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.
Required Sources
- 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.
- Chapter 13, “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. - 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. - 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. - 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. - 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. - 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. - 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)
Shadow Health Support and Orientation Resources
- Shadow Health. (2021). Welcome to your introduction to Shadow Health
- Links to an external site.. https://link.shadowhealth.com/Student-Orientation-Video
- Shadow Health. (n.d.). Shadow Health help desk
- Links to an external site.. Retrieved from https://support.shadowhealth.com/hc/en-us
- Shadow Health. (2021). Walden University quick start guide: NURS 6512 NP students
Download Walden University quick start guide: NURS 6512 NP students.
- Links to an external site. https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
- Document: DCE (Shadow Health) Documentation Template
Download DCE (Shadow Health) Documentation Template for Focused Exam: Cough (Word document)
Use this template to complete your Assignment 2 for this week.
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.
| Criteria | Ratings | Pts | ||||
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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. |
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· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. |
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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. |
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Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation |
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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. |
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Total Points: 100
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Expert Answer and Explanation
Episodic/Focused SOAP Note
Patient Information:
James is an 11-year old boy.
S.
CC The patient complains that he has had a mild earache for the past two days.
HPI: The location of the illness is the head. He started feeling mild earache two days ago. The patient reports that the pain often becomes worse during sleeping, and this makes it hard for him to hear. His grandmother also mentions that he had a fever. The problem started after the patient had spent a lot of time in the pool. The level of the patient is 6/10.
Current Medications: the patient did not mention the medication he was taking.
Allergies: the patient has no reported allergies.
PMHx: the patient has not reported any immunization.
Soc Hx: the patient likes swimming during summer.
Fam Hx: the patient has his grandmother did not mention the health history of their family.
ROS:
GENERAL: The patient feels pain in the ear and fever or fatigue.
HEENT: The patient feels pain in the ear.
SKIN: No itching or rash.
CARDIOVASCULAR: No cardiovascular disease.
RESPIRATORY: No respiratory illness.
GASTROINTESTINAL: No gastrointestinal illnesses.
O.
Physical exam: The patient feels pain in the ear. Also, the patient has a prominent tan in his ear.
Diagnostic results: the first diagnostic for a strategy for the patient is physical examination. Also, pneumatic otoscope will be used to diagnose the patient. According to Bakshi (2019), a pneumatic otoscope to find adequate data about an ear infection.
Differential Diagnoses
Primary Otalgia
Primary otalgia is also called ear pain. This disease is the most probable diagnosis because the patient feels pain mild pain in the ear. According to Earwood et al. (2019), primary otalgia is caused by mastoiditis, otitis media, auricular infections, and external otitis. This patient may be suffering from primary otalgia because he has a problem hearing during sleep. The condition will be diagnosed through physical examination and pneumatic otoscope.
Laryngitis
Laryngitis is among the common diseases affecting people’s ears. The condition can manifest in both chronic and acute form. However, this patient is likely to have acute laryngitis because he has suffered pain in about two days. Chronic laryngitis occurs when pain persists for more than three weeks (Bakshi, 2019).
Acute Otitis Media
The patient has experienced pain for the last two days. Thus, this infection might be classified as a convention because it has not gone beyond three weeks. One of the signs of acute otitis media is fever. The patient might be suffering from the condition because his grandmother reported that he was warm in those two days (Bakshi, 2019). Also, the patient experiences hearing loss at night and hearing loss is another sign of the disease.
Barosinusitis
Some of the symptoms of baronsinusitis include the following. Mild pain or pressure on the patient’s sinuses after one has returned from the sea level. The patient has visited the swimming pool for the most part of his summer holiday. Therefore, the pain he feels may be due to a lot of water in his ears. Other symptoms of baronsinusitis include occasional epistaxis and worsening congestion (Bandúrová et al., 2019).
Allergic Fungal Sinusitis
Fungal allergies commonly cause allergic fungal sinusitis. The disease also causes pain and fever in patients (Bakshi, 2019). However, this patient is most likely not to suffer from allergic fungal sinusitis because he has no history of allergies.
References
Bakshi, S. S. (2019). Image Diagnosis: Boxers Ear. The Permanente journal, 23. doi: 10.7812/TPP/18-132
Bandúrová, V., Plzák, J., & Bouček, J. (2019). Differential diagnosis of ear pain. Casopis lekaru ceskych, 158(6), 231. https://www.ncbi.nlm.nih.gov/pubmed/31931581
Earwood, J. S., Rogers, T., & Rathjen, N. A. (2018). Ear pain: diagnosing common and uncommon causes. American family physician, 97(1), 20-27. https://www.aafp.org/afp/2018/0101/p20.html
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