Advanced Health Assessment Assignment Discussion Paper

 Episodic/Focused SOAP Note

Patient Information:

Initials, Age, Sex, Race

S.

CC: proptosis and fatigue

HPI: K.N is a 44-year old female who presents for a complete physical examination. She complains of proptosis and feeling fatigued. She reports that her eyes began bulging three weeks ago, and that it affects her vision. She reports that she began experiencing fatigue two weeks ago and she has not been able to complete her daily activities. She also reports a swollen neck and has hyperlipidemia for which she takes atorvastatin. She reports weight gain but denies fever, headache, vomiting or diarrhea.

Current Medications: atorvastatin 20 mg once daily Advanced Health Assessment Assignment Discussion Paper

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Allergies: NKDA

PMHx: immunizations are up to date. Received tetanus vaccine 5/10/2021. History of hyperlipidemia

Soc Hx: K.N is an elementary school teacher at a local school. She lives with her husband and two children. Her hobbies include reading novels and traveling. She admits to drinking once in a while. Denies tobacco or illicit drug use.

Fam Hx: Mother: history of hyperlipidemia, type 2 diabetes. Father: hypertension. Her brother is in good health.

ROS:

GENERAL:  Reports weight gain and fatigue. Denies fever or chills.

HEENT:  Eyes: Reports proptosis. 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. Denies abdominal pain. Advanced Health Assessment Assignment Discussion Paper

GENITOURINARY:  Denies pain on urination.

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:  Reports enlarged nodes in the neck. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies sweating, cold or heat intolerance. Denies polyuria or polydipsia.

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

O.

Physical exam:

Vital signs: H 5’5”, W 88 kg, RR 16 HR 89 BP 128/78

HEENT: Bulging eyes noted. Intact ears with good reflex. Enlarged thyroid noted.

Diagnostic results:

TSH test, thyroid antibody test, hemoglobin A1C test results pending

A.

Differential Diagnoses 

  1. Graves’ disease: This is an immune system illness that leads to the excess production of thyroid hormones (hyperthyroidism). Even though hyperthyroidism may be caused by a variety of different conditions, Graves’ disease is the most frequent. Graves’ disease manifests itself in a variety of ways because thyroid hormones influence so many different body systems. Protrusion of the eyes, excessive perspiration, fatigue, rapid heart rate, irregular heart rate, goiter, and weight loss are all possible symptoms (Wiersinga, 2019). The major therapeutic objectives are to lower the quantity of thyroid hormones produced by the body and to reduce the severity of the associated symptoms Advanced Health Assessment Assignment Discussion Paper.
  2. Hyperthyroidism: When the thyroid gland generates an excessive amount of the hormone thyroxine, this is referred to as hyperthyroidism (overactive thyroid). There are a variety of illnesses that may induce hyperthyroidism, including Graves’ disease, Plummer’s disease, and thyroiditis, among others. It is a condition in which the body’s metabolism is accelerated, resulting in unintentional weight loss as well as a fast or irregular heartbeat. A doctor may have difficulty diagnosing hyperthyroidism since the symptoms might be similar to those of other health disorders. It may also induce a broad range of indications and symptoms, including unintentional weight loss, rapid heartbeat, sweating, tremor, fatigue, and heightened heat sensitivity, to name a few examples. People over the age of 65 are more prone than younger people to have either no signs and symptoms at all or just modest ones such as an elevated heart rate, heat intolerance, and a propensity to become tired while doing everyday tasks (Taylor et al., 2018). Hyperthyroidism may be treated in a variety of ways. The synthesis of thyroid hormones is slowed by the use of anti-thyroid medicines and radioactive iodine administered by doctors. In certain cases, surgery to remove all or part of the thyroid gland is required for hyperthyroidism management. Although hyperthyroidism may be life-threatening if left untreated, the majority of persons who are identified and treated for hyperthyroidism do well.

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  3. Thyroid hormone resistance: An uncommon genetic disorder known as thyroid hormone resistance occurs when some body tissues do not react appropriately to thyroid hormones generated by the thyroid gland. This condition may be accompanied by no symptoms or by characteristics of both an overactive and an underactive thyroid gland. Due to the fact that thyroid hormone does not properly shut down the pituitary gland (which regulates hormone synthesis from the thyroid gland), the thyroid hormone level is increased in the blood (Singh & Yen, 2017). Excessive production of thyroid hormone might result in the enlargement of the thyroid gland (goiter). When exposed to high doses of thyroid hormones, peripheral tissues may become resistant or retain sensitivity, resulting in characteristics of both an underactive and an overactive thyroid Advanced Health Assessment Assignment Discussion Paper.

References

Singh, B. K., & Yen, P. M. (2017). A clinician’s guide to understanding resistance to thyroid hormone due to receptor mutations in the TRα and TRβ isoforms. Clinical diabetes and endocrinology, 3(1), 1-11. https://doi.org/10.1186/s40842-017-0046-z

Taylor, P. N., Albrecht, D., Scholz, A., Gutierrez-Buey, G., Lazarus, J. H., Dayan, C. M., & Okosieme, O. E. (2018). Global epidemiology of hyperthyroidism and hypothyroidism. Nature Reviews Endocrinology, 14(5), 301-316. https://doi.org/10.1038/nrendo.2018.18

Wiersinga, W. M. (2019). Graves’ disease: Can it be cured? Endocrinology and Metabolism, 34(1), 29. https://doi.org/10.3803/enm.2019.34.1.29

Now, during week 5, we are covering the HEENT. You should be assigned a case to document an episodic/focused note. There is a template for you to follow posted in your week 5 resources. Please review Evidenced Based/Scholarly resources as you provide documentation within the note. Remember that evidence base literature are journals NOT BOOKS or regular internt 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. Kali ,a 44year 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 overweightBall, 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 Advanced Health Assessment Assignment Discussion Paper.

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” 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” 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” 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” 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” 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” 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. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019)Advanced Health Assessment Assignment Discussion Paper.

Head and neck: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1, 3, 4, and 5) Hayashi, T., Kitamura, K., Hashimoto, S., Hotomi, M., Kojima, H., Kudo, F., Maruyama, Y., Sawada, S., Taiji, H., Takahashi, G., Takahashi, H., Uno, Y., & Yano, H. (2020). Clinical practice guidelines for the diagnosis and management of acute otitis media in children—2018 update. Auris Nasus Larynx, 47(4), 493–526. https://doi.org/10.1016/j.anl.2020.05.019 Mustafa, Z., & Ghaffari, M. (2020). Diagnostic methods, clinical guidelines, and antibiotic treatment for Group A streptococcal pharyngitis: A narrative review. Frontiers in Cellular and Infection Microbiology, 10. https://doi.org/10.3389/fcimb.2020.563627 Patel, G. B., Kern, R. C., Bernstein, J. A., Hae-Sim, P., & Peters, A. T. (2020). Current and future treatments of rhinitis and sinusitis. The Journal of Allergy and Clinical Immunology: In Practice, 8(5), 1522–1531. https://doi.org/10.1016/j.jaip.2020.01.031Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat Photo Credit: Getty Images/Blend Images Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature Advanced Health Assessment Assignment Discussion Paper.

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However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. 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. 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. 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. By Day 6 of Week 5 Submit your Assignment Advanced Health Assessment Assignment Discussion Paper.

Submission and Grading Information To submit your completed Assignment for review and grading, do the following: Please save your Assignment using the naming convention “WK5Assgn1+last name+first initial.(extension)” as the name. Click the Week 5 Assignment 1 Rubric to review the Grading Criteria for the Assignment. Click the Week 5 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area. Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK5Assgn1+last name+first initial.(extension)” and click Open. If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database. Click on the Submit button to complete your submission. Grading Criteria To access your rubric:Rubric Detail Select Grid View or List View to change the rubric’s layout. Name: NURS_6512_Week_5_Assignment_1_Rubric Grid View List View Excellent Good Fair Poor 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 support diagnostic tests that would be appropriate for your case. 45 (45%) – 50 (50%) 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 detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 39 (39%) – 44 (44%) 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 support diagnostic tests that would be appropriate for the patient in the assigned case study. 33 (33%) – 38 (38%) 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 support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected. 0 (0%) – 32 (32%) The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study Advanced Health Assessment Assignment Discussion Paper.

The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. · List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 30 (30%) – 35 (35%) The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected. 24 (24%) – 29 (29%) The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected. 18 (18%) – 23 (23%) The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 0 (0%) – 17 (17%) The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow 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%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity Advanced Health Assessment Assignment Discussion Paper.

A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 (3%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 0 (0%) – 2 (2%) Paragraphs and sentences follow writing standards for flow, 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%) Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 (3%) – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 2 (2%) Contains many (≥ 5) grammar, spelling, and punctuation errors that 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%) Uses correct APA format with no errors. 4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors. 3 (3%) – 3 (3%) Contains several (3 or 4) APA format errors. 0 (0%) – 2 (2%) Contains many (≥ 5) APA format errors. Total Points: 100 Name: NURS_6512_Week_5_Assignment_1_Rubric

Advanced Health Assessment Assignment Discussion Paper