CASE STUDY 2: Centered Throat Examination
Lily is a 20-year-old scholar at the local people faculty. When a few of her mates and classmates instructed her about an outbreak of flu-like signs sweeping her campus throughout the previous 2 weeks, Lily figured she should not take her Three-day sore throat evenly. Your clinic has handled just a few instances just like Lily’s. All of the sufferers reported decreased urge for food, complications, and ache with swallowing. As Lily recounts these signs to you, you discover that she has a runny nostril and a slight hoarseness in her voice however would not sound congested.
Project 1: Case Examine Project: Assessing the Head, Eyes, Ears, Nostril, and Throat
Photograph Credit score: Getty Photographs/Mix Photographs
Most ear, nostril, and throat circumstances that come up in non-critical care settings are minor in nature. Nonetheless, refined signs can generally escalate into life-threatening circumstances that require immediate evaluation and therapy.
Nurses conducting assessments of the ears, nostril, and throat should be capable of establish the small variations between life-threatening circumstances and benign ones. For example, if a affected person with a sore throat and a runny nostril additionally has infected lymph nodes, the irritation might be as a result of pathogen inflicting the sore throat moderately than a case of throat most cancers. With this data and a ample affected person well being historical past, a nurse wouldn’t must escalate the evaluation to a biopsy or an MRI of the lymph nodes however would in all probability carry out a easy strep take a look at.
On this Case Examine Project, you take into account case research of irregular findings from sufferers in a scientific setting. You identify what historical past needs to be collected from the sufferers, what bodily exams and diagnostic exams needs to be performed, and formulate a differential prognosis with a number of potential circumstances.
To Put together
By Day 1 of this week, you may be assigned to a particular case examine for this Case Examine Project. Please see the “Course Bulletins” part of the classroom to your project out of your Teacher.
Additionally, your Case Examine Project needs to be within the Episodic/Centered SOAP Be aware format moderately than the standard narrative model format. Seek advice from Chapter 2 of the Sullivan textual content and the Episodic/Centered SOAP Template within the Week 5 Studying Assets for steerage. Keep in mind that all Episodic/Centered SOAP Notes have particular knowledge included in each affected person case.
With regard to the case examine you have been assigned:
Overview this week’s Studying Assets and take into account the insights they supply.
Think about what historical past can be crucial to gather from the affected person.
Think about what bodily exams and diagnostic exams can be applicable to collect extra details about the affected person’s situation. How would the outcomes be used to make a prognosis?
Determine a minimum of 5 potential circumstances that could be thought-about in a differential prognosis for the affected person.
The Project
Use the Episodic/Centered SOAP Template and create an episodic/centered observe concerning the affected person within the case examine to which you have been assigned utilizing the episodic/centered observe template offered within the Week 5 sources. Present proof from the literature to help diagnostic exams that may be applicable for every case. Checklist 5 completely different potential circumstances for the affected person’s differential prognosis and justify why you chose every.
Studying Assets
Required Readings (click on to develop/cut back)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Chapter 11, “Head and Neck”
This chapter evaluations the anatomy and physiology of the top and neck. The authors additionally describe the procedures for conducting a bodily examination of the top and neck.
Chapter 12, “Eyes”
On this chapter, the authors describe the anatomy and performance of the eyes. As well as, the authors clarify the steps concerned in conducting a bodily examination of the eyes.
Chapter 13, “Ears, Nostril, and Throat”
The authors of this chapter element the correct procedures for conducting a bodily examination of the ears, nostril, and throat. The chapter additionally gives footage and descriptions of widespread abnormalities within the ears, nostril, and throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Superior well being evaluation and scientific prognosis in main care (sixth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Superior Well being Evaluation and Scientific Prognosis in Major Care, sixth Version by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby through the Copyright Clearance Heart.
Chapter 15, “Earache”
This chapter covers the principle questions that must be requested concerning the affected person’s situation previous to the bodily examination in addition to how these questions result in a centered bodily examination.
Chapter 21, “Hoarseness”
This chapter focuses on the commonest causes of hoarseness. It gives methods for evaluating the affected person, each via questions and thru bodily exams.
Chapter 25, “Nasal Signs and Sinus Congestion”
On this chapter, the authors spotlight the important thing inquiries to ask concerning the sufferers signs, the important thing components of the bodily examination, and potential laboratory work that is perhaps wanted to offer an correct prognosis of nasal and sinus circumstances.
Chapter 30, “Purple Eye”
The main focus of this chapter is on methods to decide the reason for purple eyes in a affected person, together with key signs to contemplate and potential diagnoses.
Chapter 32, “Sore Throat”
A sore throat is one commonest considerations sufferers describe. This chapter contains inquiries to ask when taking the affected person’s historical past, issues to search for whereas conducting the bodily examination, and potential causes for the sore throat.
Chapter 38, “Imaginative and prescient Loss”
This chapter highlights the causes of imaginative and prescient loss and the way the causes of the situation may be identified.
Be aware: Obtain the six paperwork (Pupil Checklists and Key Factors) under, and use them as you apply conducting assessments of the top, neck, eyes, ears, nostril, and throat.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Pupil guidelines. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key factors. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Pupil guidelines. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key factors. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nostril, and throat: Pupil guidelines. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nostril, and throat: Key factors. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Colyar, M. R. (2015). Superior apply nursing procedures. Philadelphia, PA: F. A. Davis.
Credit score Line: Superior apply nursing procedures, 1st Version by Colyar, M. R. Copyright 2015 by F. A. Davis Firm. Reprinted by permission of F. A. Davis Firm through the Copyright Clearance Heart.
Chapter 71, “Visible Perform Analysis: Snellen, Illiterate E, Pictorial
This part explains the procedural data wanted to carry out eyes, ears, nostril, and mouth procedures.
Sullivan, D. D. (2019). Information to scientific documentation (third ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Complete Historical past and Bodily Examination” (Beforehand learn in Weeks 1, Three, four, and 5)
Bedell, H. E., & Stevenson, S. B. (2013). Eye motion testing in scientific examination. Imaginative and prescient Analysis 90, 32–37. doi:10.1016/j.visres.2013.02.001. Retrieved from https://www.sciencedirect.com/science/article/pii/S0042698913000217
Rubin, G. S. (2013). Measuring studying efficiency. Imaginative and prescient Analysis, 90, 43–51. doi:10.1016/j.visres.2013.02.zero15. Retrieved from http://www.sciencedirect.com/science/article/pii/S0042698913000436
Harmes, Ok. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Prognosis and therapy. American Household Physicians, 88(7), 435–440.
Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html
This web site gives medical photographs of sinusitis, together with X-rays, CT scans, and MRIs (magnetic resonance imaging).
Doc: Episodic/Centered SOAP Be aware Exemplar (Phrase doc)
Doc: Episodic/Centered SOAP Be aware Template (Phrase doc)
Doc: Midterm Examination Overview (Phrase doc)
Shadow Well being Help and Orientation Assets
Frey, C. [Chris Frey]. (2015, September four). Pupil orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Well being. (n.d.). Shadow Well being assist desk. Retrieved from https://help.shadowhealth.com/hc/en-us
Doc: Shadow Well being. (2014). Helpful suggestions and methods (Model 2) (PDF)
Doc: Pupil Acknowledgement Type (Phrase doc)
Be aware: You’ll signal and date this type every time you full your DCE Project in Shadow Well being to acknowledge your dedication to Walden College’s Code of Conduct.
Doc: DCE (Shadow Well being) Documentation Template for Centered Examination: Cough (Phrase doc)
Use this template to finish your Project 2 for this week.
USE 6 RESOURCES FROM THE SCHOOL
