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[ANSWERED] Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

Assignment 1: 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.

Case study 3:

Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past 2 days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he\’s been spending his summer, James responds that he\’s been spending a lot of time in the pool.

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

Patient Information:

Initials, Age, Sex, Race

S.

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.

O.

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)

A.

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.

Expert Answer and Explanation

Episodic/Focused SOAP Note

Patient Information:

Name: James                            Age: 11 y/o                                   Gender: Male

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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