CASE STUDY 2: 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 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. Episodic/Focused SOAP Note Template – (delete information on this template and input one related to the patient in the case study above). 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: h.

1. CASE STUDY 2: 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
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.

2. · 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.
Episodic/Focused SOAP Note Template
– (delete information on this template and input one related to
the patient in the case study above).
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

3. 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

4. : 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: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or

5. 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.
O.

6. 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.
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 6th edition formatting.

7. Resources for references
Ball, 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. 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

8. (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.

9. 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.
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). 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.

10. 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

11. 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.
Colyar, M. R. (2015).
Advanced practice nursing procedures.
Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition
by Colyar, M. R. Copyright 2015 by F. A. Davis Company.
Reprinted by permission of F. A. Davis Company via the
Copyright Clearance Center.
Chapter 71, “Visual Function Evaluation: Snellen, Illiterate
E, Pictorial
This section explains the procedural knowledge needed to
perform eyes, ears, nose, and mouth procedures.
Sullivan, D. D. (2019).

12. 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)
Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing
in clinical examination.
Vision Research
90, 32–37. doi:10.1016/j.visres.2013.02.001. Retrieved from
https://www.sciencedirect.com/science/article/pii/S0042698913
000217
Rubin, G. S. (2013). Measuring reading performance.
Vision Research,
90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from
http://www.sciencedirect.com/science/article/pii/S00426989130
00436
Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J.
M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media:
Diagnosis and treatment. American Family Physicians, 88(7),
435–440.
Otolaryngology Houston. (2014). Imaging of maxillary sinusitis
(X-ray, CT, and MRI). Retrieved from
http://www.ghorayeb.com/ImagingMaxillarySinusitis.html
This website provides medical images of sinusitis, including X-
rays, CT scans, and MRIs (magnetic resonance imaging).