Use the Episodic/Focused SOAP Template and create an episodic
Answer: Use the Episodic/Focused SOAP Template and create an episodic
The majority of ear, nose and throat diseases that emerge in non-critical care settings are mild. Subtle symptoms, on the other hand, can occasionally progress to life-threatening diseases that need immediate evaluation and treatment.
Nurses performing examinations of the ears, nose, and throat must be able to distinguish between life-threatening and benign disorders. For example, if a patient has a painful throat and a runny nose, as well as swollen lymph nodes, the inflammation is most likely caused by the pathogen causing the sore throat, rather than 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.
You will look at case studies of aberrant data from patients in a clinical environment for this Case Study Assignment. You decide what history should be taken from patients, what physical exams and diagnostic testing should be performed, and how to build a differential diagnosis with numerous probable illnesses.
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.
Chapter 11, “Head and Neck”
This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.
Chapter 12, “Eyes”
In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.
Chapter 13, “Ears, Nose, and Throat”
The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.
Question: Use the Episodic/Focused SOAP Template and create an episodic
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.
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.