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Health Assessment

Health Assessment

Health Assessment
Health Assessment Essay Paper
Health Assessment Essay Paper

Week 5: Assignment 1

Assessment of Head, Neck, Eyes, Ears, Nose, and Throat

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 (attached).

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.
Apply assessment skills to diagnose eye, ears, and throat conditions. Health Assessment Essay Paper
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat
Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past 2 days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he\’s been spending his summer, James responds that he\’s been spending a lot of time in the pool.

This week, you will explore how to assess the head, neck, eyes, ears, nose, and throat. Whether dealing with a detached retina, sinusitis, meningitis, or even cough, advanced practice nurses need to know the proper assessment techniques in order to form accurate diagnoses.Health Assessment Essay Paper

Resources:

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.

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.

https://www.sciencedirect.com/science/article/pii/S0042698913000217

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Episodic/Focused SOAP Note

Patient Information:

James, an 11-year-old Caucasian male

Subjective

CC: “I have persistent ache on my right ear”

HPI: The patient, an11-year-old Caucasian male presented for assessment with his grandmother after complaints of earache for two days. The patient reported that the pain worsens while falling asleep and he has been having difficulties in hearing. According to the grandmother, the patient feels warm, even though she did not take his temperature. The patient spends most of his time swimming.Health Assessment Essay Paper

Location: Ear

Onset: 2 days ago

Character: Crackling pain, pressure in the ear

Associated signs and symptoms: Difficulties in hearing & fever

Timing: Constant but gets worse at night

Exacerbating/ relieving factors: The pain becomes worse when he sleeps

Severity: 4/10 pain scale

Medications: Not currently taking any medications

Allergies: No known allergy

PMH: All immunizations are up to date; No history of any surgery; No significant sickness

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Family History: No previous history of ear disease in the family; the mother has arthritis; the grandmother has hypertension; father is diabetic

Social history: The patient is a pupil in a public school andis spends summertime with his grandparents. During school, the patient lives with his parents. His hobbies include swimming. The patient does not have any pet

ROS

General: No changes in weight; negative for chills; patient currently having fever

HEENT: No headacheor migraine; No Visual problem; Pain in the ear; mild hearing loss; earache gets worse when sleeping;No runny nose or any other nose problem; No sore throat. Health Assessment Essay Paper

Skin: No itching or itching

Cardiovascular: No murmurs; no palpitations; no Chest Pain

Respiratory: Normal breathing; no wheezing, or cough

Gastrointestinal: No abdominal pain; no vomiting; no nausea

Genitourinary: No pain in the genitals or during urination; no urinary tract infection

Neurological: No Headache, no dizziness;no numbness in theextremities; no seizures

Musculoskeletal: No Muscle pain; no joint stiffness or pain; denies any back pain

Hematologic: No bruising or bleeding

Lymphatics: Normal lymphnodes

Psychiatric: Sleep disturbances; anxious about the earache

Endocrinologic: No thyroid problem; no sweating problems; no cold or heat intolerance

Allergies: No allergies

Objective

Vital Signs: T 100.8, P 94, R 18, BP 98/64

General: The patient is alert/oriented, but seems to be in mild pain as he slightly holds his head to the right side

Vital signs: T 37.8, B/P 98/64; BP 98/64; RR 18; P 68; Weight 40 kgs

HEENT: There is obscuring of the right tympanic membrane;red ear canal is read with musty odor; watery drainage in the ear canal; head normocephalic;no sore throat; no nasal drainage, PEARL

Skin: Good skin turgor; prominent tan; dry & warm

Neck: No lymph nodes or any sign of palpation

Neurological: No complaints about dizziness or headache

Diagnostic results: Low-grade temperature; Slight elevation of white blood cells. Health Assessment Essay Paper

Assessment

Assessment of the ear infection involves obtaining information from the patient and performing a physical assessment. The vital information includes recent travel, family history, trauma, day-to-day activities, and history of previous sicknesses(Dains et al., 2019).

Diagnostic examinations that can be utilized to identify the specific microorganism causing the infection include obtaining the culture of purulent drainage for microbiological culture. Visual inspection of the ear canal is also useful in establishing the physical symptoms. Lastly, a blood test to assess the level of White blood cell count will provide information regarding the overall health of the patient and indicate a possible infection (Dains et al., 2019).

Differential Diagnoses:

Acute Otitis Externa
Acute Otitis Media
Pharyngitis
Primary Diagnoses: Acute otitis externa

Acute otitis externa: This is the most common infection of the external ear canal and it manifests as pain; watery, purulent, thick drained with a musty odor (Demirel et al., 2018). According to Ball et al (2019), acute otitis normally occurs when water remains within the ear after swimming, creating a moist environment for the bacteria or fungi to grow. External otitis can lead to conductive hearing losstemporarily (Wiegand et al., 2019). The patient had been spending a lot of time swimming, reported hearing loss, and there is watery drainage from the ear canal and musty odor and this justifies acute otitis externa as the primary diagnosis for the patient.

Acute Otitis Media: This is among the most common bacterial infection among the pediatric population. symptoms of otitis media among children include ear pain, trouble in sleeping, hearing problems, fever, headache, drainage from the ear, fussiness, loss of balance, feeling of a blockage, crying, and fussiness (Sundvall et al., 2019). Risk factors for otitis media include exposure to tobacco smoke. This diagnosis was ruled out because the patient did not report any feeling of a blockage or irritation.

Pharyngitis: Acute pharyngitis is characterized by a sore throat with an earache, malaise, dysphagia, fever, headache, abdominal pain, and fetid breath (Ball et al, 2019). The diagnosis of pharyngitis was ruled out because the patient did not report any headache, sore throat or abdominal pain.Health Assessment Essay Paper

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.

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.

Demirel, H., Arlı, C., Özgür, T., İnci, M., & Dokuyucu, R. (2018). The Role of Topical

Thymoquinone in the Treatment of Acute Otitis Externa; an Experimental Study in

Rats. Journal of International Advanced Otology, 14(2), 285–289.

Sundvall, P. D., Papachristodoulou, C. E., & Nordeman, L. (2019). Diagnostic methods for acute otitis media in 1 to 12-year-old children: a cross-sectional study in primary health care. BMC family practice, 20(1), 127.

Wiegand, S., Berner, R., Schneider, A., Lundershausen, E., & Dietz, A. (2019). Otitis Externa. Deutsches Arzteblatt international, 116(13), 224–234. https://doi.org/10.3238/arztebl.2019.0224.Health Assessment Essay Paper

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