Advanced Health Assessment, NURS 6512, Week 5
*Please use the attached "Focused Note Template" for this assignment.
*Please use the following resources for all references/citations, thanks:
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 Exemplar Download Episodic/Focused SOAP Note Exemplar(Word document)
Document: Episodic/Focused SOAP Note Template Download Episodic/Focused SOAP Note Template(Word document)
Document: Midterm Exam Review Download 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 Template Download DCE (Shadow Health) Documentation Template for Focused Exam: Cough (Word document).
***Assessment of head, ears, eyes, nose, and throat exam***
*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.
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.
*For this assignment, there will be information that you will need to"make up" to complete the entire soap note.
*Please use the soap note exemplar example as a guide.
* I think it is important to document a detailed HEENT exam and HEENT ROS for this assignment. Documenting a heart and lung exam on each patient is also important.
*For the Subjective Data (document constitutional/general ROS) on all patients as well as Psych.
*Please use your clinical guide to documentation textbook as a guide as needed for documentation purposes.
Focused Nose Exam: Case #1
A 28-year-old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Her eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and her ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, obstructing airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.
Thank you, Peter!
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