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. ******BELOW IS THE ASSIGNED CASE STUDY CASE STUDY 1: Focused Nose Exam Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken Mucinex OTC (over the counter) the past 2 nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous. -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 (UPLOADED) 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. ******THE ASSIGNMENT: -Use the Episodic/Focused SOAP Template (UPLOADED) 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. ***** MINIMUM OF 4 RELIABLE SOURCES IS REQUIRED Learning Resources FOR NURS 6512 Advanced Health Assessment and Diagnostic Reasoning Class Required Readings (Helpful sources that may help for the assignment) 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, ., 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 patients 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 patients 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. 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). Eyes: 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). Eyes: Key points. 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). Ears, nose, and throat: 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). Ears, nose, and throat: Key points. 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. 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) Hayashi, T., Kitamura, K., Hashimoto, S., Hotomi, M., Kojima, H., Kudo, F., Maruyama, Y., Sawada, S., Taiji, H., Takahashi, G., Takahashi, H., Uno, Y., & Yano, H. (2020). Clinical practice guidelines for the diagnosis and management of acute otitis media in children2018 update. Auris Nasus Larynx, 47(4), 493526. Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for Group A streptococcal pharyngitis: A narrative review. Frontiers in Cellular and Infection Microbiology, 10. Patel, G. B., Kern, R. C., Bernstein, J. A., Hae-Sim, P., & Peters, A. T. (2020). Current and future treatments of rhinitis and sinusitis. The Journal of Allergy and Clinical Immunology: In Practice, 8(5), 15221531.
