Throat Exam Lily is a 20-year-old student at the local community college.

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.
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.
Episodic/Focused SOAP Note Template – (delete information on this template and input one related to the patient in the case study above).
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:  No weight loss, fever, chills, weakness or fatigue.
HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN:  No rash or itching.
CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY:  No shortness of breath, cough or sputum.
GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC:  No anemia, bleeding or bruising.
LYMPHATICS:  No enlarged nodes. No history of splenectomy.
PSYCHIATRIC:  No history of depression or anxiety.
ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES:  No 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 3 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 three 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 6th edition formatting.
Resources for references
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, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby 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)

Comments

Post a Comment

Popular posts from this blog

The merchandise sold at Costco may be similar to that of its two main competitors—Sam’s Club and BJ’s—but Costco aims to be a cut above by offering many unique and unusual items. Its stores also look slightly more upscale than other club stores, the brands it carries have more cachet, and the products are often a bit more expensive, but they still offer extremely good value. And unlike some other discounters, Costco does not have everything under the sun. The stores carry only about 4,000 products each, which is a small fraction of the more than 100,000 items stocked by other warehouse clubs and conventional discounters such as Target and Walmart. About 3,000 of Costco’s products are a consistent array of carefully chosen basics, from canned tuna to laundry detergent to printer cartridges. The other 1,000 items are a fast-moving assortment of goods such as designer-label clothing, watches, and premium wines. These items change from week to week, reinforcing the idea of buying something when you see it because it’ll probably be gone next week. Costco prefers to offer name-brand products and has successfully introduced some branded luxury items such as Kate Spade and Coach purses. However, high-end suppliers such as Cartier and Cannondale flinch at the idea of their goods being sold in a warehouse setting, so carrying those brands isn’t always possible. Some suppliers, hoping to protect their higherend retail customers, have been known to spurn Costco’s offers “officially,” only to call back later to quietly cut a deal. In other cases, Costco goes on its own treasure hunts, using third-party distributors to track down hot products, even though these “gray market” channels can be unpredictable. And if that doesn’t work, Costco can commission another manufacturer to create a lookalike product—leather handbags are one example—with its own Kirkland Signature label. To give its millions of members the best prices on everything, Costco negotiates directly—and fiercely—with suppliers. Aiming to be known as the toughest negotiators in the business, Costco’s buyers won’t let up until they get their target price on the merchandise. Often, the “right” price is determined by how much less expensively Costco can make a product itself. Using this approach, the company has managed to drive down price points in several categories, such as over-the-counter drugs. Costco then passes on the savings to customers, who never pay more than 15 percent above the company’s cost. Cofounder and recently retired CEO Jim Sinegal was determined not to let the wheel of retailing take Costco for a spin, either. “When I started, Sears, Roebuck was the Costco of the country, but they allowed someone else to come in under them. We don’t want to be one of the casualties. We don’t want to turn around and say, ‘We got so fancy we’ve raised our prices,’ and all of a sudden a new competitor comes in and beats our prices.” Inventory turnover rate is also a key to Costco’s financial success. By focusing on fast-selling items, the company moves its merchandise significantly faster than competitors—so quickly, in fact, that it often sells products to shoppers before it has to pay its suppliers. Costco is rolling through its third decade with strong financial health, a dominant market position, and millions of consumers and business customers that rely on Costco bargains. Annual sales will break the $80 billion barrier soon, and $100 billion doesn’t look too far out of reach. Online sales remain a fairly small fraction of total revenue, but the company expects those sales to pick up as the economy improves and consumers are more confident to spend on the more expensive items that are typically offered on the website. International expansion is another item on Costco’s strategic menu, with sales recently growing at a faster clip outside the United States. Per-store sales are up in other countries, but the number of new store openings has tapered off over the past few years, thanks in part to the economy and in part to a cautious approach to finding the right locations. For instance, the company thinks Taiwan could support 20 Costco stores and Japan could support 50, but finding enough land for the giant footprint of a warehouse store—typically 15 acres—that is near population centers but not in areas with zoning regulations that prohibit bigbox retailers is a particular challenge in some countries.37 Question 1. If customers repeatedly ask Costco to carry certain items that the company thinks are outside its price/quality “comfort zone” (because they’re too expensive or not of high enough quality), should it give in and carry the items? Why or why not? 2. Most of the items on Costco’s website are available only through Costco; should it expand its online product selection to include more commonly available products, since an online store doesn’t have the physical constraints of a brick-and-mortar location? Why or why not? 3. If Costco can’t find enough land in, say, Japan, to build its usual store format, should it leverage the Costco brand name anyway and build something such as conventional department stores or grocery stores in these areas? Why or why not?

Image
The merchandise sold at Costco may be similar to that of its two main competitors—Sam’s Club and BJ’s—but Costco aims to be a cut above by offering many unique and unusual items. Its stores also look slightly more upscale than other club stores, the brands it carries have more cachet, and the products are often a bit more expensive, but they still offer extremely good value. And unlike some other discounters, Costco does not have everything under the sun. The stores carry only about 4,000 products each, which is a small fraction of the more than 100,000 items stocked by other warehouse clubs and conventional discounters such as Target and Walmart. About 3,000 of Costco’s products are a consistent array of carefully chosen basics, from canned tuna to laundry detergent to printer cartridges. The other 1,000 items are a fast-moving assortment of goods such as designer-label clothing, watches, and premium wines. These items change from week to week, reinforcing the idea of buying something
Read more

As she begins her new journey at CSU, Claudia has identified a new goal that she has, but she still needs your help

 Instructions As she begins her new journey at CSU, Claudia has identified a new goal that she has, but she still needs your help. Review the material that is found within this unit. Click  here to access the goal worksheet, and use this worksheet to help Claudia summarize a SMART plan for managing her goals and priorities. In the same worksheet, complete a SMART plan for your own goals and priorities. You should use the details found within the Unit I Lesson to help establish a plan for Claudia. Do not forget to embrace the reading assignments for this unit as well. WE HAVE DONE THIS ASSIGNMENT BEFORE, WE CAN ALSO DO IT FOR YOU GET SOLUTION FOR THIS ASSIGNMENT,  Get Impressive Scores in Your Class CLICK HERE TO MAKE YOUR ORDER   on As she begins her new journey at CSU, Claudia has identified a new goal that she has, but she still needs your help Are You looking for Assignment and Homework Writing help?  We Provide High-Quality Academic Papers at Affordable Rates. No Plagiarism
Read more

Decide which play you would like to write about.

Image
Assignment #3 - Essay 3: Drama - preparation (including ONE outside source) Here’s a brief summary of important steps to follow in writing Essay 3, which involves the use of an outside critical source [for more complete information, see ‘Complete guidelines for writing Essay 3 below]: 1) Decide which play you would like to write about. 2) Think about what aspect of the play you’d like to investigate as the topic of your essay. 3) Search the scholarly databases for a critical article dealing with that topic. [NOTE: As you begin to read scholarly articles, you may find one that is so interesting that you decide to change your topic just so you can use it. That’s a legitimate part of the research process, so keep an open mind!] 4) Read the article several times so that you’re familiar with it; then read the play again so that you can see how they connect. 5) Begin writing your rough draft. 6) Be sure to review the correct methods for using MLA documentation, both within the body of your e
Read more