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1. Healthcare Discussion: Focused Throat Exam Case Study Analysis
Healthcare Discussion: Focused Throat Exam Case Study Analysis ON Healthcare
Discussion: Focused Throat Exam Case Study AnalysisNurses 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.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.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 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 eachCASE STUDY 2: Focused Throat ExamLily 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.
Healthcare Discussion: Focused Throat Exam Case Study
Analysisfe71d0b4ba43be908f6104822949e3d.doca0065755d3c13dc15ea703b38de4.docr
ubric_detail_____blackboarUnformatted Attachment PreviewEpisodic/Focused SOAP Note
Template Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF
statement identifying why the patient is here – in the patient’s own words – for instance
“headache”, NOT “bad headache for 3 days”. HPI: This is the symptom analysis section of

2. your note. Thorough documentation in this section is essential for patient care, coding, and
billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic
to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-
old AA male). You must include the seven attributes of each principal symptom in
paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like
the following example: Location: head Onset: 3 days ago Character: pounding, pressure
around the eyes and temples Associated signs and symptoms: nausea, vomiting,
photophobia, phonophobia Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not
completely better Severity: 7/10 pain scale Current Medications: include dosage, frequency,
length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of
what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction
vs intolerance). PMHx: include immunization status (note date of last tetanus for all adults),
past major illnesses and surgeries. Depending on the CC, more info is sometimes needed Soc
Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous ©
2019 Walden University Page 1 of 3 and current use), any other pertinent data. Always add
some health promo question here – such as whether they use seat belts all the time or
whether they have working smoke detectors in the house, living environment, text/cell
phone use while driving, and system. Fam Hx: illnesses with possible genetic
predisposition, contagious or chronic illnesses. Reason for death of any deceased first
degree relatives should be included. Include parents, grandparents, siblings, and children.
Include grandchildren if pertinent. ROS: cover all body systems that may help you include or
rule out a differential diagnosis You should list each system as follows: General: Head:
EENT: etc. Healthcare Discussion: Focused Throat Exam Case Study AnalysisYou should list
these in bullet format and document the systems in order from head to toe. Example of
Complete ROS: GENERAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Eyes:
No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No
hearing loss, sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or
edema. RESPIRATORY: No shortness of breath, cough or sputum. GASTROINTESTINAL: No
anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY:
Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY. NEUROLOGICAL:
No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities.
No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint
pain or stiffness. HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No
enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or
anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or
polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis. © 2019 Walden
University Page 2 of 3 O. Physical exam: From head-to-toe, include what you see, hear, and
feel when doing your physical exam. You only need to examine the systems that are
pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe
what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

3. Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop
the differential diagnoses ( with evidenced and guidelines) A. Differential Diagnoses (list a
minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at
the top of the list. For each diagnosis, provide ive documentation with evidence based
guidelines. P. This section is not required for the assignments in this course (NURS 6512)
but will be required for future courses. References You are required to include at least three
evidence based peer-reviewed journal articles or evidenced based guidelines which relates
to this case to your diagnostics and differentials diagnoses. Be sure to use correct APA 6th
edition formatting. © 2019 Walden University Page 3 of 3 Episodic/Focused SOAP Note
Exemplar Focused SOAP Note for a patient with chest pain S. CC: “Chest pain” HPI: The
patient is a 65 year old AA male who developed sudden onset of chest pain, which began
early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms
of intensity. The pain is located in the middle of the chest and is accompanied by shortness
of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal
relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH:
Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature
cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or
previously; consumes moderate alcohol; married for 39 years ROS General–Negative for
fevers, chills, fatigue Cardiovascular–Negative for orthopnea, PND, positive for intermittent
lower extremity edema Gastrointestinal–Positive for nausea without vomiting; negative for
diarrhea, abdominal pain Pulmonary–Positive for intermittent dyspnea on exertion,
negative for cough or hemoptysis O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs;
Ht 70” Healthcare Discussion: Focused Throat Exam Case Study AnalysisGeneral–Pt appears
diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid
clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right
inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No
fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+
LE edema is noted. Gastrointestinal–The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-
umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric
tenderness with deep palpation. Pulmonary– Lungs are clear to auscultation and percussion
bilaterally Diagnostic results: EKG, CXR, CK-MB ( with evidenced and guidelines) A.
Differential Diagnosis: 1) Myocardial Infarction (provide ive documentation with evidence
based guidelines). 2) Angina (provide ive documentation with evidence based guidelines).
3) Costochondritis (provide ive documentation with evidence based guidelines). Primary
Diagnosis/Presumptive Diagnosis: Myocardial Infarction © 2019 Walden University Page 1
of 2 P. This section is not required for the assignments in this course (NURS 6512) but will
be required for future courses. © 2019 Walden University Page 2 of 2 Rubric Detail Select
Grid View or List View to change the rubric’s layout. Name:
NURS_6512_Week_5_Assignment_1_Rubric Grid View EXIT List View Excellent Good Fair
Poor 45 (45%) – 50 (50%) 39 (39%) – 44 (44%) 33 (33%) – 38 (38%) 0 (0%) – 32 (32%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the
patient in the assigned case study. The response thoroughly and accurately provides

4. detailed evidence from the literature to diagnostic tests that would be appropriate for the
patient in the assigned case study. The response accurately follows the SOAP format to
document the patient in the assigned case study. The response accurately provides detailed
evidence from the literature to diagnostic tests that would be appropriate for the patient
in the assigned case study. The response follows the SOAP format to document the patient
in the assigned case study, with some vagueness and inaccuracy. The response provides
evidence from the literature to diagnostic tests that would be appropriate for the patient
in the assigned case study, with some vagueness or inaccuracy in the evidence selected. The
response incompletely and inaccurately follows the SOAP format to document the patient in
the assigned case study. The response provides incomplete, inaccurate, and/or missing
evidence from the literature to diagnostic tests that would be appropriate for the patient
in the assigned case study. · List !ve di”erent possible conditions for the patient’s di”erential
diagnosis, and justify why you selected each. 30 (30%) – 35 (35%) 24 (24%) – 29 (29%) 18
(18%) – 23 (23%) 0 (0%) – 17 (17%) The response lists !ve distinctly di”erent and detailed
possible conditions for a di”erential diagnosis of the patient in the assigned case study, and
provides a thorough, accurate, and detailed justi!cation for each of the !ve conditions
selected. The response lists four or !ve di”erent possible conditions for a di”erential
diagnosis of the patient in the assigned case study and provides an accurate justi!cation for
each of the !ve conditions selected. Healthcare Discussion: Focused Throat Exam Case Study
AnalysisThe response lists three to !ve possible conditions for a di”erential diagnosis of the
patient in the assigned case study, with some vagueness and/or inaccuracy in the
conditions and/or justi!cation for each. The response lists two or fewer, or is missing,
possible conditions for a di”erential diagnosis of the patient in the assigned case study, with
inaccurate or missing justi!cation for each condition selected. Written Expression and
Formatting – Paragraph Development and Organization: Paragraphs make clear points that
well-developed ideas, #ow 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. 5 (5%) – 5 (5%) 4 (4%) – 4 (4%) 3 (3%) – 3 (3%) 0 (0%) – 2 (2%) Paragraphs and
sentences follow writing standards for #ow, continuity, and clarity. A clear and
comprehensive purpose statement, introduction, and conclusion are provided that
delineate all required criteria. Paragraphs and sentences follow writing standards for #ow,
continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the
assignment are stated, yet are brief and not descriptive. Paragraphs and sentences follow
writing standards for #ow, continuity, and clarity 60%–79% of the time. Purpose,
introduction, and conclusion of the assignment are vague or o” topic.Paragraphs and
sentences follow writing standards for #ow, 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 5 (5%) – 5 (5%) 4 (4%) – 4 (4%) 3 (3%) – 3 (3%) 0 (0%) – 2 (2%) Uses correct
grammar, spelling, and punctuation with no errors. Contains a few (1 or 2) grammar,
spelling, and punctuation errors. Contains several (3 or 4) grammar, spelling, and
punctuation errors. Contains many (? 5) grammar, spelling, and punctuation errors that

5. 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. 5 (5%) – 5
(5%) 4 (4%) – 4 (4%) 3 (3%) – 3 (3%) 0 (0%) – 2 (2%) Uses correct APA format with no
errors. Contains a few (1 or 2) APA format errors. Contains several (3 or 4) APA format
errors. Contains many (? 5) APA format errors. Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the
case study to which you were assigned. · Provide evidence from the literature to
diagnostic tests that would be appropriate for your case. Total Points: 100 Name:
NURS_6512_Week_5_Assignment_1_Rubric EXIT …Purchase answer to see full attachment