This document provides instructions for a case study assignment on HEENT. Students are assigned to complete an episodic/focused SOAP note on one of two case studies depending on whether their last name starts with A-J or K-Z. The case study for students with last names A-J involves a 20-year-old female college student named Lily presenting with a 3-day sore throat. Students are instructed to review learning resources, consider the history and exam needed to make a diagnosis, and provide a differential diagnosis listing of at least five possible conditions for the patient.

1. This week we are covering HEENT. At this time you are
assigned an episodic/focused note. You will need this assigned
case study to complete the Case Study Assignment for this
week. Focused assessment means you still fill out all review of
systems and as needed type “Patient denies” in the sections that
you are not covering or are needed. Again, you are allowed to
make up the information that is needed to fill out the episodic
note.
If your LAST NAME starts with letters A – J: please proceed
with Option 1.
If your LAST NAME starts with letters K – Z: please proceed
with Option 2.
Option 1:
CASE STUDY: 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 a slight
hoarseness in her voice but doesn't sound congested.
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

2. 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.
This
week
we
are
covering

3. HEENT.
At
this
time
you
are
assigned
an
episodic
/
focuse
d
note.
You
will
need
this
assigned
case
study

4. to
complete
the
Case
Study
Assignment
for
this
week.
Focused
assessment
means
you
still
fill
out
all
review

5. of
systems
and
as
needed
type
“Patient
denies”
in
the
sections
that
you
are
not
covering
or
are

6. needed.
Again,
you
are
allowed
to
make
up
the
information
that
is
needed
to
fill
out
the
episodic

7. note
.
If
your
LAST
NAME
starts
with
letters
A
–
J:
please
proceed
with
Option

8. 1
.
If
your
LAST
NAME
starts
with
letters
K
–
Z:
please
proceed
with
Option
2
.

9. Option
1
:
CASE
STUDY:
Focused
Throat
Exa
m
Lily
is
a
20
-
year
-
old
student
at
the
local

10. community
college.
When
some
of
her
friends
and
classmates
told
her
about
an
outbreak
of
flu
-
like
symptoms

11. sweeping
her
campus
during
the
past
2
weeks,
Lily
figured
she
shouldn't
take
her
3
-
day
sore
throat

12. lightly
.
Your
clinic
has
treated
a
few
cases
similar
to
Lily's.
All
the
patients
reported
decreased
appetite,
headaches,

13. and
pain
with
swallowing.
As
Lily
recounts
these
symptoms
to
you,
you
notice
that
she
has
a
runny

14. nose
and
a
slight
hoarseness
in
her
voice
bu
t
doesn't
sound
congested
.
To Prepare
·
By Day 1 of th
is week, you will be assigned to a specific case study for this
Case Study Assignment. Please see the

15. “Course Announcements” section of the classroom for your
assignment from your Instructor.
·
Also, your Case Study Assignment should be in the
Episodic/Focus
ed 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 specifi
c 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 physic
al 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?
·

16. Identify at least five
possible conditions that may be considered in a differential
diagnosis fo
r 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
evide
nce 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.
Episodic/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 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

17. 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

18. 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.

19. 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.
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 support your diagnostics and differentials
diagnoses. Be sure to use correct APA 7th edition formatting.
© 2021 Walden University, LLC
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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

20. chest and is accompanied by shortness of breath. The patient
reports feeling nauseous. The patient tried an antacid with
minimal relief of his symptoms.
Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg
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
Allergies: PCN-rash; food-none; environmental- none
Immunizations: UTD on immunizations, covid vaccine #1
1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna
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”
General--Pt appears diaphoretic and anxious
Cardiovascular--PMI is in the 5th inter-costal space at the mid

21. 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 (support with evidenced
and guidelines)
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).

22. Primary Diagnosis/Presumptive Diagnosis: Myocardial
Infarction
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
P. This section is not required for the assignments in this course
(NURS 6512) but will be required for future courses.
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© 2021 Walden University

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