Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat (2024)

Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat

Episodic/Focused SOAP Note Template

Patient Information:

Initials: Kali Age: 44 years old Sex: Female Race: Not specified.

S.

CC (chief complaint): Kali’s primary concerns include proptosis (bulging of the eyes) and fatigue.

HPI: Ms. Kali, a 44-year-old female, presents to the office for a comprehensive physical examination with specific concerns. She reports experiencing proptosis (bulging of the eyes) and persistent fatigue. Notably, her thyroid-stimulating hormone (TSH) levels are elevated, indicating potential thyroid dysfunction. Moreover, she has a history of hyperlipidemia, further suggesting an underlying endocrine issue. Upon examination, an observable swelling in the neck is noted, indicative of thyroid enlargement. This physical manifestation, combined with the elevated TSH levels, raises suspicions of thyroid-related disorders. The patient also presents as overweight, a finding that may be associated with thyroid dysfunction.

Location: Kali reports discomfort and a noticeable bulging sensation in both eyes (proptosis). She points to the anterior part of her eye sockets as the primary site of discomfort.

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Onset: The proptosis has been progressively worsening over the last several months, with Kali first noticing the bulging approximately six months ago. Fatigue has been persistent during this period.

Character: The proptosis is described as a protrusion or bulging sensation in both eyes, causing her eyes to appear larger and more prominent. A constant feeling of tiredness and lethargy characterizes the fatigue.

Associated Symptoms: Kali reports hyperlipidemia, as evidenced by elevated cholesterol levels. Additionally, she notes a swollen appearance in her neck, consistent with a goiter, and reports being overweight.

Timing: The proptosis and fatigue have been present continuously for the past six months, with no specific exacerbating or alleviating factors identified by the patient.

Exacerbating/Relieving Factors: Kali denies any specific triggers that worsen or alleviate her symptoms. Fatigue is not significantly improved with rest.

Severity: The proptosis has been progressively worsening, impacting both Kali’s appearance and comfort. The fatigue is described as moderate to severe, significantly affecting her daily activities.

Current Medications: No current medications provided.

Allergies: Denies history of asthma or rhinitis.

PMHx: No past medical history for the patient

Soc Hx: No social history provided

Fam Hx: No family history provided

ROS:

• GENERAL: No fevers or chills were reported. No unintentional weight loss or gain. No changes in appetite.
• HEAD: No headaches or migraines reported. No head injuries or trauma. No dizziness or lightheadedness.
• EYES (EENT – Eyes, Ears, Nose, Throat): Proptosis (bulging eyes) reported. No changes in vision or visual disturbances. No eye pain, redness, or discharge. No ear pain or hearing difficulties. No nasal congestion, discharge
• CARDIOVASCULAR: No chest pain or discomfort. No palpitations or irregular heartbeat were reported. No history of high blood pressure or cardiovascular disease.
• RESPIRATORY: No difficulty breathing. No cough or respiratory infections were reported. No history of asthma.
• GASTROINTESTINAL: No abdominal discomfort. No changes in bowel habits. No nausea, vomiting, or diarrhea was reported. No history of gastrointestinal conditions.
• MUSCULOSKELETAL: No joint pain. No muscle pain was reported. No history of arthritis or autoimmune disorders affecting the musculoskeletal system.
• INTEGUMENTARY (Skin, Hair, Nails): No changes in skin colour or texture. No rashes, itching, or lesions were reported. No hair loss or changes in hair texture.
• NEUROLOGICAL: No seizures or convulsions were reported. No numbness or tingling sensations. No changes in coordination or balance.
• PSYCHIATRIC: No symptoms of depression or anxiety reported. No changes in mood or sleep patterns.
• ENDOCRINE: No excessive thirst or urination reported. No heat or cold intolerance reported. No changes in hair or nail texture.
• GENITOURINARY: No urinary frequency or urgency. No pain or discomfort during urination. No changes in urinary habits.
• HEMATOLOGIC/LYMPHATIC: No history of bleeding disorders. No swollen lymph nodes were reported. No easy bruising or petechiae.

O.

Physical exam

GENERAL: Kali appears tired and overweight. Signs of fatigue and reduced energy levels.

HEAD: No abnormalities noted. No significant changes were observed in the hair.

EYES: Bilateral proptosis is evident, with an abnormal protrusion of the eyes. No signs of inflammation or irritation. Pupils are equal and reactive to light.

EARS: No abnormalities noted.

NOSE: No signs of congestion or discharge.

MOUTH AND THROAT: Absence of dryness or signs of dehydration. There are no visible abnormalities in the throat.

NECK: Noticeable swelling in the anterior neck region, consistent with a goiter. Palpation

CARDIOVASCULAR: Normal heart sounds

RESPIRATORY: Average respiratory rate and effort.

ABDOMEN: abdominal tenderness or enlargement of the liver or spleen.

MUSCULOSKELETAL: No muscle pain.

SKIN: No changes in skin colour or texture,

NEUROLOGICAL: No signs of cognitive impairment or altered mental status. No tendon reflexes.

Diagnostic results

Thyroid Function Tests (TFTs)

TSH: Elevated. TSH is elevated as the body attempts to stimulate the thyroid to produce more hormones. In hypothyroidism, free thyroxine (T4) levels are often below the normal range. Free T4 is a direct measure of the active thyroid hormone circulating in the bloodstream.

Lipid Profile

LDL-C: Elevated. The American Heart Association guidelines recommend lipid profile testing for cardiovascular risk assessment. Elevated LDL-C is a risk factor for atherosclerosis and cardiovascular disease. Hypothyroidism can also contribute to decreased high-density lipoprotein cholesterol (HDL-C), another component of dyslipidemia.

Autoantibody Testing

Anti-TPO: Elevated. The presence of anti-TPO antibodies is consistent with autoimmune destruction of the thyroid gland. Elevated anti-Tg antibodies may also indicate autoimmune thyroid disease.

Ophthalmologic Evaluation

A comprehensive eye examination, including assessment of visual acuity, eye movement, and eye pressure, is crucial to evaluate the severity of proptosis and identify any associated eye complications in Graves’ disease.

A.

Differential Diagnoses

Thyroid Disorder (Graves’ Disease or Hypothyroidism)

Graves’ Disease is an autoimmune disorder with characteristics of overproduction of thyroid hormones (Antonelli et al., 2020). The presence of elevated Thyroid Stimulating Hormone (TSH) levels is indicative of a malfunctioning thyroid gland. In hypothyroidism, TSH is elevated as the body attempts to stimulate the thyroid to produce more hormones. Proptosis is a characteristic feature of Graves’ disease. In this autoimmune disorder, the immune system mistakenly attacks the thyroid gland, leading to the overproduction of thyroid hormones and associated eye changes. A visibly swollen neck suggests the presence of a goiter, which can be associated with both hyperthyroidism and hypothyroidism.

Hyperlipidemia

Hyperlipidemia refers to increased levels of lipids (fats) in the blood, including cholesterol and triglycerides. It is a common metabolic disorder that can contribute to the development of cardiovascular diseases (Bułdak et al., 2019). Hyperlipidemia is evidenced by elevated levels of lipids (cholesterol and triglycerides) in the blood. Thyroid dysfunction, particularly hypothyroidism, can lead to elevated lipid levels, contributing to hyperlipidemia.

Metabolic Syndrome

Metabolic syndrome is a cluster of interconnected metabolic abnormalities that collectively increase the risk of cardiovascular disease and other health-related issues (Ndumele et al., 2023). Kali’s reported overweight status is a component of metabolic syndrome, a cluster of conditions that often include abdominal obesity, elevated blood pressure, elevated blood sugar, and abnormal lipid levels. While fatigue is a nonspecific symptom, it can be associated with metabolic syndrome due to factors such as insulin resistance, inflammation, and hormonal imbalances.

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 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 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 support 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. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: Denies weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: Denies anemia, bleeding or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.

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.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support 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 supportive documentation with evidence based guidelines.

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 support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting.

A.

Differential Diagnosis:

1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).

2) Angina (provide supportive documentation with evidence based guidelines).

3) Costochondritis (provide supportive documentation with evidence based guidelines).

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

1. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

Nurses 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.

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.

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

Case Study 2: Focused Thyroid Exam

Kali, a 44 year old female is in the office for a complete physical examination. She complains of proptosis and feeling fatigued. Her TSH levels are elevated, she has hyperlipidemia, her neck appears swollen, and is overweight.

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INSTRUCTIONS:

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 fivepossible conditions that may be considered in a differential diagnosis for the patient.

THE ASSIGMENT:

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.

A SOAP TEMPLATE WILL BE ATTACHED.

REQUIRED READING:

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &Stewart, R. W. (2023).Seidel’s guide to physical examination: An interprofessional approach(10th 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

• Dains, J. E., Baumann, L. C., & Scheibel, P. (2019).Advanced health assessment and clinical diagnosis in primary care(6th ed.). St. Louis, MO: Elsevier Mosby.
  Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
  • Chapter 15, “Earache”Download Chapter 15, “Earache”
    This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination.
  • Chapter 21, “Hoarseness”Download Chapter 21, “Hoarseness”
    This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams.
  • Chapter 25, “Nasal Symptoms and Sinus Congestion”Download Chapter 25, “Nasal Symptoms and Sinus Congestion”
    In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.
  • Chapter 30, “Red Eye”Download Chapter 30, “Red Eye”
    The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.
  • Chapter 32, “Sore Throat”Download Chapter 32, “Sore Throat”
    A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.
  • Chapter 38, “Vision Loss”Download Chapter 38, “Vision Loss”
    This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.
    Note:Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.
• Document:Episodic/Focused SOAP Note ExemplarDownload Episodic/Focused SOAP Note Exemplar(Word document)
• Document:Episodic/Focused SOAP Note TemplateDownload Episodic/Focused SOAP Note Template(Word document)
• Document:Midterm Exam ReviewDownload Midterm Exam Review(Word document)

Shadow Health Support and Orientation Resources

• Shadow Health. (2021).Welcome to your introduction to Shadow HealthLinks to an external site.. https://link.shadowhealth.com/Student-Orientation-Video
• Shadow Health. (n.d.).Shadow Health help deskLinks to an external site.. Retrieved from https://support.shadowhealth.com/hc/en-us
• Shadow Health. (2021).Walden University quick start guide: NURS 6512 NP students.Download Walden University quick start guide: NURS 6512 NP students.https://link.shadowhealth.com/Walden-NURS-6512-Student-Guide
• Document:DCE (Shadow Health) Documentation TemplateDownload DCE (Shadow Health) Documentation Templatefor Focused Exam: Cough (Word document)
  Use this template to complete your Assignment 2 for this week.

References

Antonelli, A., Fallahi, P., Elia, G., Ragusa, F., Paparo, S. R., Ruffilli, I., … & Ferrari, S. M. (2020). Graves’ disease: Clinical manifestations, immune pathogenesis (cytokines and chemokines) and therapy.Best Practice & Research Clinical Endocrinology & Metabolism,34(1), 101388. https://doi.org/10.1016/j.beem.2020.101388

Bułdak, Ł., Marek, B., Kajdaniuk, D., Urbanek, A., Janyga, S., Bołdys, A., … & Okopień, B. (2019). Endocrine diseases as causes of secondary hyperlipidemia.Endokrynologia Polska,70(6), 511-519. 10.5603/EP.a2019.0041

Ndumele, C. E., Rangaswami, J., Chow, S. L., Neeland, I. J., Tuttle, K. R., Khan, S. S., … & American Heart Association. (2023). Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association.Circulation,148(20), 1606-1635. https://doi.org/10.1161/CIR.0000000000001184 Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat