[ANSWERED 2023] Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks,

Written By: Dan Palmer, RN

Edited By: Ethan Green, MSN-FNP

Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping

Lily is a 20-year-old student at the local community college. When some of her friends

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

CASE STUDY 2: Focused Throat Exam

Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, Lily figured she shouldn’t take her 3-day sore throat lightly. Your clinic has treated a few cases similar to Lily’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn’t sound congested.

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.

Episodic/Focused SOAP Note Template – (delete information on this template and input one related to the patient in the case study above).

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: No anemia, bleeding or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: No history of asthma, hives, eczema or rhinitis.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

Resources for references

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.

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.

Rubric Detail

	Excellent	Good	Fair	Poor
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.	45 (45%) – 50 (50%) The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.	39 (39%) – 44 (44%) The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.	33 (33%) – 38 (38%) The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.	0 (0%) – 32 (32%) The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.	30 (30%) – 35 (35%) The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected.	24 (24%) – 29 (29%) The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.	18 (18%) – 23 (23%) The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.	0 (0%) – 17 (17%) The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
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.	5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.	4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.	3 (3%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.	0 (0%) – 2 (2%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation	5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors.	4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors.	3 (3%) – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors.	0 (0%) – 2 (2%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
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.	5 (5%) – 5 (5%) Uses correct APA format with no errors.	4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors.	3 (3%) – 3 (3%) Contains several (3 or 4) APA format errors.	0 (0%) – 2 (2%) Contains many (≥ 5) APA format errors.

Total Points: 100

Expert Answer and Explanation

Focused SOAP Note for a Patient with Flu-Like Symptoms

S.

CC: “Sore throat for three days”

HPI: Lily is a 20-year-old student at the local community college. The patient has been suffering sore throat for the last three days but she had not taken the medical problem serious. However, when her classmates told her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks, she decided to seek medical help to reduce the impact of the disease. The healthcare center had treated patients with few cases similar to those of Lily. The patients reported headaches, decreased appetite, and pain with swallowing. Lily reported that she was worried that she might have flu or infleunza. The patient reported that she had not medication to remedy her symptoms. She rated the symptoms as 4/10.

Medications: No medications.

Allergies: No allergies.

PMH: No history of prior medical history.

PSH: No history of prior surgical operations.

Immunization History: Her vaccinations are up to date. She received typhoid and pneumonia vaccines recently.

Sexual/Reproductive History: She is sexually active. She notes that she has only one sexual mate.

SH: No history of substance abuse but drinks two packets of beer per night.

FH: Both parents are alive. However, the mother is suffering from cervical cancer. She was diagnosed with the disease at 40 years and the father is healthy. She has two siblings and both are healthy.

Lifestyle: Likes swimming, watching movies, and going for hikes on weekends.

ROS
General: Positive for runny nose, fever, and nausea. However, she reports negative for weight gain or loss, vomiting, and fatigue.

HEENT: Negative for blurred vision, hearing problems, and headaches. However, she reports positive for runny nose and sore throat.

Cardiovascular: Negative for chest pain, intermittent edema, orthopnea, PND, and other heart conditions. She also reports negative for shortness of breath.

Respiratory: She reports negative for chest pain, difficulty breathing, coughing, wheezing, and shortness of breath. In other words, she does not have any respiratory health condition.

Gastrointestinal: Positive for nausea but negative for vomiting. She reports negative for abdominal pain and diarrhea.

Pulmonary: Negative for hemoptysis or cough, negative for exertion or dyspnea.

O.

Physical Exam: The patient walked in to the clinic in an upright position. She wore causal clothing and spoken fluently when describing her symptoms. However, hoarseness could be heard in her voice. She was experiencing runny nose and was using handkerchief to manage the runny it. She also appeared anxious.

Vitals: T 37.8, BP 94/85, P 74 and normal, Wt 62 kgs, Ht 159cm, R18

General: Negative for fatigue, weakness, or weight loss; positive for fever, nausea, and runny nose.

Cardiovascular: Negative for edema, chest pain, shortness of breath, high blood pressure, clubbing, and cyanosis.

Respiratory: Negative for shortness of breath, difficulty breathing, and any other respiratory condition.

Gastrointestinal: Bowel sounds are normal in intensity and quality in all areas. Negative for vomiting and abdominal pain. No splenomegaly or masses in umbilical area; positive for nausea.

Pulmonary: Negative for vessels blockage; lungs are clear to percussion and auscultation bilaterally.

Diagnostic tests: The throat can be examined by using a lighted tool to observe the throat for sores. The laboratory tests for throat disease include throat culture, molecular test, and antigen rapid test (Ball et al., 2019).

Diagnostic results: If a patient has sore throat, throat checking will show swollen, red tonsils and white pus on the tonsils. The lab tests will show positive for streptococcal bacteria if the patient has strep throat or virus if the individuals has sore throat (Dezman et al., 2017).

A.

Differential Diagnosis:

1) Sore Throat: Sore Throat is the primary diagnosis for this case. Sore throat can be described as irritation, scratchiness, or pain of the throat that often worsens when a patient swallow food or a drink. Cates et al. (2019) argue that sore throat is caused by a vital infection, such as the flu or cold. The disease often heals on its own. However, if not handled on time, sore throat can result to severe throat conditions.

Some of the symptoms of the disease include scratchy, or pain sensation in the throat, difficulty swallowing, swollen and sore glands in the jaw or neck, pain that worsens when talking or swallowing, muffled or hoarse voice, and red, swollen tonsils. A patient with sore throat can also experience runny nose and fever. This disease has been recommended as the primary diagnosis because the patient experiences vitals symptoms including runny nose, hoarse voice, sore throat, and fever.

2) Strep Throat: Strep Throat is the second diagnosis for this case. Strep throat is a bacterial infection causing scratchy or sore throat (Wagner et al., 2019). The disease can be mistaken by sore throat because they have almost similar symptoms. The symptoms of the disease include rash, fever, headache, tiny red spots on hard or soft palate, swollen and red tonsils, pain when swallowing or talking, nausea, and pain that comes and goes quickly.

This disease has been included in the diagnosis because the patient has fever, nausea, swollen and sore throat, and swollen tonsils. However, the disease has been classified as a secondary diagnosis because the patient does not complain of rash, red spots or the palates, and has hoarse voice.

3) Retropharyngeal Abscess: Retropharyngeal abscess is a medical condition that affects one’s throat. The disease occurs by causing the gathering of pus at the back of the throat; hence leading to throat infection. The infection is caused by bacteria. The symptoms of the disease include a fever, noisy breathing, stiff neck, swollen tonsils, and pain during swallowing. The disease has been included in the diagnosis because the patient has fever, pain when swallowing and swollen tonsils. However, it has been classified as a secondary diagnosis because the patient does not complain of noisy breathing and stiff neck.

4) Epiglottitis: Epiglottitis is a medical condition that impacts the epiglottis. The symptoms of the disease include fever, drooling, abnormal-high-pitched sound, severe sore throat, and restless behavior (Dains et al., 2019). This disease has been included in the diagnosis because the patient experiences fever and sore throat. However, it as been categorized as a secondary diagnosis because the patient has no abnormal-high-pitched sound.

5) Acute Respiratory Distress Syndrome (ARDS): The disease occurs when fluid builds up in the alveoli in the lungs. The fluid can keep the patient’s lungs from filling enough oxygen, and making the individual suffer low oxygen level. The symptoms of the disease include low blood pressure, extreme tiredness and confusion, rapid breathing, and severe shortness of breath (Wagner et al., 2019). The disease has been included in the diagnosis because the patient has low blood pressure (94/85). However, the disease is last in the diagnosis list because the patient does not experience shortness of breath, low oxygen, and confusion.

References

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.

Cates, A. L., Leriotis, T., & Herres, J. (2019). A Case of Burning Throat Pain. The Journal of emergency medicine, 57(3), e69-e71. https://doi.org/10.1016/j.jemermed.2019.05.022

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.

Dezman, Z. D., Mattu, A., & Body, R. (2017). Utility of the history and physical examination in the detection of acute coronary syndromes in emergency department patients. Western Journal of Emergency Medicine, 18(4), 752. doi: 10.5811/westjem.2017.3.32666

Wagner, M., Becker, C., & Jakob, T. (2019). Spontaneous pneumomediastinum with cervical emphysema: Rare differential diagnosis of acute sore throat and dysphagia. Laryngo-Rhino-Otologie, 98(S 02), 11317. DOI: 10.1055/s-0039-168575

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