Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Te

 

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.

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USW1.575.202130 – NURS-6512C-1/NURS-6512D-1/NURS-6512N-1-Advanced Health Assessment2020 Winter Qtr 11/30-02/21-PT27

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Monica Castelao on Wed, Jan 06 2021, 3:32 AM 68% highest match Submission ID: bb56b440-40e4-4e90-8c80-18bff0b840f6

  • Week5Castelao.M.extention.docx

    Word Count: 907

    Attachment ID: 3891174207

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Running head: FOCUSED EAR EXAMINATION 1 FOCUSED EAR EXAMINATION 5 Focused Ear Examination Monica Castelao Walden University 1 Focused Ear Examination Close Panel Suspected Entry: 63% match Uploaded – Week5Castelao.M.extention.docx Focused Ear Examination Source – Another student's paper Focused Ear Exam Patient Information: 2 JK is an 11 year old male African American Close Panel Suspected Entry: 65% match Uploaded – Week5Castelao.M.extention.docx JK is an 11 year old male African American Source – Another student's paper The patient is an 11-year-old African American male brought into the clinic by his grandmother S 3 Chief Complaint (CC): Close Panel Suspected Entry: 100% match Uploaded – Week5Castelao.M.extention.docx Chief Complaint (CC) Source – Another student's paper CC (chief complaint) 4 I have had a mild earache for the past 2 days Close Panel Suspected Entry: 68% match Uploaded – Week5Castelao.M.extention.docx I have had a mild earache for the past 2 days Source – Another student's paper “Mild earache for the past two days” HPI: Location: Right ear Onset: 3 2 days ago Close Panel Suspected Entry: 99% match Uploaded – Week5Castelao.M.extention.docx 2 days ago Source – Another student's paper 2 days ago Character: Aching 3 Associated signs and symptoms: Close Panel Suspected Entry: 100% match Uploaded – Week5Castelao.M.extention.docx Associated signs and symptoms Source – Another student's paper Associated signs and symptoms 5 Pain when falling asleep and hearing difficulty. Close Panel Suspected Entry: 89% match Uploaded – Week5Castelao.M.extention.docx Pain when falling asleep and hearing difficulty Source – Another student's paper difficulty hearing, pain worsen when falling asleep Timing: 5 Troubling all the time Close Panel Suspected Entry: 64% match Uploaded – Week5Castelao.M.extention.docx Troubling all the time Source – Another student's paper all the time 6 Exacerbating/ relieving factors: Close Panel Suspected Entry: 100% match Uploaded – Week5Castelao.M.extention.docx Exacerbating/ relieving factors Source – Another student's paper Exacerbating/ relieving factors Going to sleep worsens the situation. Paracetamol relieves the pain. Severity: 1 5/10 pain scale Close Panel Suspected Entry: 100% match Uploaded – Week5Castelao.M.extention.docx 5/10 pain scale Source – Another student's paper 5/10 pain scale Current Medication: 7 Over the counter paracetamol 200 mg, 1 tablet after every 8 hours for pain relief. Close Panel Suspected Entry: 67% match Uploaded – Week5Castelao.M.extention.docx Over the counter paracetamol 200 mg, 1 tablet after every 8 hours for pain relief Source – Another student's paper Ibuprofen 200 mg, 1 tablet every 8 hours Allergies: None PMHx: All immunizations up-to-date, including recent tetanus and influenza shots received in November 2020. 5 No previous hospitalizations except at birth, which was uneventful. Close Panel Suspected Entry: 63% match Uploaded – Week5Castelao.M.extention.docx No previous hospitalizations except at birth, which was uneventful Source – Another student's paper no previous hospitalizations except for birth (no complications) No surgeries. Soc Hx: Lives with grandmother alongside his brother after the loss of his parents in 2017 due to car accident. The grandmother is a retired k-12 teacher. He enjoys swimming and outdoor games. He is not exposed to secondhand cigarette smoke. The grandmother quit drinking alcohol in 2016 after a long history of alcoholism. James usually wears seat belt and does not need booster seat when travelling. He only uses the back seat of a car when travelling in their family car. The grandmother does not use text or mobile phone while driving. 8 The family has working smoke and carbon dioxide detectors. Close Panel Suspected Entry: 62% match Uploaded – Week5Castelao.M.extention.docx The family has working smoke and carbon dioxide detectors Source – Another student's paper Working smoke and carbon monoxide detectors in house They live in a quiet middle class neighborhood and take part in local activities such as cleaning their church compound. Fam Hx: Older brother died in 2015 at age of 9 years due to malignant neoplasm. Grandfather died in 2010 aged 60 years due to type 2 diabetes. ROS General: 9 No fatigue, weakness, fever, and weight loss Close Panel Suspected Entry: 84% match Uploaded – Week5Castelao.M.extention.docx No fatigue, weakness, fever, and weight loss Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/ No weight loss, fever, chills, weakness or fatigue HEENT: Eyes: 3 no blurred vision, yellow sclera, loss of sight or double vision. Close Panel Suspected Entry: 87% match Uploaded – Week5Castelao.M.extention.docx no blurred vision, yellow sclera, loss of sight or double vision Source – Another student's paper No visual loss, blurred vision, double vision or yellow sclera 9 Ears, Nose, Throat: Close Panel Suspected Entry: 100% match Uploaded – Week5Castelao.M.extention.docx Ears, Nose, Throat Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/ Ears, Nose, Throat 8 Hearing difficulty in the right ear for the past 2 days. Close Panel Suspected Entry: 70% match Uploaded – Week5Castelao.M.extention.docx Hearing difficulty in the right ear for the past 2 days Source – Another student's paper Difficulty hearing to right ear x2 days 1 No sneezing, sore throat, runny nose, and/or congestion. Close Panel Suspected Entry: 98% match Uploaded – Week5Castelao.M.extention.docx No sneezing, sore throat, runny nose, and/or congestion Source – Another student's paper no sneezing, congestion, runny nose or sore throat SKIN: 9 No itching or rashes Close Panel Suspected Entry: 64% match Uploaded – Week5Castelao.M.extention.docx No itching or rashes Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/ No rash or itching CARDIOVASCULAR: 9 No chest discomfort, chest pain, and chest pressure. Close Panel Suspected Entry: 94% match Uploaded – Week5Castelao.M.extention.docx No chest discomfort, chest pain, and chest pressure Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/ No chest pain, chest pressure or chest discomfort 4 No edema and palpitation. Close Panel Suspected Entry: 86% match Uploaded – Week5Castelao.M.extention.docx No edema and palpitation Source – Another student's paper No palpitation or edema RESPIRATORY: 4 No cough or shortness of breath Close Panel Suspected Entry: 100% match Uploaded – Week5Castelao.M.extention.docx No cough or shortness of breath Source – Another student's paper No shortness of breath or cough GASTROINTESTINAL: 9 No nausea, diarrhea, vomiting, and anorexia. Close Panel Suspected Entry: 92% match Uploaded – Week5Castelao.M.extention.docx No nausea, diarrhea, vomiting, and anorexia Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/ No anorexia, nausea, vomiting or diarrhea 10 No abdominal pain GENITOURINARY: Close Panel Suspected Entry: 80% match Uploaded – Week5Castelao.M.extention.docx No abdominal

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