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Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and T

Assignment 1: Case
Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
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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.
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.
Case
Study 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 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.
Remember…..this is just a
portion of the SOAP note. You will be creating the remainder of the
information.

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