Last Updated on February 15, 2023 by Admin
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
Week 5: Assessment of Head, Neck, 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 slight hoarseness in her voice but doesn\’t sound congested.
- 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.
Students will:
- Apply assessment skills to diagnose eye, ear, and throat conditions
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat
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.
| 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 Sore Throat
Patient Information:
Lily, a 20-year-old female of Caucasian origin.
S.
CC: “Complains of sore throat for three days”
HPI: Lily, a 20-year-old female of Caucasian origin and a student at the local community college presented to the healthcare facility complaining of sore throat that has lasted three days. She notes that the pain is located in the throat area. Other associated symptoms include headaches, reduced appetite, and scratchy throat sensation. She has not tried any medication to improve the symptoms. The patient scales the pain in a scale of 6/10.
Medications: Denies taking any drug.
Allergies: No food, pollen, environmental, or drug allergies.
PMH: Denies any prior medical problems.
Immunization History: She has not received any vaccination for the last four years.
Sexual/Reproductive History: She is sexually active but does not have any sexual partner.
SH: She does not use hard drugs, tobacco, or alcohol.
FH: Her parents separated but they are both healthy. Her siblings are also healthy.
Lifestyle: She is a student and likes singing.
ROS
General: Positive for headaches, difficulty swallowing, and decreased appetite.
HEENT: Positive for headaches and sore throat.
Cardiovascular: Denies edema, chest pain, cardiovascular issues.
Respiratory: Denies breathing issues.
Gastrointestinal: Denies nausea.
O.
Physical Exam:
Vitals: Temp 38.1 orally, Ht. 5’3, P66, Wt 53, R 18, B/P 118/87.
General: The patient looks anxious. She looks alert and knows the person assessing her, where she is, and the time of the year. Her speech is good and communicates effectively.
HEENT: The patient sneezes a lot during communication; she has a runny nose; she has uncongested hoarse voice; throat observation shows white patches on her tonsils; the tonsils are red and swollen.
Cardiovascular: External is does not have thrills, heaves, or lifts. Heart rate and rhythm are regular.
Respiratory: No edema; chest wall palpation shows no tenderness; no respiratory distress; chest is atraumatic in appearance and is not deformed.
Diagnostic tests:
Throat Culture (Ball et al., 2019): Pending
A.
- Sore Throat-Primary diagnosis
- Strep Throat
- Viral Pharyngitis
- EBV Fatigue
- Epiglottis
Primary Diagnosis
The primary diagnosis for this case is sore throat. Sore throat can be defined as a disease that causes swelling, scratchiness, and pain in the throat that makes it difficult for one to swallow (Sadeghirad et al., 2017). The symptoms of sore throat include pain when swallowing, pain sensation in the throat, red and swollen tonsils, pus on the tonsils, and a muffed voice.
The disease can also cause fever. Body aches, nausea, headache, sneezing, and runny nose (Wagner et al., 2019). This disease has been categorized as the primary disorder because the patient’s vital signs shows that she has fever. Physical exam also shows that the patient has runny nose, sneezing, has uncongested hoarse voice, pus in the throat, and red and swollen tonsils.
All these symptoms are those of sore throat. Strep throat also causes most of the symptoms experienced by the patient. However, the disease causes tender lymph nodes in one’s neck, a sign not experienced by the patient. Viral pharyngitis also causes sore throat but it is a secondary diagnosis because caused by measles, whooping cough, or chickenpox all not experienced by the patient (Collins & Moles, 2019).
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.
Collins, J. C., & Moles, R. J. (2019). Management of respiratory disorders and the pharmacist’s role: Cough, colds, and sore throats and allergies (including eyes). Encyclopedia of Pharmacy Practice And Clinical Pharmacy, 282. doi: 10.1016/B978-0-12-812735-3.00510-0
Sadeghirad, B., Siemieniuk, R. A., Brignardello-Petersen, R., Papola, D., Lytvyn, L., Vandvik, P. O., … & Agoritsas, T. (2017). Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. Bmj, 358. https://doi.org/10.1136/bmj.j3887
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
