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.
USW1.575.202130 – NURS-6512C-1/NURS-6512D-1/NURS-6512N-1-Advanced Health Assessment2020 Winter Qtr 11/30-02/21-PT27
SafeAssign Drafts
Monica Castelao
on Wed, Jan 06 2021, 3:32 AM
68% highest match
Submission ID: bb56b440-40e4-4e90-8c80-18bff0b840f6
Week5Castelao.M.extention.docx
Word Count: 907
Attachment ID: 3891174207
68%
Citations (19/19)
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https://besthomeworkhelp.org/assessing-neurological-symptoms/
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Running head: FOCUSED EAR EXAMINATION 1
FOCUSED EAR EXAMINATION 5
Focused Ear Examination Monica Castelao Walden University
1
Focused Ear Examination
Suspected Entry: 63% match
Uploaded – Week5Castelao.M.extention.docx
Focused Ear Examination
Source – Another student’s paper
Focused Ear Exam
Patient Information:
2
JK is an 11 year old male African American
Suspected Entry: 65% match
Uploaded – Week5Castelao.M.extention.docx
JK is an 11 year old male African American
Source – Another student’s paper
The patient is an 11-year-old African American male brought into the clinic by his grandmother
S
3
Chief Complaint (CC):
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
Chief Complaint (CC)
Source – Another student’s paper
CC (chief complaint)
4
I have had a mild earache for the past 2 days
Suspected Entry: 68% match
Uploaded – Week5Castelao.M.extention.docx
I have had a mild earache for the past 2 days
Source – Another student’s paper
“Mild earache for the past two days”
HPI:
Location: Right ear
Onset:
3
2 days ago
Suspected Entry: 99% match
Uploaded – Week5Castelao.M.extention.docx
2 days ago
Source – Another student’s paper
2 days ago
Character: Aching
3
Associated signs and symptoms:
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
Associated signs and symptoms
Source – Another student’s paper
Associated signs and symptoms
5
Pain when falling asleep and hearing difficulty.
Suspected Entry: 89% match
Uploaded – Week5Castelao.M.extention.docx
Pain when falling asleep and hearing difficulty
Source – Another student’s paper
difficulty hearing, pain worsen when falling asleep
Timing:
5
Troubling all the time
Suspected Entry: 64% match
Uploaded – Week5Castelao.M.extention.docx
Troubling all the time
Source – Another student’s paper
all the time
6
Exacerbating/ relieving factors:
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
Exacerbating/ relieving factors
Source – Another student’s paper
Exacerbating/ relieving factors
Going to sleep worsens the situation. Paracetamol relieves the pain.
Severity:
1
5/10 pain scale
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
5/10 pain scale
Source – Another student’s paper
5/10 pain scale
Current Medication:
7
Over the counter paracetamol 200 mg, 1 tablet after every 8 hours for pain relief.
Suspected Entry: 67% match
Uploaded – Week5Castelao.M.extention.docx
Over the counter paracetamol 200 mg, 1 tablet after every 8 hours for pain relief
Source – Another student’s paper
Ibuprofen 200 mg, 1 tablet every 8 hours
Allergies: None
PMHx: All immunizations up-to-date, including recent tetanus and influenza shots received in November 2020.
5
No previous hospitalizations except at birth, which was uneventful.
Suspected Entry: 63% match
Uploaded – Week5Castelao.M.extention.docx
No previous hospitalizations except at birth, which was uneventful
Source – Another student’s paper
no previous hospitalizations except for birth (no complications)
No surgeries.
Soc Hx: Lives with grandmother alongside his brother after the loss of his parents in 2017 due to car accident. The grandmother is a retired k-12 teacher. He enjoys swimming and outdoor games. He is not exposed to secondhand cigarette smoke. The grandmother quit drinking alcohol in 2016 after a long history of alcoholism. James usually wears seat belt and does not need booster seat when travelling. He only uses the back seat of a car when travelling in their family car. The grandmother does not use text or mobile phone while driving.
8
The family has working smoke and carbon dioxide detectors.
Suspected Entry: 62% match
Uploaded – Week5Castelao.M.extention.docx
The family has working smoke and carbon dioxide detectors
Source – Another student’s paper
Working smoke and carbon monoxide detectors in house
They live in a quiet middle class neighborhood and take part in local activities such as cleaning their church compound.
Fam Hx: Older brother died in 2015 at age of 9 years due to malignant neoplasm. Grandfather died in 2010 aged 60 years due to type 2 diabetes.
ROS
General:
9
No fatigue, weakness, fever, and weight loss
Suspected Entry: 84% match
Uploaded – Week5Castelao.M.extention.docx
No fatigue, weakness, fever, and weight loss
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No weight loss, fever, chills, weakness or fatigue
HEENT:
Eyes:
3
no blurred vision, yellow sclera, loss of sight or double vision.
Suspected Entry: 87% match
Uploaded – Week5Castelao.M.extention.docx
no blurred vision, yellow sclera, loss of sight or double vision
Source – Another student’s paper
No visual loss, blurred vision, double vision or yellow sclera
9
Ears, Nose, Throat:
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
Ears, Nose, Throat
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
Ears, Nose, Throat
8
Hearing difficulty in the right ear for the past 2 days.
Suspected Entry: 70% match
Uploaded – Week5Castelao.M.extention.docx
Hearing difficulty in the right ear for the past 2 days
Source – Another student’s paper
Difficulty hearing to right ear x2 days
1
No sneezing, sore throat, runny nose, and/or congestion.
Suspected Entry: 98% match
Uploaded – Week5Castelao.M.extention.docx
No sneezing, sore throat, runny nose, and/or congestion
Source – Another student’s paper
no sneezing, congestion, runny nose or sore throat
SKIN:
9
No itching or rashes
Suspected Entry: 64% match
Uploaded – Week5Castelao.M.extention.docx
No itching or rashes
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No rash or itching
CARDIOVASCULAR:
9
No chest discomfort, chest pain, and chest pressure.
Suspected Entry: 94% match
Uploaded – Week5Castelao.M.extention.docx
No chest discomfort, chest pain, and chest pressure
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No chest pain, chest pressure or chest discomfort
4
No edema and palpitation.
Suspected Entry: 86% match
Uploaded – Week5Castelao.M.extention.docx
No edema and palpitation
Source – Another student’s paper
No palpitation or edema
RESPIRATORY:
4
No cough or shortness of breath
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
No cough or shortness of breath
Source – Another student’s paper
No shortness of breath or cough
GASTROINTESTINAL:
9
No nausea, diarrhea, vomiting, and anorexia.
Suspected Entry: 92% match
Uploaded – Week5Castelao.M.extention.docx
No nausea, diarrhea, vomiting, and anorexia
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No anorexia, nausea, vomiting or diarrhea
10
No abdominal pain GENITOURINARY:
Suspected Entry: 80% match
Uploaded – Week5Castelao.M.extention.docx
No abdominal pain GENITOURINARY
Source – Another student’s paper
No abdominal pain
9
No burning urination
Suspected Entry: 89% match
Uploaded – Week5Castelao.M.extention.docx
No burning urination
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No burning on urination
MUSCULOSKELETAL:
3
No muscle, back pain, joint pain, and stiffness.
Suspected Entry: 93% match
Uploaded – Week5Castelao.M.extention.docx
No muscle, back pain, joint pain, and stiffness
Source – Another student’s paper
No muscle, back pain, joint pain or stiffness
HEMATOLOGIC: No bleeding. Minor bruising to right elbow
LYMPHATICS:
11
No enlarged nodes and history of splenectomy
Suspected Entry: 82% match
Uploaded – Week5Castelao.M.extention.docx
No enlarged nodes and history of splenectomy
Source – Another student’s paper
No history of splenectomy or enlarged nodes · ENDOCRINOLOGIC
PSYCHIATRIC:
9
No history of depression and anxiety
Suspected Entry: 88% match
Uploaded – Week5Castelao.M.extention.docx
No history of depression and anxiety
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No history of depression or anxiety
ENDOCRINOLOGIC:
9
No reports of cold, heat intolerance, and sweating.
Suspected Entry: 93% match
Uploaded – Week5Castelao.M.extention.docx
No reports of cold, heat intolerance, and sweating
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No reports of sweating, cold or heat intolerance
No reports of polyuria or polydipsia.
Suspected Entry: 84% match
Uploaded – Week5Castelao.M.extention.docx
No reports of polyuria or polydipsia
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No polyuria or polydipsia
ALLERGIES:
9
No history of rhinitis, eczema, and asthma as well as hives.
Suspected Entry: 82% match
Uploaded – Week5Castelao.M.extention.docx
No history of rhinitis, eczema, and asthma as well as hives
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No history of asthma, hives, eczema or rhinitis
O Physical Examination:
EENT:
1
Non reddened eyes and normal sclera.
Suspected Entry: 97% match
Uploaded – Week5Castelao.M.extention.docx
Non reddened eyes and normal sclera
Source – Another student’s paper
Eyes non reddened, normal sclera
5
Visualize external auditory canal and the middle ear using otoscope, with results showing mild redness with serous fluid and no pearly white lesions.
Suspected Entry: 84% match
Uploaded – Week5Castelao.M.extention.docx
Visualize external auditory canal and the middle ear using otoscope, with results showing mild redness with serous fluid and no pearly white lesions
Source – Another student’s paper
use otoscope visualized external auditory canal and middle ear showing mild redness and bulging, with serous fluid, no pearly white lesions
12
No facial grimace and drainage from ears.
Suspected Entry: 69% match
Uploaded – Week5Castelao.M.extention.docx
No facial grimace and drainage from ears
Source – Another student’s paper
Upon further investigation, no signs of facial grimace and no drainage from his ears
3
The patient is not tugging on his ears or demonstrating signs of distress.
Suspected Entry: 66% match
Uploaded – Week5Castelao.M.extention.docx
The patient is not tugging on his ears or demonstrating signs of distress
Source – Another student’s paper
Patient is not pulling or tugging on ear, or showing signs of distress
Nose:
5
No congestion, drainage, soreness, or redness.
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
No congestion, drainage, soreness, or redness
Source – Another student’s paper
No redness, congestion, drainage or soreness
3
No enlarged nodes or sore throat with swallowing.
Suspected Entry: 88% match
Uploaded – Week5Castelao.M.extention.docx
No enlarged nodes or sore throat with swallowing
Source – Another student’s paper
No sore throat with swallowing, or enlarged nodes, no redness
Diagnostic results:
The patient is not feverish at 37.20 c. Though not breastfed, he takes pacifiers
13
Otoscope used to visualize external auditory canal and the middle ear.
Suspected Entry: 95% match
Uploaded – Week5Castelao.M.extention.docx
Otoscope used to visualize external auditory canal and the middle ear
Source – Another student’s paper
Otoscope to visualize external auditory canal, and middle ear
14
The patient has intact hearing after checking cranial nerve V111.
Suspected Entry: 66% match
Uploaded – Week5Castelao.M.extention.docx
The patient has intact hearing after checking cranial nerve V111
Source – Another student’s paper
Hearing evaluated to check cranial nerve V111:intact
15
Results from Weber and Rinne tests showed that the patient could hear whispered sound.
Suspected Entry: 63% match
Uploaded – Week5Castelao.M.extention.docx
Results from Weber and Rinne tests showed that the patient could hear whispered sound
Source – Another student’s paper
Patient was able to hear whispered voice according Weber and Rinne tests
Left Weber had better hearing.
12
Rinne tests demonstrated air heard longer with slight variation to the right side.
Suspected Entry: 64% match
Uploaded – Week5Castelao.M.extention.docx
Rinne tests demonstrated air heard longer with slight variation to the right side
Source – Another student’s paper
Rinne test (positive) showed air heard longer, a slight difference to the right side
Weber and Rinne tests help in detecting hearing problems (Ball et al., 2015).
7
Pneumatic otoscopy Tympanogram tests carried out to detect otitis media with effusion
Suspected Entry: 71% match
Uploaded – Week5Castelao.M.extention.docx
Pneumatic otoscopy Tympanogram tests carried out to detect otitis media with effusion
Source – Another student’s paper
Pneumatic otoscopy Tympanogram used to check for otitis media with effusion
3
Answers to Key Questions:
Suspected Entry: 91% match
Uploaded – Week5Castelao.M.extention.docx
Answers to Key Questions
Source – Another student’s paper
Key questions and answers
Patient reported swimming at least three times a day, hitting the water hard a few times, and landing on his right side quite often. He denied cleaning and swabbing his ears, without the help of his grandmother.
1
No history of excessive earwax and putting objects in the ear.
Suspected Entry: 66% match
Uploaded – Week5Castelao.M.extention.docx
No history of excessive earwax and putting objects in the ear
Source – Another student’s paper
No history of placing objects in ears, or excessive earwax
16
He reports muffed sounds on right ear but can hear well and denies dizziness.
Suspected Entry: 68% match
Uploaded – Week5Castelao.M.extention.docx
He reports muffed sounds on right ear but can hear well and denies dizziness
Source – Another student’s paper
He reports that ear sounds are slightly more muffled on the right side, but he can hear good, denies ringing, dizziness
He can repeat simple sentences without any hesitation and does not appear to have hearing difficulties.
Suspected Entry: 64% match
Uploaded – Week5Castelao.M.extention.docx
He can repeat simple sentences without any hesitation and does not appear to have hearing difficulties
Source – Another student’s paper
Does not turn head when listening or appear to have difficulty hearing and can repeat back simple sentences without hesitation (Dains et al., 2016)
A
Differential Diagnosis
Primary Diagnosis:
3
Acute otitis media.
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
Acute otitis media
Source – Another student’s paper
Acute Otitis Media
Although he is not feverish, Marchisio et al. (2019) associate acute otitis media with symptoms such as reddening of ears and ear pains.
Differential Diagnosis:
Ear trauma: While there is no perforation, this may have occurred during swimming. Dains, Baumann, and Scheibel (2016) indicate that blunt trauma and no vertigo can lead to ear trauma
3
Middle ear effusion:
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
Middle ear effusion
Source – Another student’s paper
Middle ear effusion
Common symptoms of middle ear effusion include serous fluid and rightward lateralization, which can occur due to occluded ear (Ball et al., 2015).
Cholesteatoma: This infection is associated with hearing difficulties but no loss of hearing and perforations (Gulati et al., 2019).
References
Ball, J.
14
W., Dains, J.
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
W., Dains, J
Source – Another student’s paper
W., Dains, J
E., Flynn, J.
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
E., Flynn, J
Source – Another student’s paper
E., Flynn, J
A., Solomon, B.
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
A., Solomon, B
Source – Another student’s paper
A., Solomon, B
S., & Stewart, R.
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
S., & Stewart, R
Source – Another student’s paper
S., Stewart, R
W. (2015).
14
Siedel’s guide to physical examinations (8th ed.).
Suspected Entry: 64% match
Uploaded – Week5Castelao.M.extention.docx
Siedel’s guide to physical examinations (8th ed.)
Source – Another student’s paper
Seidel’s guide to physical examination (8th ed.)
St. Louis, MO: Elsevier Mosby.
Dains, J.
17
E., Baumann, L.C., & Scheibel, P.
Suspected Entry: 66% match
Uploaded – Week5Castelao.M.extention.docx
E., Baumann, L.C., & Scheibel, P
Source – Another student’s paper
Dains, J., Baumann, L., & Scheibel, P
(2016).
9
Advanced health assessment and clinical diagnosis in primary care (5th ed.).
Suspected Entry: 100% match
Uploaded – Week5Castelao.M.extention.docx
Advanced health assessment and clinical diagnosis in primary care (5th ed.)
Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
Advanced health assessment and clinical diagnosis in primary care (5th ed.)
St. Louis, MO: Elsevier Mosby Gulati, M., Gupta, S., Prakash, A., Garg, A., & Dixit, R. (2019). HRCT imaging of acquired cholesteatoma: A pictorial review. Insights into Imaging, 10(1), 1-8.
Marchisio, P., Bortone, B., Ciarcià, M., Motisi, M. A., Torretta, S., Gattinara, G. C.,. & Varricchio, A. (2019).
18
Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics:
Suspected Entry: 95% match
Uploaded – Week5Castelao.M.extention.docx
Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics
Source – Another student’s paper
Updated guidelines for the management of acute otitis media in children by the Italian society of pediatrics diagnosis
Prevention.
19
The Pediatric Infectious Disease Journal, 38(12), 22-36.
Suspected Entry: 64% match
Uploaded – Week5Castelao.M.extention.docx
The Pediatric Infectious Disease Journal, 38(12), 22-36
Source – Another student’s paper
Pediatric Infectious Disease Journal, 38, S3-S9
