NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5
Online media for Seidel’s Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapters 10, 11, and 12 that relate to the assessment of the head, neck, eyes, ears, nose, and throat. Refer to the Week 4 Learning Resources area for access instructions on
Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Photo Credit: Getty Images/Blend Images
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.
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.
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.
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.
By Day 6 of Week 5
Submit your Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK5Assgn1+last name+first initial.(extension)” as the name.
- Click the Week 5 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
- Click the Week 5 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK5Assgn1+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 5 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 5 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 6 of Week 5
To participate in this Assignment:
Week 5 Assignment 1
NURS_6512_Week_5_Assignment_1_Rubric
| Excellent | Good | Fair | Poor | ||
| Using the SOAP (Subjective, Objective, Assessment, and Plan) note format: · Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). · Use clinical terminologies to explain the physical characteristics featured in the graphic. |
Points Range: 30 (30%) – 35 (35%)
The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies. |
Points Range: 24 (24%) – 29 (29%)
The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies. |
Points Range: 18 (18%) – 23 (23%)
The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies. |
Points Range: 0 (0%) – 17 (17%)
The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies. |
|
| · Formulate a different diagnosis of three to five possible considerations for the skin graphic. · Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature. | Points Range: 45 (45%) – 50 (50%)
The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature. |
Points Range: 39 (39%) – 44 (44%)
The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature. |
Points Range: 33 (33%) – 38 (38%)
The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature. |
Points Range: 0 (0%) – 32 (32%)
The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature. |
|
| 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. |
Points Range: 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. |
Points Range: 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. |
Points Range: 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. |
Points Range: 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 |
Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. |
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. |
Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors. |
Points Range: 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. | Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors. |
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. |
Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors. |
Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors. |
|
| Total Points: 100 | |||||
Name: NURS_6512_Week_5_Assignment_1_Rubric
Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Student’s Name
Institution
Course
Lecturer’s Name
Episodic/Focused SOAP Note Template
Patient Information:
Initials: L.M Age: 20 years old Sex: Female Race: Caucasian
S.
CC (chief complaint): “Sore throat.”
HPI: Lily is a 20-year-old Caucasian female patient who came to the clinic complaining of a sore throat that had lasted for the past three days. The patient was taking the sore throat lightly until when there was a flu outbreak at her college about two weeks ago when she got concerned that this incident might be associated with her symptoms. The patient also reported additional symptoms such as headache, pain with swallowing, and decreased appetite. She claims that some of her classmates presented with similar symptoms. She however denies chills or fever. She has not taken any medication for her present condition.
Location: Throat
Onset: 3 days ago
Character: scratchy and sore.
Associated signs and symptoms: decreased appetite, headache, running nose, and pain with swallowing
Timing: Started two weeks after a flu outbreak at her school.
Exacerbating/ relieving factors: swallowing food or drinking water worsens the pain. Gargling with warm water reduces the pain.
Severity: 6/10 pain scale
Current Medications: Multivitamin oral tablets, once daily for the past 6 months.
Allergies: Dust mite. No drug or food allergies.
PMHx: Immunization status is up to date, with the last flu vaccine received in October 2020. Her last tetanus shot was received in June 2019. The patient denies any history of medical diagnosis or surgery.
Soc Hx: The patient is a full-time college student studying economics. She enjoys spending time with his friends and reading comic books. She denies taking alcohol, cigarettes, or any other illicit drug of abuse.
Fam Hx: Patient mother has a history of diabetes and hypertension. His father was diagnosed with Gout. Her paternal grandfather died at the age of 65 years from stroke, with a history of diabetes. Her paternal grandmother is still alive with a history of HTN, and osteoarthritis. She has no information regarding her maternal grandparents.
ROS:
GENERAL: No weight loss, chills. Report fever, weakness, and fatigue. Reports decreased appetite.
HEENT: Head: Reports headache. No signs of trauma or injury. Eyes: No vision changes or double or blurry vision. The sclera has no abnormal discoloration. Ears: No hearing loss. Nose and throat: congestions, or sneezing. The patient complains of a sore and scratchy throat. The patient also reports pain with swallowing that she rates as a 6/10 severity on a pain scale for the past 3 days.
SKIN: No itchiness or rashes.
CARDIOVASCULAR: No chest pressure, pain, or any other discomfort. No edema or palpitations.
RESPIRATORY: Report shortness of breath and cough. No sputum
GASTROINTESTINAL: No nausea or vomiting, anorexia, or diarrhea. No abdominal pain.
GENITOURINARY: No burning on urination, hesitancy, no urgency, no foul odor or urine color.
NEUROLOGICAL: Reports intermittent headache for the past 3 days.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness
HEMATOLOGIC: No bruises, anemia, or bleeding.
LYMPHATICS: No history of splenectomy. Swollen lymph nodes were noted in the neck
PSYCHIATRIC: No history of anxiety or depression. Denies any history of harming self or others.
ENDOCRINOLOGIC: No reports of sweating, heat, or cold intolerance. No polydipsia or polyuria.
ALLERGIES: Dust mites
O.
Physical exam:
General: The patient is alert and cooperative all through the examination period. She displays no signs of distress. Her vitals are T: 98.6, Pls: 85, RR: 19, BP: 105/78, and O2 99% on room air.
HEENT: Head is atraumatic and normocephalic. Pupils are round, equal, and reactive to light. No erythema or effusion on the tympanic membrane. No discharge or swelling was noted in the ear canals. The neck is supple with anterior cervical lymphadenopathy. Throat with mild swelling and exudates. Tonsils are swollen. Nostrils are red and swollen.
Chest/lungs: Breathing sounds clear to auscultation
Heart: Regular heart rate and rhythm with no murmur or gallop.
Abdomen: Soft, non-distended, non-tender abdomen, with bowel sounds present in all four quadrants.
Neurological: Intermittent headache.
Diagnostic results: Complete Blood Count (CBC) 7.9: Red Blood Cells 4.7, Platelets 200, and H/H: 12.6/37.8. Throat swab culture ordered with preliminary findings reveal negative results of Group A streptococcus bacteria.
A.
- Influenza: This is a viral infection that affects the lung characterized by upper respiratory symptoms. Patients diagnosed with this condition normally present with several signs and symptoms such as cough, fever, malaise, headache, coryza, respiratory distress, and sore throat (Chow et al., 2019). The patient in the provided case study displays most of these symptoms making it the most appropriate diagnosis. Additionally, the patient might have been infected with the virus during the flu outbreak. However, a throat culture is needed to confirm the presence of the influenza virus.
- Acute Pharyngitis: Acute pharyngitis is a medical condition affecting the tonsils or posterior pharynx caused by microorganisms. Common symptoms displayed include sore throat, dysphagia, fever, headaches, abdominal pain, and fetid breath (Sykes et al., 2020). This condition is normally associated with acute pharyngitis. Some of the symptoms were displayed by the patient. However, no signs of abdominal pain, among others were not displayed by the patient.
- Acute epiglottitis: This is a severe and rapidly progressing health condition characterized by sore throat, dyspnea, and hoarseness caused by Hemophilus influenza infection (Baird et al., 2018). The patient displayed most of these symptoms, however, a throat culture is needed to confirm this diagnosis.
- Acute Sinusitis: This is a bacterial infection characterized by paranasal sinuses. Symptoms include fever, headache, nasal discharge, congestion, and cough that can occur suddenly and become worse over a few days (Ebell et al., 2019). All of these symptoms, some of these symptoms, or even none of these symptoms may occur in individuals with sinusitis, just like the patient in the provided case study.
- Laryngitis: This is an inflammation of the larynx that can either be non-infectious or infectious. The most common symptoms associated with laryngitis include hoarseness, voice fatigue, throat pain, a sensation of lumping in the throat, and cough (Lechien et al., 2018). The patient in the provided case study displayed most of these symptoms. However, he also reported a running nose which is not experienced with this diagnosis.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Baird, S. M., Marsh, P. A., Padiglione, A., Trubiano, J., Lyons, B., Hays, A., … & Phillips, D. (2018). Review of epiglottitis in the post Haemophilus influenzae type‐b vaccine era. ANZ journal of surgery, 88(11), 1135-1140.
Chow, E. J., Doyle, J. D., & Uyeki, T. M. (2019). Influenza virus-related critical illness: prevention, diagnosis, treatment. Critical care, 23(1), 1-11.
Ebell, M. H., McKay, B., Dale, A., Guilbault, R., & Ermias, Y. (2019). Accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis. The Annals of Family Medicine, 17(2), 164-172. https://doi.org/10.1370/afm.2354
Lechien, J. R., Saussez, S., & Karkos, P. D. (2018). Laryngopharyngeal reflux disease: clinical presentation, diagnosis and therapeutic challenges in 2018. Current opinion in otolaryngology & head and neck surgery, 26(6), 392-402. doi:10.1097/MOO.0000000000000486
Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: approach to diagnosis and treatment. Canadian Family Physician, 66(4), 251-257. PMCID:
