NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
Walden University NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat-Step-By-Step Guide
This guide will demonstrate how to complete the Walden University NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.
How to Research and Prepare for NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
Whether one passes or fails an academic assignment such as the Walden University NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.
After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.
How to Write the Introduction for NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
The introduction for the Walden University NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.
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How to Write the Body for NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
After the introduction, move into the main part of the NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.
Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.
How to Write the Conclusion for NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.
How to Format the References List for NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.
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Episodic/Focused SOAP Note Template
Patient Information:
CT, 32 years old
S.
CC (chief complaint) “I feel tired and my hair is falling off”
HPI: Chantal is a 32-year-old female who visited the facility with complaints of feeling tired and her hair falling out. She reports that she has gained 30 pounds of weight in the past year. Chantal also reports that her appetite has significantly decreased. She denied accompanying symptoms such as nausea, vomiting, and pain. She reports that engaging in active physical activities worsens the fatigue that she is experiencing.
Current Medications: Chantal denies any current use of medications
Allergies: Chantal reports seasonal allergies. She denies food or drug allergies.
PMHx: Chantal’s immunization record is up-to-date. Her last tetanus vaccination was 10/10/23. She has no history of hospitalization or chronic illnesses. She also denied any history of surgeries.
Soc Hx: Chantal is married with no children. She works as a teacher. She lives with her husband in a rented apartment. She does not smoke or abuse any drugs. She loves spending her leisure time with her husband and family. She wears a seat belt while driving. Their home has smoke detectors. She engages in regular exercises at least four times weekly.
Fam Hx: Chantal’s mother was diagnosed with cervical cancer a year ago and has been on treatment. Her father is an alcoholic and has hypertension and asthma. Her paternal grandfather died of heart disease. Her paternal grandmother died of major depression. Her maternal grandmother died of diabetes mellitus type 2.
ROS:
GENERAL: Chantal was dressed appropriately for the occasion. She was alert and oriented to herself, time, and events. She reported fatigue and weight gain. She denied fever, pain, or chills.
HEENT: Eyes: Chantal denies blurred vision, eye drainage, pain, or double vision. Ears, Nose, Throat: Chantal denies ear pain, decreased hearing, ringing, or ear fullness. She denies sneezing, nasal drainage, or septum deviation. She denies a sore throat, difficulty swallowing, or postnasal drainage.
SKIN: Chantal reports her hair falling out. She denies abnormal changes in her skin color, itching, or skin rashes. CARDIOVASCULAR: Chantal denies palpitation, peripheral edema, palpitations, or chest pain and discomfort.
RESPIRATORY: Chantal denies wheezing, cough, dyspnea, cyanosis, or sputum. GASTROINTESTINAL: Chantal reports decreased appetite. She denies nausea, vomiting, diarrhea, heartburn, abdominal pain, or bleeding.
GENITOURINARY: Chantal reports that her last menstrual period was 24/12/2023. She denies urgency, frequency, or dysuria.
NEUROLOGICAL: Chantal denies loss of balance, difficulty with movement, tingling sensations, syncope, dizziness, or paralysis. Her bowel and bladder movements are normal.
MUSCULOSKELETAL: Chantal denies fractures, joint pains, muscle pain, stiffness, and back pains.
HEMATOLOGIC: Chantal denies easy bruising and a history of excessive bleeding and bleeding disorders
LYMPHATICS: Chantal denies any enlarged notes or a history of splenectomy. PSYCHIATRIC: Chantal has no history of any mental health disorders
ENDOCRINOLOGIC: Chantal reports weight gain, feeling cold, fatigue, and disturbance in her sleeping pattern. She denies polydipsia or polydipsia.
ALLERGIES: Chantal reports a history of her hair falling out.
O.
Physical exam:
Vital signs: T 37.3, RR 20, BP 102/62, P 70, and SPO2 96%, Weight 276 lbs Height 5’5
Skin: Scarce hair distribution, dry and cold skin to touch
Diagnostic results: A complete blood count and thyroid function tests were ordered. This was to rule out infections and abnormal thyroid hormones as the cause of Chantal’s problems.
A.
Differential Diagnoses
Hypothyroidism: Hypothyroidism is Chantal’s primary diagnosis. Hypothyroidism is a thyroid disorder that develops from low thyroid hormone levels. Hypothyroidism develops due to central or secondary causes. Central hypothyroidism arises from inadequate stimulation of the thyroid gland by the central nervous system while secondary hypothyroidism develops due to other causes such as thyroid surgery. Patients suffering from hypothyroidism experience symptoms such as cold intolerance, skin changes, puffiness, decreased sweating, gastrointestinal disturbances, hair loss, voice changes, fatigue, sleep disturbances, and weight gain. They also experience galactorrhea and menstrual cycle abnormalities (Patil et al., 2023; Wilson et al., 2021). Chantal has symptoms seen in hypothyroidism, hence, her primary diagnosis.
Major depression: Major depression is the secondary diagnosis that should be considered for Chantal. Major depression is a mental health disorder characterized by a severely depressed mood on most days, throughout the day. Patients also report additional symptoms such as fatigue, feelings of worthlessness and guilt, and changes in appetite, sleep patterns, and weight. Patients are also easily distracted, and experience difficulties concentrating and making decisions, suicidal thoughts, plans, and attempts (Bode et al., 2021). Chantal has some symptoms of major depression such as weight and appetite changes and sleep disturbances. However, she does not have a depressed mood, hence; major depression is the secondary diagnosis.
Sleep apnea: Sleep apnea is the other differential diagnosis that should be considered for Chantal. Sleep apnea is a sleep disorder characterized by problems with sleeping patterns. The affected patients experience repeated episodes of interrupted sleep due to the stopping of the breathing process. Patients experience symptoms such as snoring loudly, feeling tired after a night’s sleep, gasping for air during sleep, morning headaches, and irritability (Gottlieb & Punjabi, 2020; Malhotra et al., 2021). Chantal has sleep disturbance problems, which do not qualify her for sleep apnea, hence, it being a secondary diagnosis.
Chronic fatigue syndrome: Chronic fatigue syndrome is the other differential that should be considered for Chantal. Chronic fatigue syndrome is a condition associated with symptoms such as profound tiredness despite bed rest. The symptoms worsen when patients engage in any activity that requires intensive mental or physical activity. Additional symptoms associated with the syndrome include light sensitivity, headaches; tender lymph nodes, insomnia, and difficulties with concentration (Deumer et al., 2021; Sandler & Lloyd, 2020). Despite Chantal reporting fatigue, she does not suffer from chronic fatigue syndrome because of the presence of other symptoms such as weight gain and cold intolerance.
Addison’s disease: Addison’s disease is the other differential diagnosis that should be considered for Chantal. Addison’s disease develops from insufficient production of steroid hormones by the adrenal gland. Patients experience symptoms that include skin hyperpigmentation, low blood pressure, nausea, vomiting, diarrhea, constipation, and abdominal pain, weight loss. Patients might also experience fever, convulsions, severe gastrointestinal disturbances, and hypoglycemia during adrenal crises (Husebye et al., 2021; Saverino & Falorni, 2020). Addison’s disease is Chantal’s least likely diagnosis because of weight gain, cold intolerance, and lack of skin hyperpigmentation.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Bode, H., Ivens, B., Bschor, T., Schwarzer, G., Henssler, J., & Baethge, C. (2021). Association of Hypothyroidism and Clinical Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry, 78(12), 1375–1383. https://doi.org/10.1001/jamapsychiatry.2021.2506
Deumer, U.-S., Varesi, A., Floris, V., Savioli, G., Mantovani, E., López-Carrasco, P., Rosati, G. M., Prasad, S., & Ricevuti, G. (2021). Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): An Overview. Journal of Clinical Medicine, 10(20), Article 20. https://doi.org/10.3390/jcm10204786
Gottlieb, D. J., & Punjabi, N. M. (2020). Diagnosis and Management of Obstructive Sleep Apnea: A Review. JAMA, 323(14), 1389–1400. https://doi.org/10.1001/jama.2020.3514
Husebye, E. S., Pearce, S. H., Krone, N. P., & Kämpe, O. (2021). Adrenal insufficiency. The Lancet, 397(10274), 613–629. https://doi.org/10.1016/S0140-6736(21)00136-7
Malhotra, A., Ayappa, I., Ayas, N., Collop, N., Kirsch, D., Mcardle, N., Mehra, R., Pack, A. I., Punjabi, N., White, D. P., Gottlieb, D. J., & for SRS Task Force. (2021). Metrics of sleep apnea severity: Beyond the apnea-hypopnea index. Sleep, 44(7), zsab030. https://doi.org/10.1093/sleep/zsab030
Patil, N., Rehman, A., & Jialal, I. (2023). Hypothyroidism. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519536/
Sandler, C. X., & Lloyd, A. R. (2020). Chronic fatigue syndrome: Progress and possibilities. Medical Journal of Australia, 212(9), 428–433. https://doi.org/10.5694/mja2.50553
Saverino, S., & Falorni, A. (2020). Autoimmune Addison’s disease. Best Practice & Research Clinical Endocrinology & Metabolism, 34(1), 101379. https://doi.org/10.1016/j.beem.2020.101379
Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: Diagnosis and Treatment. American Family Physician, 103(10), 605–613.
NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
Patient Information:
CT, 32 years old
S.
CC (chief complaint) “I feel tired and my hair is falling off”
HPI: Chantal is a 32-year-old female who visited the facility with complaints of feeling tired and her hair falling out. She reports that she has gained 30 pounds of weight in the past year. Chantal also reports that her appetite has significantly decreased. She denied accompanying symptoms such as nausea, vomiting, and pain. She reports that engaging in active physical activities worsens the fatigue that she is experiencing.
Current Medications: Chantal denies any current use of medications
Allergies: Chantal reports seasonal allergies. She denies food or drug allergies.
PMHx: Chantal’s immunization record is up-to-date. Her last tetanus vaccination was 10/10/23. She has no history of hospitalization or chronic illnesses. She also denied any history of surgeries.
Soc Hx: Chantal is married with no children. She works as a teacher. She lives with her husband in a rented apartment. She does not smoke or abuse any drugs. She loves spending her leisure time with her husband and family. She wears a seat belt while driving. Their home has smoke detectors. She engages in regular exercises at least four times weekly.
Fam Hx: Chantal’s mother was diagnosed with cervical cancer a year ago and has been on treatment. Her father is an alcoholic and has hypertension and asthma. Her paternal grandfather died of heart disease. Her paternal grandmother died of major depression. Her maternal grandmother died of diabetes mellitus type 2.
ROS:
GENERAL: Chantal was dressed appropriately for the occasion. She was alert and oriented to herself, time, and events. She reported fatigue and weight gain. She denied fever, pain, or chills.
HEENT: Eyes: Chantal denies blurred vision, eye drainage, pain, or double vision. Ears, Nose, Throat: Chantal denies ear pain, decreased hearing, ringing, or ear fullness. She denies sneezing, nasal drainage, or septum deviation. She denies a sore throat, difficulty swallowing, or postnasal drainage.
SKIN: Chantal reports her hair falling out. She denies abnormal changes in her skin color, itching, or skin rashes. CARDIOVASCULAR: Chantal denies palpitation, peripheral edema, palpitations, or chest pain and discomfort.
RESPIRATORY: Chantal denies wheezing, cough, dyspnea, cyanosis, or sputum. GASTROINTESTINAL: Chantal reports decreased appetite. She denies nausea, vomiting, diarrhea, heartburn, abdominal pain, or bleeding.
GENITOURINARY: Chantal reports that her last menstrual period was 24/12/2023. She denies urgency, frequency, or dysuria.
NEUROLOGICAL: Chantal denies loss of balance, difficulty with movement, tingling sensations, syncope, dizziness, or paralysis. Her bowel and bladder movements are normal.
MUSCULOSKELETAL: Chantal denies fractures, joint pains, muscle pain, stiffness, and back pains.
HEMATOLOGIC: Chantal denies easy bruising and a history of excessive bleeding and bleeding disorders
LYMPHATICS: Chantal denies any enlarged notes or a history of splenectomy. PSYCHIATRIC: Chantal has no history of any mental health disorders
ENDOCRINOLOGIC: Chantal reports weight gain, feeling cold, fatigue, and disturbance in her sleeping pattern. She denies polydipsia or polydipsia.
ALLERGIES: Chantal reports a history of her hair falling out.
O.
Physical exam:
Vital signs: T 37.3, RR 20, BP 102/62, P 70, and SPO2 96%, Weight 276 lbs Height 5’5
Skin: Scarce hair distribution, dry and cold skin to touch
Diagnostic results: A complete blood count and thyroid function tests were ordered. This was to rule out infections and abnormal thyroid hormones as the cause of Chantal’s problems.
A.
Differential Diagnoses
Hypothyroidism: Hypothyroidism is Chantal’s primary diagnosis. Hypothyroidism is a thyroid disorder that develops from low thyroid hormone levels. Hypothyroidism develops due to central or secondary causes. Central hypothyroidism arises from inadequate stimulation of the thyroid gland by the central nervous system while secondary hypothyroidism develops due to other causes such as thyroid surgery. Patients suffering from hypothyroidism experience symptoms such as cold intolerance, skin changes, puffiness, decreased sweating, gastrointestinal disturbances, hair loss, voice changes, fatigue, sleep disturbances, and weight gain. They also experience galactorrhea and menstrual cycle abnormalities (Patil et al., 2023; Wilson et al., 2021). Chantal has symptoms seen in hypothyroidism, hence, her primary diagnosis.
Major depression: Major depression is the secondary diagnosis that should be considered for Chantal. Major depression is a mental health disorder characterized by a severely depressed mood on most days, throughout the day. Patients also report additional symptoms such as fatigue, feelings of worthlessness and guilt, and changes in appetite, sleep patterns, and weight. Patients are also easily distracted, and experience difficulties concentrating and making decisions, suicidal thoughts, plans, and attempts (Bode et al., 2021). Chantal has some symptoms of major depression such as weight and appetite changes and sleep disturbances. However, she does not have a depressed mood, hence; major depression is the secondary diagnosis.
Sleep apnea: Sleep apnea is the other differential diagnosis that should be considered for Chantal. Sleep apnea is a sleep disorder characterized by problems with sleeping patterns. The affected patients experience repeated episodes of interrupted sleep due to the stopping of the breathing process. Patients experience symptoms such as snoring loudly, feeling tired after a night’s sleep, gasping for air during sleep, morning headaches, and irritability (Gottlieb & Punjabi, 2020; Malhotra et al., 2021). Chantal has sleep disturbance problems, which do not qualify her for sleep apnea, hence, it being a secondary diagnosis.
Chronic fatigue syndrome: Chronic fatigue syndrome is the other differential that should be considered for Chantal. Chronic fatigue syndrome is a condition associated with symptoms such as profound tiredness despite bed rest. The symptoms worsen when patients engage in any activity that requires intensive mental or physical activity. Additional symptoms associated with the syndrome include light sensitivity, headaches; tender lymph nodes, insomnia, and difficulties with concentration (Deumer et al., 2021; Sandler & Lloyd, 2020). Despite Chantal reporting fatigue, she does not suffer from chronic fatigue syndrome because of the presence of other symptoms such as weight gain and cold intolerance.
Addison’s disease: Addison’s disease is the other differential diagnosis that should be considered for Chantal. Addison’s disease develops from insufficient production of steroid hormones by the adrenal gland. Patients experience symptoms that include skin hyperpigmentation, low blood pressure, nausea, vomiting, diarrhea, constipation, and abdominal pain, weight loss. Patients might also experience fever, convulsions, severe gastrointestinal disturbances, and hypoglycemia during adrenal crises (Husebye et al., 2021; Saverino & Falorni, 2020). Addison’s disease is Chantal’s least likely diagnosis because of weight gain, cold intolerance, and lack of skin hyperpigmentation.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Bode, H., Ivens, B., Bschor, T., Schwarzer, G., Henssler, J., & Baethge, C. (2021). Association of Hypothyroidism and Clinical Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry, 78(12), 1375–1383. https://doi.org/10.1001/jamapsychiatry.2021.2506
Deumer, U.-S., Varesi, A., Floris, V., Savioli, G., Mantovani, E., López-Carrasco, P., Rosati, G. M., Prasad, S., & Ricevuti, G. (2021). Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): An Overview. Journal of Clinical Medicine, 10(20), Article 20. https://doi.org/10.3390/jcm10204786
Gottlieb, D. J., & Punjabi, N. M. (2020). Diagnosis and Management of Obstructive Sleep Apnea: A Review. JAMA, 323(14), 1389–1400. https://doi.org/10.1001/jama.2020.3514
Husebye, E. S., Pearce, S. H., Krone, N. P., & Kämpe, O. (2021). Adrenal insufficiency. The Lancet, 397(10274), 613–629. https://doi.org/10.1016/S0140-6736(21)00136-7
Malhotra, A., Ayappa, I., Ayas, N., Collop, N., Kirsch, D., Mcardle, N., Mehra, R., Pack, A. I., Punjabi, N., White, D. P., Gottlieb, D. J., & for SRS Task Force. (2021). Metrics of sleep apnea severity: Beyond the apnea-hypopnea index. Sleep, 44(7), zsab030. https://doi.org/10.1093/sleep/zsab030
Patil, N., Rehman, A., & Jialal, I. (2023). Hypothyroidism. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519536/
Sandler, C. X., & Lloyd, A. R. (2020). Chronic fatigue syndrome: Progress and possibilities. Medical Journal of Australia, 212(9), 428–433. https://doi.org/10.5694/mja2.50553
Saverino, S., & Falorni, A. (2020). Autoimmune Addison’s disease. Best Practice & Research Clinical Endocrinology & Metabolism, 34(1), 101379. https://doi.org/10.1016/j.beem.2020.101379
Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: Diagnosis and Treatment. American Family Physician, 103(10), 605–613.
Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
Focused SOAP Note for a patient with chest pain
S.
CC: “nasal congestion and rhinitis * 5 days”
HPI: The patient is a 50-year old person who presented to the clinic suffering from rhinorrhoea, nasal congestion, postnasal drainage as well as sneezing. The patient has struggled with the itchy palate, nose, as well as eyes for a period of 5 days. Moreover, he suffers from a pale, boggy nasal mucosa alongside enlarged turbinate as well as clear thin secretions. The tonsils are not enlarged; though, he has mild erythematous in his throat.
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Medications: Mucinex
PMH: No significant medical history. The patient denies having been admitted or undergoing surgical intervention in the last 2 years. He is up to date on his immunization.
FH: Both of the patient’s parents are alive. The patient is married and they have two children aged 14
and 12. He has two siblings who are aged 42 and 46 years. They are all healthy, except the mother who presents with breast cancer.
SH: The patient denies smoking. He indicates that he quit smoking in 2006. On the other hand, he occasionally drinks alcohol. The patient engages actively in religious activities. The patient understands the importance the eating healthy and engaging in regular physical exercise.
Allergies: NKDA, indicates seasonal allergic reactions.
Immunizations: n/a
ROS
The general-The patient is well-groomed and oriented. He denies fever or fatigue. He is AAOX 4.
HEENT: The patient denies headache, but the eyes are itchy and red. There are no changes in the visual acuity. The tympanic membranes are intact with no hearing changes. The patient has nasal congestion and itchy nasal mucosal. The nasal turbinate is also enlarged.
Cardiovascular–Negative chest pain, no palpitations.
Gastrointestinal– No nausea, non-distended abdomen.
Pulmonary– negative for dyspnea or hemoptysis. NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
O.
VS: BP 121/82; P 67; R 20; T 97.8; 02 96% Wt 191lbs; Ht 70”
General-The patient denies weakness or fatigue. He is well-groomed and nourished.
Cardiovascular- No chest pain or cyanosis noted in the patient.
HEENT: Eyes are itchy and red. The tympanic membranes are intact with no discharge. No tonsillitis or purulent discharge was produced. The throat is moderately erythematous. Enlarges nasal turbinate with clear thin secretions.
Gastrointestinal-The abdomen is symmetrical and non-distended.
Pulmonary– Lungs are clear to auscultation, no chest pain or murmuring sound produced.
Diagnostic results: Skin test positive for allergy, Allergen-specific IgE antibody test not done.
A.
Differential Diagnosis:
- Allergic rhinitis: The condition is characterized by sneezing and nasal congestion. The condition
NURS 6512 Week 5 Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat result from inhalation of allergens. Most of the symptoms indicated by the patient are consistent with the allergic rhinitis and this could be the most possible diagnosis (Hoyte & Nelson, 2018).
- Sinusitis: The condition is characterized by the inflammation of the sinuses due to bacterial or viral infection. The common symptoms of the disease include nasal congestion, itchiness, and reddening. Also, the patient may have facial pain and pressure (Almutairi et al., 2018).
- Common cold: Common cold is caused influenza virus. The virus is limited to the sinuses and is mainly spread through contact. The symptoms include nasal congestion, fever and headache (Singh et al., 2017). The patient denied fever and headache in this case.
- Administer nasal corticosteroids with oral antihistamine (Urrutia Pereira, 2018).
References
Almutairi, M. B., Alsulaimi, S. M., Alghamdi, R. A., Alrehaili, K. A., Habhab, S. A., Althagafi, A. M., Alghamdi, F. A., Meighrbl, N. A., Alsuhaymi, W. M., & AlYahya, M. S. (2018). Evaluation of GERD diagnosis, management, and outcomes. The Egyptian Journal of Hospital Medicine, 72(9), 5195-5202. https://doi.org/10.21608/ejhm.2018.10741
Hoyte, F. C., & Nelson, H. S. (2018). Recent advances in allergic rhinitis. F1000Research, 7, 1333. https://doi.org/10.12688/f1000research.15367.1
Singh, M., Singh, M., Jaiswal, N., & Chauhan, A. (2017). Heated, humidified air for the common cold. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd001728.pub6
Urrutia Pereira, M. (2018). Knowledge of pharmacists about allergic rhinitis and its impact on asthma guidelines (Aria guidelines): A comparative Brazilian/Paraguayan pilot survey. https://doi.org/10.26226/morressier.5acc8ad0d462b8028d89aaca
Week 5: Assessment of Head, Neck, Eyes, Ears, Nose and Throat
Episodic/Focused SOAP Note
Patient Information:
D.R. 8 years old male, Hispanic Initials, Age, Sex, Race
S.
CC (chief complaint) “I have been coughing for five days, feeling sick and fatigued due to lack of sleep.”
HPI: The eight-year-old presents with a cough that started some five days ago, and the cough becomes worse at night. The nighttime cough causes the patient to have fatigue due to a lack of sleep. Even though the sputum is clear, the cough is watery and gurgly. Even though the cough does not aggravate with activity, the patient coughs every few minutes. The patient reports pain in the throat and right year with scales of 3/10 and 2/10, respectively. The mother administered some over-the-counter yellow cough syrup for treatment which gave temporary relief.
Current Medications: unknown over-the-counter cough syrup to suppress the cough and daily intake of vitamins.
Allergies: Denies any seasonal, food, or medication allergies
PMHx: The patient has no history of hospitalizations or past surgical history. He was treated for pneumonia in the past year and had had recurrent ear infections.
Fam Hx: The father had a history of asthma as a child, and the father currently smokes cigarettes; hence the patient is exposed to secondhand smoke
ROS:
General: The patient denies night sweats, chills, or fevers. No changes in normal activities or appetite. However, the patient admits to enhanced fatigue.
Skin: Denies any skin changes or rashes.
HEENT: No headaches, denies blurred vision or vision changes. Reports pain in the right ear as a 3/10. Denies any hearing changes, vertigo, or tinnitus. Has throat pain as a 2/10.
Respiratory: Admits to coughing that commenced five days ago and worsening at night. Denies wheezing or shortness of breath. No history of asthma.
Cardiovascular: Denies palpitations, chest tightness, or pain.
Gastrointestinal: normal appetite, denies abdominal pain, constipation, diarrhea, or vomiting.
O.
Physical exam:
General: The boy appears fatigued but stable, good eye contact during the exam, appropriately dressed
Skin: The skin is intact with no visible rashes, lesions, or wounds
Head: Normocephalic and atraumatic
Eyes: No conjunctival discharge, the conjunctiva is pink and moist. The sclera is white. The eyes are dull in appearance.
Ears: The right tympanic membrane is inflamed and red. No noticeable visible findings like perforations, bulging, or fluid. The left auditory canal looks pink, and the tympanic membrane is pearly gray.
Nose: The mucus membrane has a clear discharge and is moist.
Throat: cobblestoning and redness observed in the throat back
Lymph nodes: The right cervical lymph node appears bigger, and tenderness also observed upon palpation
Respiratory: There is an increased respiratory rate, but no acute distress was observed. No bronchophony and adventitious breath sounds were observed. The breath sounds are clear. The chest wall is resonant to percussion. Productive cough even though the sputum is clear, expected fremitus.
Spirometry: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%)
A.
Differential Diagnoses
From the observation and the physical assessment accomplished, the following differential diagnoses apply.
- Common cold: This diagnosis is highly likely as indicated from the symptoms described by the patient including running nose cough and sore throat. From the physical examination, the patient’s lymph nodes were also observed to be swollen
- Strep throat- The condition is also likely due to the sore throat and the condition is also common among children. However the patient had no fever, headache, rash, vomiting or nausea.
- Rhinitis: Rhinitis is another condition that is likely for this patient. Various symptoms could point to it. Some of the symptoms include stuffy nose, itchy throat, and clear nose drainage. Ear infections that keep on coming back
- Asthma and allergies: Asthma and allergies are also a possibility, even though the patient denies any history of allergic reactions. The patients has had coughs which is a major symptom of cough. However, there was no shortness of breath, chest tightness or pain or wheezing.
Primary Diagnosis/Presumptive Diagnosis: Common cold
Additional tests and referrals should be made to help confirm or rule out certain suggested conditions. The patient should do an allergy test to help rule out the possibilities of allergies. A rapid strep test should also be conducted to help eliminate strep throat through a Strep culture (Bickley et al., 2020). Another assessment is necessary to identify a possible bacterial infection. The patient should be offered medication as guided by the outcomes of the rapid strep test. An RX antitussive therapy at bedtime or OTC should be introduced for ten days. Education is key for the management of this patient.
The patient and the family members should be educated on how to avoid possible allergens which can aggravate the situation or trigger a new attack (Sexton et al., 2019). The family members are also to be advised to maintain cleanliness by washing the child’s bedsheets weekly. The father smokes, and this could be an aggravating factor. Therefore, the parents should be advised to smoke away from the house, away from the patient. Some of the indicated referrals and consultations include allergy tests to rule out allergies and lung function tests to help rule out asthma.
In terms of follow-ups, the patient needs to visit the facility in a fortnight for review and assessments. However, they should seek medical attention immediately in case other symptoms such as fainting, chest pain, dizziness, shortness of breath, and high fever appear.
References
Brooker, C. (2021). Cough and cold: The perils of the season. AJP: The Australian Journal of Pharmacy, 102(1206). Doi: 10.3316/informit.789777137910856
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2020). Bates’ pocket guide to physical examination and history taking. Lippincott Williams & Wilkins.
CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT
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.
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.
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.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
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.
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
Submit your Assignment.
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK5Assgn1+last name+first initial.
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
| 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 5mgPMH: Positive history of GERD and hypertension is controlledFH: 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 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
- This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Episodic/Focused SOAP Note: Assessing the Head, Eyes, Ears, Nose, and Throat
Patient Information:
Initials: Kali
Age: 44 years
Sex: Female
Race: African American
S.
CC (chief complaint): “Proptosis and fatigue.”
HPI: Kali is a 44-year-old African American female who has come for her physical exam complaining of proptosis and fatigue. She states that she began having increased fatigue about five months, but she thought it was because of the fatigue from the gym since she had just subscribed to a gym. However, the fatigue has gradually increased and occurs even on her rest days. About three months ago, she noticed that her eyes appeared strange as they had started protruding. She reports that the fatigue is exacerbated by intense physical exercises and is alleviated by rest. The fatigue has affected her occupational functioning because she is always tired, which affects her productivity.
Current Medications: Simvastatin 20 mg PO once daily for hyperlipidemia.
Allergies: None.
PMHx: Positive medical history of hyperlipidemia and overweight. Hx of Appendectomy in 2013.
Last Tdap- 07/2017
Last Flu shot- 03/2022
COVID vaccination- 05/2021 & 06/2021 (Astrazeneca)
Soc Hx: Kali has a degree in Business Administration and works as a supermarket supervisor. She is married and has three children, 16, 14, and 5 years old. Her hobbies include watching basketball and listening to podcasts. She smokes tobacco 1PPD and takes vodka 3-4 glasses on weekends. She reports going to the gym 3-4 days a week, but this has become difficult due to increased fatigue. She considers her husband and mother as her support system.
Fam Hx: The maternal and paternal grandmother had HTN and Diabetes. The father has Prostate cancer. The elder brother has HTN. Children are alive and well.
ROS:
GENERAL: Positive for fatigue, low energy levels, and weight gain. Negative for fever or chills.
HEENT: Eyes: Positive for bilateral proptosis. Negative for visual loss, blurred/ double vision, or excessive tearing. Ears: Negative for hearing loss or ear pain. Nose: Denies nose bleed, sneezing, or nasal discharge. Throat: Denies sore throat or pain in swallowing.
Neck: Reports neck swelling. Denies neck stiffness or pain.
SKIN: Negative for rash, lesion, discoloration, or itching.
CARDIOVASCULAR: Negative for neck vein distension, chest pain, edema, palpitations, or dyspnea.
RESPIRATORY: Negative for SOB, cough, chest pain, or sputum.
GASTROINTESTINAL: Negative for regurgitation, anorexia, vomiting, epigastric/abdominal pain, or rectal bleeding.
GENITOURINARY: Negative for genitourinary symptoms.
NEUROLOGICAL: Negative for headache, syncope, muscle weakness, dizziness, or numbness.
MUSCULOSKELETAL: Negative for back pain, joint pain, or joint stiffness.
HEMATOLOGIC: Negative for bruising, bleeding, or history of transfusion.
LYMPHATICS: Negative for enlarged lymph nodes.
PSYCHIATRIC: Denies mood or anxiety symptoms.
ENDOCRINOLOGIC: Denies excessive sweating, polyuria, increased hunger, polydipsia, or cold or heat intolerance.
ALLERGIES: Denies history of allergic symptoms.
O.
Physical exam:
Vital signs: BP- 124/74; HR-84; RR- 20; Temp- 98.4F
Wt-192 lbs; Ht-5’5; BMI- 31.9
HEENT: Head: Symmetrical and normocephalic. Eyes: Eyes bulging bilaterally, the sclera is white, the conjunctiva is pink, retraction and lag of the lid, and PERRLA. Ears: TMs are intact and shiny. Nose: Moist mucous membranes, well-aligned septum. Throat: The tongue is pink and midline; Tonsillar glands are patent.
NECK: Swollen; On palpation, the thyroid gland is smooth but have bruits.
CARDIOVASCULAR: Regular heart rate and rhythm. S1 and S2 present with no systolic murmur S gallop.
RESPIRATORY: Smooth respirations; The chest rises and falls uniformly; Lungs clear on auscultation.
Diagnostic results: Thyroid Stimulating Hormone (TSH) levels- are above the normal range.
A.
Differential Diagnoses
Grave’s Disease: The classic features of Grave’s disease include ophthalmopathy, a diffusely enlarged thyroid gland, thyroid bruits, pretibial myxedema, and elevated levels of Thyroxine. Ophthalmopathy presents with conjunctiva irritation, lid lag, lid retraction, widening of the palpebral fissures, proptosis, and defect in extraocular motion. Other common symptoms include general body weakness, fatigue, increased sweating, heat intolerance, warm, moist, fine skin, photophobia, eye pain, protruding eyes, double vision, and weight loss (Davies et al., 2020). Grave’s disease is a likely diagnosis owing to the positive symptoms of proptosis, increased fatigue, neck swelling, increased TSH levels, enlarged thyroid gland, and thyroid bruits.
Subacute Thyroiditis: This is an acute inflammatory disorder of the thyroid likely caused by a virus. Clinical features include fever, anterior neck pain, and thyroid tenderness. Patients initially present with hyperthyroidism, often followed by a transient period of hypothyroidism (Doubleday & Sippel, 2020). Positive symptoms of swollen neck and elevated TSH levels make Subacute Thyroiditis a differential diagnosis.
Hashitoxicosis: Hashitoxicosis is an autoimmune thyroid disorder that at first presents with hyperthyroidism and an increased radioiodine uptake caused by TSH-receptor antibodies. This is followed by hypothyroidism because lymphocytes infiltrate the thyroid gland (Shahbaz et al., 2018). Symptoms include the presence of a hard but painless goiter, sweating, hand tremors, increased appetite, sleeping difficulties, weight loss, fatigue, and heat intolerance. Hashitoxicosis is a differential diagnosis based on the patient’s history of fatigue and elevated TSH levels.
Exogenous hyperthyroidism: The condition develops due to excess exogenous thyroid hormone due to increased thyroid hormone intake. It is connected with low concentrations of serum thyroglobulin. Symptoms include weight loss, anxiety, palpitations, fatigue, increased frequency of bowel movements, and dyspnea (Doubleday & Sippel, 2020). Symptoms consistent with exogenous hyperthyroidism include fatigue and increased TSH levels.
Exophthalmos: Exophthalmos is characterized by protrusion of the eyeball and causes changes in the face and eyes. Ocular examination findings characteristic of hyperthyroidism but not related to infiltrative eye disease include eyelid lag, eyelid retraction, a temporal flare of the upper eyelid, and staring (Topilow et al., 2020). Exophthalmos is a differential diagnosis based on positive proptosis, lid retraction, and lid lag findings.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Davies, T. F., Andersen, S., Latif, R., Nagayama, Y., Barbesino, G., Brito, M., Eckstein, A. K., Stagnaro-Green, A., & Kahaly, G. J. (2020). Graves’ disease. Nature reviews. Disease primers, 6(1), 52. https://doi.org/10.1038/s41572-020-0184-y
Doubleday, A. R., & Sippel, R. S. (2020). Hyperthyroidism. Gland surgery, 9(1), 124–135. https://doi.org/10.21037/gs.2019.11.01
Shahbaz, A., Aziz, K., Umair, M., & Sachmechi, I. (2018). Prolonged Duration of Hashitoxicosis in a Patient with Hashimoto’s Thyroiditis: A Case Report and Review of Literature. Cureus, 10(6), e2804. https://doi.org/10.7759/cureus.2804
Topilow, N. J., Tran, A. Q., Koo, E. B., & Alabiad, C. R. (2020). Etiologies of Proptosis: A review. Internal medicine review (Washington, D.C.: Online), 6(3), 10.18103/imr.v6i3.852. https://doi.org/10.18103/imr.v6i3.852
HPI: Charlotte is a 28-year-old lady who presented with complaints of a runny nose and itchy eyes for 9 days. These symptoms are intermittent and occur every spring for approximately six to eight weeks. The nasal discharge is of clear mucus. There is an associated fullness and popping of ears, on-and-off sneezes throughout the day, and a tickle in the throat. There is a history of partial relief with Claritin. There is no reported cough, hotness of the body, or hearing loss.
Location: Nose and eyes.
Onset: 9 days ago.
Character: Intermittent.
Associated signs and symptoms: On and off sneezing, tickle in the throat, fullness, and popping of the ears.
Timing: Every spring for six to eight weeks.
Exacerbating/ relieving factors: Partial relief by Claritin. There is no known exacerbating factor.
Severity: Unknown.
Current Medications: The patient is currently not on any medication.
Allergies: There is no known allergy to any medication, food, or environmental components. The patient’s symptoms, however, recur every spring thus there is a possible allergy to pollen which could be the major trigger of the patient’s seasonality of symptoms.
PMH: The patient is neither hypertensive nor diabetic. There is no other reported significant chronic medical condition. The patient has never undergone any surgical procedure.
Soc Hx: The patient is an accountant. She likes traveling and photography. She is recently married with one child. There is no reported history of smoking or chronic alcohol use. She is currently lactating and is not on any contraception.
Fam Hx: The patient has a positive history of similar presentations in her grandfather. There is no family history of diabetes or hypertension.
ROS:
GENERAL: She reports no recent unintended weight loss, fever, or generalized body malaise.
SKIN: She reports no pruritus, abnormal skin discoloration, or skin rash.
CARDIOVASCULAR: She reports no left-sided chest pains, palpitations, easy fatigability, or shortness of breath even on exertion or lying flat.
RESPIRATORY: She reports no dyspnea, no chest pain, no cough, and no chest tightness.
ABDOMINAL: She reports no abdominal swelling, abdominal pain, nausea, vomiting, diarrhea, or constipation.
GENITOURINARY: She denies discomfort or burning sensation on urination, no blood in urine, and no frequency. Her menstrual cycle is regular with her last experienced menstrual period occurring two weeks ago.
NEUROLOGICAL: She denies headaches, dizziness, seizures, tingling sensation, numbness, weakness, loss of bladder and bowel control, or loss of consciousness.
MUSCULOSKELETAL: She has a history of joint swelling and tenderness with a diagnosis of gout that has since resolved with treatment.
HEMATOLOGIC: She reports no anemia, no excessive bleeding, and no easy bruising.
LYMPHATICS: She denies any lymphadenopathy, splenomegaly, or past splenectomy.
PSYCHIATRIC: She has no psychiatric history of depression, psychosis, or other mental disorder.
ENDOCRINOLOGIC: She denies excessive diaphoresis and heat or cold intolerance. She experiences polydipsia and polyuria.
ALLERGIES: She reports no history of allergic reactions.
O.
Physical exam:
VITALS: BP 102/80 mmHg, HR 72 bpm, RR 14, Temperature 98.0 F, BMI 22.0
GENERAL: The patient is in good general condition and not distressed. She is mildly dehydrated. The patient is obese.
HEENT: The head is atraumatic. Extraocular movements are intact with pupils being equally and bilaterally reactive to light. There is no scleral jaundice but there is redness of the eyes. The tonsils are not swollen but her throat is mildly erythematous. The external ear canals are free of foreign bodies or wax. The nasal mucosa is pale, boggy, and has clear thin secretions. The nasal turbinates are enlarged with resultant airway obstruction.
RESPIRATORY: The chest moves with respiration. It is resonant on percussion. There are normal vesicular breath sounds and good bilateral air entry on auscultation.
CARDIOVASCULAR: The point of maximal pulsation is in the fifth intercostal space midclavicular line. There is a normal cardiac activity in the precordium. S1 and S2 heart sounds were present with no murmurs or thrills.
ABDOMINAL: The abdomen is no abdominal distension. There is minimal tenderness in the right upper quadrant. There are no elicited masses or organomegaly. Bowel sounds are present.
MUSCULOSKELETAL: There is joint swelling, joint stiffness, or tenderness. There is no limitation in the range of motion.
NEUROLOGICAL: The patient is alert and oriented. There are no focal neurological deficits, weakness, or loss of sensation.
SKIN: The skin is warm and dry.
PSYCHIATRIC: The mood is stable with congruent affect.
Diagnostic results:
A complete blood count showed elevated eosinophilic cell count with the other differential cell count being within normal ranges. This suggests an allergic process or parasitic infestation which is unlikely based on the patient’s presentations.
Rhinoscopy showed a pale and boggy nasal mucosa covered with clear mucus. The absence of purulent nasal discharge rules out an infective process.
Skin prick test was positive for allergic reaction.
A CT scan of the head showed no evidence of basal skull fracture, chronic sinusitis, or nasal polyposis.
A.
Differential Diagnoses:
- Allergic rhinitis: This is the most likely diagnosis. This is because the patient presented with typical nasal and non-nasal symptoms. The nasal symptoms included a runny nose and sneezing whereas non-nasal symptoms included itchy eyes, redness of the eyes, and tickling of the throat (Nur Husna et al., 2022). Allergic rhinitis can also present with eustachian tube dysfunction which manifests with features such as aural fullness, aural pressure, ear pain, and popping (Juszczak et al., 2020). The patient reported fullness of the ears and popping of the ears thus there is a possibility of eustachian tube dysfunction attributed to existing allergic rhinitis. Allergic rhinitis can be seasonal, perennial, or episodic (Emeryk et al., 2019). The patient probably has seasonal allergic rhinitis due to the recurrence of symptoms during spring which is associated with the abundance of triggering pollens. The presence of a positive family history of similar presentation may point to the genetic predisposition of the atopic condition. The effectiveness of Claritin in symptomatic relief suggests an allergic process. This is because Claritin is an antihistamine that can effectively reduce allergic reactions through the suppression of proinflammatory reactions.
- Non-allergic rhinitis: Non-allergic rhinitis is another possible diagnosis. This is because some of the presenting complaints are similar to those of allergic rhinitis. This includes rhinorrhea, sneezing, and nasal congestion. However, non-allergic rhinitis does not display seasonality of symptoms as witnessed in the patient in this case. The presence of non-nasal symptoms such as itchy eyes makes allergic rhinitis more probable than non-allergic rhinitis. Non-allergic rhinitis of inflammatory and non-inflammatory etiologies such as post-infectious rhinitis, eosinophilic rhinitis, and medication-induced rhinitis should thus be excluded through further workups (Agnihotri et al., 2019). This will enable the formulation of a tailored appropriate management plan.
- Eustachian tube dysfunction: This is a likely differential diagnosis. The aural fullness and popping sounds reported by the patient are characteristic of eustachian tube dysfunction (Hamrang-Yousefi et al., 2022). The presence of additional seasonal features such as itchy eyes and runny nose rules out eustachian tube dysfunction as the only diagnosis. Serious complications such as otitis media with effusion should be assessed.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Case Study
Shawn Billings, a 28 year-old African American patient comes in to the clinic today. He has been deemed a “frequent flyer” by the staff at the clinic and was at the clinic last week and 4 days ago with a migraine, given a shot of Toradol and Ativan and sent home. He is here today again for an extreme headache. He is very agitated today. He is here with his father and worried that he will not get any medication.
Considering this scenario, several socioeconomic, spiritual, lifestyle, and cultural factors can impact this individual’s health. Frequent clinic visits may indicate limited access to healthcare resources or inability to effectively manage his health conditions. This patient may lack health insurance or have financial constraints that prevent him from receiving expedient medical care or obtaining necessary medications.
Shawn’s occupation and working conditions may cause him to experience tension and migraines. His health may be affected by job insecurity, lengthy work hours, or exposure to environmental hazards. Identifying Shawn’s stressors and using stress-reduction methods like exercise may improve his headaches. Treatment for migraines include non-drug treatments for prevention, and mindfulness-based stress reduction have recently been shown to help with pain and function, (Seminowicz, et al., 2020). Assessing Shawn’s diet and exercise may help reveal migraine triggers. Changing his diet and exercising may improve his symptoms.
Shawn’s healthcare seeking and adherence may be influenced by cultural beliefs and attitudes about sickness and treatment. Cultural Awareness is the deliberate self-examination and in-depth study of one’s biases, stereotypes, prejudices, assumptions, and “isms” about people and groups who are different from themselves, (Ball, J. W., et al., 2019). As an African American patient, Shawn may be mistrustful due to healthcare inequities. His health depends on culturally competent treatment, open communication, and trust. These economical, spiritual, lifestyle, and cultural characteristics can help the Nurse Practitioner understand Shawn’s health needs and customize interventions to his situation.
When it comes to making clinical decisions, there can be a lot of confusion and ambiguity, (Dains, et al., 2019). Shawn Billings’ health history should be attentive to his background, lifestyle, and culture. Healthcare practitioners can learn about Shawn’s health history, understand his circumstances, and create a personalized care plan by asking these questions in a non-judgmental and culturally sensitive manner. These five targeted questions can assist in obtaining information about his health history and analyze his health risks while considering his specific circumstances.
- Can you tell me about your previous experiences with migraines and headaches? How long have you been experiencing them, and have you noticed any specific triggers or patterns? This question allows Shawn to share his experiences and provides insights into the duration, frequency, and potential triggers of his headaches.
- Are there any specific factors in your daily life, such as work or personal stressors, that you believe may contribute to your migraines? How do you manage stress in your life? This question acknowledges the impact of lifestyle and stress on Shawn’s health. It shows respect for his experiences and provides an opportunity for him to discuss coping mechanisms he may already use.
- Can you describe your typical daily routine, including your sleeping patterns, dietary habits, and physical activity levels? This question helps understand how Shawn’s lifestyle choices, such as sleep, diet, and exercise, may affect his overall health and migraine frequency.
- Are there any cultural or spiritual practices that are important to you or that you engage in regularly? How do you feel these practices contribute to your well-being? This question recognizes the significance of cultural and spiritual factors in Shawn’s life and encourages him to share how these practices impact his overall well-being and coping strategies.
- Could you please share any concerns or challenges you face regarding accessing healthcare or medications? Do you have any specific preferences or cultural beliefs related to healthcare that you would like us to consider? This question addresses potential barriers to healthcare that Shawn may encounter due to his socioeconomic background or cultural factors. It demonstrates sensitivity to his needs and preferences, facilitating a patient-centered approach to his care.
Ball, J. W., et al., (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis,
MO: Elsevier Mosby.
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.
Seminowicz, D. A., et al., (2020). Enhanced mindfulness based stress reduction (MBSR+) in episodic migraine: a
randomized clinical trial with MRI outcomes. Pain, 161(8), 1837.
Interview Summary
The interview is conducted with a 4-year-old African American male living in a rural community. I took the child’s background and environment into consideration to establish effective communication. The primary goal is to assess the child’s development, emotional well-being, and any potential risk factors. To achieve this, I must employ various communication techniques suited for the child’s age, cultural background, and context.
Communication Techniques
Active Listening: I will actively listen to the child’s words, sounds, and nonverbal cues to encourage the child to express themselves comfortably.
Use of Visual Aids: I intend to use visual aids such as pictures, drawings, and toys to help the child communicate thoughts and feelings that might be difficult to express verbally.
Simple Language: I will use simple and concise language that is appropriate for the child’s developmental stage and vocabulary.
Cultural Sensitivity
I am African American, so I am aware of the cultural needs of the child. However, I will demonstrate cultural sensitivity by acknowledging and respecting the child’s heritage which may differ from mine, integrating familiar cultural references, and understanding the community’s values as he sees them.
Play-Based Approach: Utilizing play-based techniques allows the child to engage in an environment they are comfortable with, encouraging them to share their thoughts and feelings through play activities.
Selected Risk Assessment Instrument
The Ages and Stages Questionnaire (ASQ-3) is selected as the applicable risk assessment instrument for the child. ASQ-3 is designed to assess developmental milestones in children from birth to 5 years old. Given the child’s age, it is well-suited to identify potential developmental delays and provide insights into areas that might need further evaluation.
Targeted Questions
- Can you show me your favorite toy and tell me about it?
- What do you like to do with your friends when you’re playing outside?
- Can you count from one to five for me?
- How do you feel when you’re around new people or in new places?
- Tell me a story about something fun you did recently.
Justification for Selected Questions
These questions are designed to assess the child’s communication, social interaction, cognitive development, emotional well-being, and recent experiences. They are formulated using simple language and are open-ended, allowing the child to respond comfortably and providing valuable insights into their developmental and emotional state. The questions also encourage the child to express themselves through both verbal and nonverbal means, aligning with the chosen communication techniques.
References
Fisher, A. K., Mackey, T. D., Langendoen, C., & Barnard, M. (2019). Child and interviewer race in forensic interviewing. Journal of Child Sexual Abuse, 25(7), 777–792. https://doi.org/10.1080/10538712.2016.1208705
Hall, M. T., Sears, J., & Walton, M. T. (2019). Motivational interviewing in Child Welfare Services: A systematic review. Child Maltreatment, 25(3), 263–276. https://doi.org/10.1177/1077559519893471
Hsiao, C., Richter, L., Makusha, T., Matafwali, B., van Heerden, A., & Mabaso, M. (2016). Use of the ages and stages questionnaire adapted for South Africa and Zambia. Child: Care, Health and Development, 43(1), 59–66. https://doi.org/10.1111/cch.12413
Segre, G., Campi, R., Scarpellini, F., Clavenna, A., Zanetti, M., Cartabia, M., & Bonati, M. (2021). Interviewing children: The impact of the covid-19 quarantine on children’s perceived psychological distress and changes in routine. BMC Pediatrics, 21(1), 1–11. https://doi.org/10.1186/s12887-021-02704-1
Episodic/Focused SOAP Note
Patient Information:
C.M, 28, F
S.
CC (chief complaint): Patient has come in due to complaints of a runny nose and itchy eyes.
HPI: Patient is a female 28 years of age who is presenting with clinical manifestations of a runny nose and itchy eyes. Patient reports the onset of the signs and symptoms as well as ears feeling full started 9 days ago. Patient reports the nasal discharge to be clear and runny. Patient reports that she is also sneezing on and off during the course of the day. Patient describes her eyes to be so itchy to the point she feels she feels to scratch them out. Patient reports a tickle sensation in her throat and at times her ears that feel full pop. Patient reports these clinical manifestations occur every spring and could last a duration of about six to eight weeks.
Current Medications: Patient is not on medication at the moment though previously used Claritin to relieve similar clinical manifestations that occurred the previous year.
Allergies: Patient reports no known food or drug allergies.
PMHx: Patient is up to date with her immunizations, has not been previously hospitalized or suffered from chronic illnesses.
Soc Hx: Patient takes alcohol on occasion. Patient enjoys ice skiing. Patient does not smoke or use illicit drugs. Patient is a travel agent.
Fam Hx: Patient reports the mother is hypertensive while the father has diabetes. Patient reports no her paternal side has a history of obesity while her maternal side has a history of high blood cholesterol. Patient reports her 3 siblings are healthy.
ROS:
GENERAL: Patient reports no fever, difficulty in sleeping or increase in weight.
HEENT: Patient reports no headache. Patient reports itchy eyes. Patient reports ears that feel full. Patient reports a runny nose. Patient reports a tickle sensation in her throat.
SKIN: Patient does not report presence of a rash or abnormality on the skin.
CARDIOVASCULAR: Patient reports no pain in the chest, palpitations or tightness of the chest RESPIRATORY: Patient reports no presence of a wheeze, difficulty in breathing or a cough.
GASTROINTESTINAL: Patient does not report constipation, diarrhea or pain in the stomach region.
GENITOURINARY: Patient does not report pain while urinating, changes in frequency or blood in the urine.
NEUROLOGICAL: Patient reports no seizures, dizziness or incidences of fainting.
MUSCULOSKELETAL: Patient reports lack of pain in the muscle, joints or feeling of weakness.
ALLERGIES: Patient reports no identifiable drug or food allergies.
O.
Physical exam: Height: 6’2 Weight: 190lbs BMI: 24.4
VITAL SIGNS: Blood pressure: 124/80 Heart rate: 111 bpm, Respiratory rate: 16, SPO2: 99%, Temperature: 96.5
General: Patient is alert and oriented responding appropriately to assessment questions.
HEENT: Head is normocephalic. On inspection erythema noted in the eyes. On inspection ears were without drainage. On inspection nasal turbinates were enlarged with a pale nasal mucosa. On inspection throat is mildly erythematous.
NECK: Presence of palpable lymph nodes in that region
PULMONARY: On inspection chest is symmetrical. On auscultation normal lung sounds are noted. On palpation chest is non-tender.
ABDOMEN: On inspection abdomen is without scars. On auscultation normal bowel sounds noted. On palpation liver is palpable. On percussion no tympany noted in the abdomen
GENITALIA AND RECTAL REGION: On inspection normal external genitalia noted and on rectal exam no trauma noted.
MUSCULOSKELETAL: On inspection no deformity noted on the back. On percussion the back and spine are non-tender. On palpation muscles are non-tender.
Rubric
| NURS_6512_Week_5_Assignment_1_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning OutcomeUsing 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. |
|
50 pts | ||||
| This criterion is linked to a Learning Outcome· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. |
|
35 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow 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 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
|
5 pts | ||||
| This criterion is linked to a Learning OutcomeWritten 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 pts | ||||
| Total Points: 100 | ||||||
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