Jason, a 13 year old male comes in with Mom complaining of painful swallowing. Started yesterday as a “really bad sore throat” made worse with swallowing.

Case Study:

Jason, a 13 year old male comes in with Mom complaining of painful swallowing. Started yesterday as a “really bad sore throat” made worse with swallowing. He reports feeling very tired. His Mom gave him over-the-counter Children’s Motrin which made his fever better but did not help sore throat. He reports his symptoms are especially, worse during nighttime. His tonsils are 2+ and erythematous, tonsil stones are present on the right side. He has white patches on his tongue.

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.

RUBRIC:

Using 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.–

Excellent 45 (45%) – 50 (50%)

Good 39 (39%) – 44 (44%)

Fair 33 (33%) – 38 (38%)

Poor 0 (0%) – 32 (32%)

· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.–

Excellent 30 (30%) – 35 (35%)

Good 24 (24%) – 29 (29%)

Fair 18 (18%) – 23 (23%)

Poor 0 (0%) – 17 (17%)

Written 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.–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

Written Expression and Formatting – English writing standards:

Correct grammar, mechanics, and proper punctuation–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

Written 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.–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3 (3%) – 3 (3%)

Poor 0 (0%) – 2 (2%)

Total Points: 100

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