Patient: Tara Coleman is a 2 years old with a diagnosis of Sinusitis. Patient came to the clinic with Runny nose, cough and fever
Patient: Tara Coleman is a 2 years old with a diagnosis of Sinusitis. Patient came to the clinic with Runny nose, cough and fever. Patient is crying a lot. Differential diagnosis Acute Otitis Media, Migraine, Nasal Polyps and Migraine Headache.
Images taken using CT can show details of your sinuses and nasal area. These might pinpoint a deep inflammation or physical blockage, such as polyps, tumors or fungi, that’s difficult to detect using an endoscope.
Plan: Saline Nasal Irrigation, nasal Corticosteroids and Antibiotics. Educated caregiver to moisturize sinuses, warm compress and rinse out nasal passages
Welcome to another i-Human Case Study. Take a moment to imagine a child and family you might meet. Based on the Learning Resources for this week, consider eye, ear, nose, and throat (EENT) conditions you may identify frequently as a Family Nurse Practitioner and those that may be more unusual. Also consider what aspects of the exam process might be more challenging for you—assessing, evaluating, providing multiple diagnoses, treatments, or offering the patient and family management advice. Work to be mindful of how to take best advantage of the simulated i-Human exam to prepare for pediatric patients with EENT conditions.
To prepare:
Review this week’s Learning Resources and consider how to apply knowledge of EENT conditions and understanding of socio-cultural family needs in assessing, diagnosing, and treating pediatric patients.
Access i-Human Patients from this week’s Learning Resources and review the i-Human Case Study. Based on the provided patient information, think about the health history you would need to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
Identify 3–5 possible conditions that may be considered in a differential diagnosis for the patient.
Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with EENT conditions and their families.
Please Include:
HPI Statement
History
Physical Exam
Testing
Differential diagnosis summary
Plan for patient
Exercise
See attachment for sample SOAP NOTE template
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