Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
This week we are covering HEENT. At this time you are assigned an episodic/ focused note. You will need this assigned case study to complete the Case Study Assignment for this week. Focused assessment means you still fill out all review of systems and as needed type “Patient denies” in the sections that you are not covering or are needed. Again, you are allowed to make up the information that is needed to fill out the episodic note.
If your LAST NAME starts with letters A – J: please proceed with Option 1.
If your LAST NAME starts with letters K – Z: please proceed with Option 2.
Option 1:
CASE STUDY: 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.
This
week
we
are
covering
HEENT.
At
this
time
you
are
assigned
an
episodic
/
focuse
d
note.
You
will
need
this
assigned
case
study
to
complete
the
Case
Study
Assignment
for
this
week.
Focused
assessment
means
you
still
fill
out
all
review
of
systems
and
as
needed
type
“Patient
denies”
in
the
sections
that
you
are
not
covering
or
are
needed.
Again,
you
are
allowed
to
make
up
the
information
that
is
needed
to
fill
out
the
episodic
note
.
If
your
LAST
NAME
starts
with
letters
A
–
J:
please
proceed
with
Option
1
.
If
your
LAST
NAME
starts
with
letters
K
–
Z:
please
proceed
with
Option
2
.
Option
1
:
CASE
STUDY:
Focused
Throat
Exa
m
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
bu
t
doesn't
sound
congested
.
To Prepare
·
By Day 1 of th
is 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/Focus
ed 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 specifi
c 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 physic
al 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 fo
r 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
evide
nce 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.