earache for the past two days.
HPI: The location of the illness is the head. He started feeling mild earache two days ago. The patient reports that the pain often becomes worse during sleeping, and this makes it hard for him to hear. His grandmother also mentions that he had a fever. The problem started after the patient had spent a lot of time in the pool. The level of the patient is 6/10.
Current Medications: the patient did not mention the medication he was taking.
Allergies: the patient has no reported allergies.
PMHx: the patient has not reported any immunization.
Soc Hx: the patient likes swimming during summer.
Fam Hx: the patient has his grandmother did not mention the health history of their family.
ROS:
GENERAL: The patient feels pain in the ear and fever or fatigue.
HEENT: The patient feels pain in the ear.
SKIN: No itching or rash.
CARDIOVASCULAR: No cardiovascular disease.
RESPIRATORY: No respiratory illness.
GASTROINTESTINAL: No gastrointestinal illnesses.
O.
Physical exam: The patient feels pain in the ear. Also, the patient has a prominent tan in his ear.
Diagnostic results: the first diagnostic for a strategy for the patient is physical examination. Also, pneumatic otoscope will be used to diagnose the patient. According to Bakshi (2019), a pneumatic otoscope to find adequate data about an ear infection.
Differential Diagnoses
Primary Otalgia
Primary otalgia is also called ear pain. This disease is the most probable diagnosis because the patient feels pain mild pain in the ear. According to Earwood et al. (2019), primary otalgia is caused by mastoiditis, otitis media, auricular infections, and external otitis. This patient may be suffering from primary otalgia because he has a problem hearing during sleep. The condition will be diagnosed through physical examination and pneumatic otoscope.
Laryngitis
Laryngitis is among the common diseases affecting people’s ears. The condition can manifest in both chronic and acute form. However, this patient is likely to have acute laryngitis because he has suffered pain in about two days. Chronic laryngitis occurs when pain persists for more than three weeks (Bakshi, 2019).
Acute Otitis Media
The patient has experienced pain for the last two days. Thus, this infection might be classified as a convention because it has not gone beyond three weeks. One of the signs of acute otitis media is fever. The patient might be suffering from the condition because his grandmother reported that he was warm in those two days (Bakshi, 2019). Also, the patient experiences hearing loss at night and hearing loss is another sign of the disease.
Barosinusitis
Some of the symptoms of baronsinusitis include the following. Mild pain or pressure on the patient’s sinuses after one has returned from the sea level. The patient has visited the swimming pool for the most part of his summer holiday. Therefore, the pain he feels may be due to a lot of water in his ears. Other symptoms of baronsinusitis include occasional epistaxis and worsening congestion (Bandúrová et al., 2019).
Allergic Fungal Sinusitis
Fungal allergies commonly cause allergic fungal sinusitis. The disease also causes pain and fever in patients (Bakshi, 2019). However, this patient is most likely not to suffer from allergic fungal sinusitis because he has no history of allergies.
References
Bakshi, S. S. (2019). Image Diagnosis: Boxers Ear. The Permanente journal, 23. doi: 10.7812/TPP/18-132
Bandúrová, V., Plzák, J., & Bouček, J. (2019). Differential diagnosis of ear pain. Casopis lekaru ceskych, 158(6), 231. https://www.ncbi.nlm.nih.gov/pubmed/31931581
Earwood, J. S., Rogers, T., & Rathjen, N. A. (2018). Ear pain: diagnosing common and uncommon causes. American family physician, 97(1), 20-27. https://www.aafp.org/afp/2018/0101/p20.html
