CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT
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.
Case Study 2: Focused Thyroid Exam
Kali, a 44 year old female is in the office for a complete physical examination. She complains of proptosis and feeling fatigued. Her TSH levels are elevated, she has hyperlipidemia, her neck appears swollen, and is overweight.
Attention………Remember that 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. 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.
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.
Required reading
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel’s guide to physical examination: An interprofessional approach (10th ed.). St. Louis, MO: Elsevier Mosby.
o 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.
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o 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.
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o 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.
o Chapter 15, “Earache”Download Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.
o Chapter 21, “Hoarseness”Download 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.
o Chapter 25, “Nasal Symptoms and Sinus Congestion”Download 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.
o Chapter 30, “Red Eye”Download 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.
o Chapter 32, “Sore Throat”Download Chapter 32, “Sore Throat”
A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.
o Chapter 38, “Vision Loss”Download 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.
• Document: Episodic/Focused SOAP Note Exemplar Download Episodic/Focused SOAP Note Exemplar(Word document)
• Document: Episodic/Focused SOAP Note Template Download Episodic/Focused SOAP Note Template(Word document)
• Document: Midterm Exam Review Download Midterm Exam Review(Word document)
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