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NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat

NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatAssignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and ThroatEmily, age 15, is brought to your clinic complaining of chills, aches, and a sore throat. Without any testing, consider all of the possible diagnoses. It could be a cold, the flu, bronchitis, or even something more serious, such as meningitis or mononucleosis. Assessing the actual cause will involve much more than simple visual inspection. Some conditions are so subtle that they require the use of special instruments and tests in addition to a trained eye and ear.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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatLearning ObjectivesStudents will:Apply assessment skills to diagnose eye, ear, and throat conditionsApply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throatLearning ResourcesRequired Readings (click to expand/reduce)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.ORDER A PLAGIARISM-FREE PAPER HEREChapter 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatChapter 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”NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatIn 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat, 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.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)NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat. 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.2020.05.019Mustafa, 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.2020.563627Patel, 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.2020.01.031Document: Episodic/Focused SOAP Note Exemplar (Word document)Document: Episodic/Focused SOAP Note Template (Word document)Document: Midterm Exam Review (Word document)Shadow Health Support and Orientation ResourcesShadow Health. (2021). Welcome to your introduction to Shadow Health. https://link.shadowhealth.com/Student-Orientation-VideoShadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-usShadow Health. (2021)NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat. Walden University quick start guide: NURS 6512 NP students. https://link.shadowhealth.com/Walden-NURS-6512-Student-GuideDocument: DCE (Shadow Health) Documentation Template for Focused Exam: Cough (Word document)Use this template to complete your Assignment 2 for this week.Optional ResourceUse the following resources to guide you through your Shadow Health orientation as well as other support resources:LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.Chapter 7, “The Head and Neck”This chapter describes head and neck examinations that can be made with general clinical resources. Also, the authors detail syndromes of common head and neck conditions.Required Media (click to expand/reduce)Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and ThroatPhoto Credit: Getty Images/Blend ImagesMost ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatNurses 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 PrepareNURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatBy 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatThe AssignmentUse 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 5Submit your Assignment.Submission and Grading InformationTo 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatClick 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. Rubric Detail Select Grid View or List View to change the rubric’s layout.ContentName: NURS_6512_Week_5_Assignment_1_RubricNURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatGrid ViewList ViewExcellentGoodFairPoorUsing 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.Points Range: 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatNURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 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.Points Range: 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 0 (0%) – 32 (32%)The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 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.Points Range: 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.Points Range: 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.Points Range: 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatWritten 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 5 (5%) – 5 (5%)Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 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.Points Range: 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 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 punctuationPoints Range: 5 (5%) – 5 (5%)Uses correct grammar, spelling, and punctuation with no errors.Points Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) grammar, spelling, and punctuation errors.Points Range: 3 (3%) – 3 (3%)Contains several (3 or 4) grammar, spelling, and punctuation errors.Points Range: 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 5 (5%) – 5 (5%)Uses correct APA format with no errors.Points Range: 4 (4%) – 4 (4%)Contains a few (1 or 2) APA format errors.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 3 (3%) – 3 (3%)Contains several (3 or 4) APA format errors.Points Range: 0 (0%) – 2 (2%)Contains many (≥ 5) APA format errors. Total Points: 100Name: NURS_6512_Week_5_Assignment_1_RubricHypothyroidism SOAP NoteHypothyroidism SOAP NotePatient Information:Mr. Kali, 44-year-old female, African -AmericanSubjective Data.CC: Protrusion of the eyeballs and feeling fatigued.HPI: A 44-year-old African American female comes to the medical clinic for a complete physical examination. She complains of proptosis and feeling fatigued with a report of a swollen neck that appeared worse for the past one week. He complains that the symptoms have worsened for one week before the current visit. The client complains of loss of appetite, feeling of tiredness on most occasions, muscle weakness, and an increased feeling of coldness. The feeling of throat fullness is also more while swallowing food. Her neck appears swollen and is overweight. There is mild to moderate pain in the neck, 4/10 on the pain scale.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatCurrent Medications: The client is on atorvastatin 20mg orally once per day as an anti-hyperlipidemia agent. The over-the-counter medication is ibuprofen 400 mg three times per day via oral route to relieve pain.Allergies: No known allergies to food or medicationsPMH: Covid-19 vaccine eight months ago, tetanus vaccine one year ago due to leg trauma. Hospital admission five years ago due to pneumonia. Minor leg surgery due to penetrating trauma.Soc Hx: He is a university graduate and a cafeteria manager in the local town. He abuses alcohol and cigarettes on daily basis. Married and has two children. The husband  is a manager in one of the local companies. He is outgoing and usually interacts with his relatives on the weekends.Family History: Father and mother have hypertension which is manageable. Mother has asthma, obesity and liver disease. The sister has gastric ulcers, and she is on medications. The children have no impending condition.Review of Systems.GENERAL: Reports general body weakness, fatigue and some chills.HEENT:  Denies itching or excessive tearing in the eyes. Report no ear pain, no discharge, good hearing. Protrusion of bilateral eyeballs noted. Reports no nose bleeding, report some difficulty in swallowing with a swollen neck.CARDIOVASCULAR: Denies palpitations or chest congestion.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat RESPIRATORY:  Denies any sneezing or difficulties in breathing.GASTROINTESTINAL:  Denies loss of appetite, stomach pains, mild moderate or severe nausea and vomiting.NEUROLOGICAL: Denies dizziness and headachesMUSCULOSKELETAL:  Reports muscle pain and fatigued.  Denies abnormal movements and paint in the joints.SKIN:  Reports no skin lesions or itchingGENITOURINARY:  Denies itching, pain, or burning sensationALLERGIES: Denies hypersensitivity to certain foods and drugs.HEMATOLOGIC:  Reports no easy bruises nor frequent nose bleedingLYMPHATICS:  Denies gland and lymph nodes swelling.PSYCHIATRIC: Denies sleeping difficulties, anxiety and suicidal thoughts.ENDOCRINOLOGIC:  Denies neither feeling thirsty nor sweating at nightObjective Data.Weight: 77 kgsTemperature: 37 degree CelsiusBP: 122/80mm HgPulse: 70b/mRR: 19 breaths/minPhysical ExamGENERAL APPEARANCE: An obese woman with average body height and oriented to time, place and person.HEENT: Protruding eyeballs, no ear discharge, no nasal discharge or lesions. On swallowing, there is swelling in the thyroid gland.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatNECK: normal range of motion, masses detected and swelling of the thyroid gland.RESPIRATORY: Symmetric movement of the chest and diaphragm during breathing.CARDIOVASCULAR: Present heart sounds S1 and S2 (DeLaune et al., 2019)BREAST; No breast mass or lump.PERIPHERAL VASCULAR: Has peripheral pulses, no tissue swelling of the extremities.NEUROLOGIC:  No confusion, normal body movement.MUSCULOSKELETAL: The upper and lower extremities allow normal movementGI: Bowel sounds are heard, no tenderness, liver is palpable.GU:  No swelling or tendernessSKIN: dry skin with no physical lesions.PSYCHIATRIC: Oriented to time, place and person. Glasgow Coma Scale of 15/15 Assessment.Diagnostic TestsUltrasound of the Neck- to determine the state of the thyroid gland and development of goiter.Thyroid function tests- to determine TSH levels, thyroxine and triiodothyronine.X-ray of the neck region to determine extra tissue or presence of other conditions like malignancy or benign tissues.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatDiagnosisHypothyroidismIt is the hypo functioning of the thyroid gland. The condition occurs due to fewer amounts of thyroid hormones. The thyroid-stimulating hormone levels increase to stimulate the thyroid gland (Hinkle & Cheever, 2018). The client usually presents with fatigue, excessive weight gain, muscle weakness, protruding eyeballs and more sensitivity to cold. The causes can be autoimmune like the presence of Hashimoto thyroiditis, thyroid surgery, pituitary gland disorders and radiation therapy.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatDifferential Diagnoses.Thyroid AdenomaIt is the excessive growth of the thyroid tissues. The tissues can produce thyroid hormones or fail to produce the hormones (Hall & Hall, 2020). The growth is usually non-cancerous. It can present with general body weakness, swelling of the neck, weight loss and heat sensitivity.Thyroid CancerThe condition entails malignancy growth of the butterfly-shaped thyroid gland’s tissues. It presents with a lump in the neck, pain in the front region, difficulty in swallowing, and general body weakness (Hall & Hall, 2020). It can arise from the thyroid gland or metastasis to other body parts.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatHyperthyroidismIt is the hyperfunctioning of the thyroid gland due to the overproduction of the thyroxine hormone. The symptoms are swelling of the neck, fatigue, weight loss, muscle weakness and high heart rate (Hinkle & Cheever, 2018). The common causes can be thyroiditis, Graves’ disease and multinodular adenomaThyroiditisIt is an inflammation of the thyroid gland. The inflammation can cause over or underproduction of the thyroid hormones. It can occur due to bacterial or viral infection, radiation, autoimmune, and medications (Hall & Hall, 2020). The condition presents with symptoms of hyperthyroidism like fatigue or hypothyroidism symptoms like excessive weight gain.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatGraves’ diseaseIt is an autoimmune disorder of the thyroid gland. It leads to the production of excess thyroid hormones. The common symptom is an enlargement of the thyroid gland, which presents as neck swelling (Hinkle & Cheever, 2018). The disease presents with weight loss which is a differentiating factor to hypothyroidism.Medications and EducationLevothyroxine- The start dose is 50mcg per day, and a maintenance dose of 75mcg per day (Hennessey & Espaillat, 2018).Atorvastatin- 20mg once per day via the oral routeLevothyroxine causes diarrhea and reduces appetite, anxiety, and alteration in sleeping patterns. It can cause seizures, heart failure, and arrhythmias in rare reactionsEvaluation– follow-up after one month to repeat the thyroid function tests and lipid profile test.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat ReferencesDeLaune, S. C., McTier, L., Tollefson, J., Lawrence, J., & Ladner, P. K. (2019). Fundamentals of Nursing: Australia & NZ Edition 2e. Cengage AU. https://books.google.com/books?hl=en&lr=&id=RFnYDwAAQBAJ&oi=fnd&pg=PR1&dq=fundamentals+of+nursing+textbook+2019&ots=QS_AgiPfZ6&sig=8BzFFSYcY1P4D16gS8sSC4OU5ZQHall, J. E., & Hall, M. E. (2020). Guyton and Hall textbook of medical physiology e-Book. Elsevier Health Sciences. https://books.google.com/books?hl=en&lr=&id=H1rrDwAAQBAJ&oi=fnd&pg=PP1&dq=medical+physiology+textbook+2019&ots=tJ-CA3AwXs&sig=uonB7xQgdS4FUJOh-_oyWPm3OPUHennessey, J. V., & Espaillat, R. (2018). Current evidence for treating hypothyroidism with levothyroxine/levotriiodothyronine combination therapy versus levothyroxine monotherapy. International journal of clinical practice, 72(2), e13062. https://onlinelibrary.wiley.com/doi/abs/10.1111/ijcp.13062Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd. https://books.google.com/books?hl=en&lr=&id=yS7vDwAAQBAJ&oi=fnd&pg=PR1&dq=medical+surgical+nursing+textbook+2018&ots=RxbvyWmARW&sig=RidkE7n8TSUCYHbxBJp2v6ZVQIQAssignment 2: Digital Clinical Experience: Focused Exam: CoughIn this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPhoto Credit: Getty ImagesTo PrepareReview this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatConsider 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?Focused Exam: Cough Assignment:Complete the following in Shadow Health:Respiratory Concept Lab (Required)Episodic/Focused Note for Focused Exam: CoughHEENT (Recommended but not required)Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline. Rubric Detail Select Grid View or List View to change the rubric’s layout.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatContentName: NURS_6512_Week_5_DCE_Assignment_2_RubricDescription: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatGrid ViewList ViewExcellentGoodFairPoorStudent DCE score(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)Note: DCE Score – Do not round up on the DCE score.Points Range: 56 (56%) – 60 (60%)DCE score>93Points Range: 51 (51%) – 55 (55%)DCE Score 86-92Points Range: 46 (46%) – 50 (50%)DCE Score 80-85Points Range: 0 (0%) – 45 (45%)DCE Score <79No DCE completed.Subjective Documentation in Provider NotesSubjective narrative documentation in Provider Notes is detailed and organized and includes:Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)ROS: covers all body systems that may help you formulate a list of differential diagnoses. 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.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 16 (16%) – 20 (20%)Documentation is detailed and organized with all pertinent information noted in professional language.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatDocumentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 11 (11%) – 15 (15%)Documentation with sufficient details, some organization and some pertinent information noted in professional language.Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 6 (6%) – 10 (10%)Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatLimited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 0 (0%) – 5 (5%)Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).orNo documentation provided.Objective Documentation in Provider Notes – this is to be completed in Shadow HealthPhysical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.You only need to examine the systems that are pertinent to the CC, HPI, and History.Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentionedDifferential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).Points Range: 16 (16%) – 20 (20%)Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.Each system assessed is clearly documented with measurable details of the exam.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatNURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 11 (11%) – 15 (15%)Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.Each system assessed is somewhat clearly documented with measurable details of the exam.Points Range: 6 (6%) – 10 (10%)Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.Each system assessed is minimally or is not clearly documented with measurable details of the exam.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatPoints Range: 0 (0%) – 5 (5%)Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.None of the systems are assessed, no documentation of details of the exam.orNo documentation provided.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat Total Points: 100Name: NURS_6512_Week_5_DCE_Assignment_2_RubricDescription: To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatName:Section: Week 5                Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation SUBJECTIVE DATA: Chief Complaint (CC): Reports cough, runny nose, sore throat, and right ear pain.History of Present Illness (HPI): Reports cough started 5 days ago with coughing every few minutes. Reports cough is wet and clear sputum and worse at night. A runny nose is frequent with clear thin discharge. Pain in the right ear is 3/10 that started after the cough with nasal discharge from the ear. Throat has now become sore with mild pain when swallowing.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatMedications: Patient denies daily prescriptions. He takes daily OTC multivitamin. Today his mother gave him a cough medication that temporarily relieved the symptoms he was experiencing.Allergies: No known allergies to food, medication, or latex.Past Medical History (PMH): History of pneumonia and frequent coughing.Past Surgical History (PSH): No surgical history.Sexual/Reproductive History: No sexual history.Personal/Social History: Patient lives in a home with mother, father, and grandparents. His father is a cigar smoker, and the patient is exposed to secondhand smoke at times. Reports feeling safe at home.Immunization History: Childhood vaccinations are up to date.Significant Family History: The mother reports her health is good with no significant concerns. The father smokes tobacco and is moderately overweight and being monitored for prediabetes. The patient’s grandmother has hypertension. The grandfather has type 2 diabetes controlled with oral medications and diet. NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatReview of Systems:  General: Denies fever, chills, or recent weight loss.                HEENT: Patient denies pain in his head. Patient denies vision changes or eye complaints bilaterally with no report of eye pain, redness, or eye drainage. Patient report right ear pain 3/10. No left ear complains. History of frequent ear infections noted but without the need for ear tubes or surgical intervention. Patient denies hearing changes. Patient reports thin clear nasal drainage without congestion. No epistaxis was reported. Patient reports throat to be soar and experiencing minor pain with swallowing.                Respiratory: Denies difficulty breathing. Denies history of asthma. Productive cough with clear wet sputum x 5days reported.                Cardiovascular/Peripheral Vascular: No chest pain or cardiac history. Denies heart palpitations or abnormal activity intolerance. Patient denies swelling in extremities.                NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat                Psychiatric: No pertinent psychiatric complaints or history.                Neurological: No complaints of headache, dizziness, or seizures.                Lymphatics: Patient denies painful or tender lymph nodes.                OBJECTIVE DATA                 Physical Exam:Vital signs: Blood pressure: 120/76, O2 Sat 96, Pulse 100, Resp. Rate 28 Temp 37.2, Height 50 inches, Weight 68 lbs, BMI 19.1General: Patient is alert and oriented x 4. Appearance of appropriate hygiene, and grooming noted. Gait is steady. Patient is calm and cooperative during assessment.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatHEENT:Head: Symmetrical and normocephalic, atraumatic Eyes: Conjunctiva moist and pink, sclera is white with no conjunctival discharge noted bilaterally. No abnormal findings noted in orbital area.Ears: Right auditory canal and tympanic membrane erythemic with intact membrane, con of light at 5:00 , and no discharge. Left auditory canal is pink and tympanic membrane is pearly gray and intact with con of light at 7:00 and no discharge.Nose: Nasal mucosa pink and moist with patent turbinates bilaterally. Clear nasal discharge noted.Throat: Oral mucosa moist and pink, posterior oropharynx erythemic with cobblestoning noted, no postnasal drip present. Tonsils has mild erythema. Respiratory: Chest symmetric with abnormal visible findings. Respirations unlabored. Breath sounds audible and clear in all areas with no adventitious sounds. Negative bronchophony. Fremitus present and equal bilaterally. No shortness of breath or use of accessory muscles with respirations. Percussion of chest revealed; all areas were resonant without dullness.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatCardiology: Hear sounds S1 and S2 audible with regular rate and rhythm. No murmurs, gallops or rubs. Peripheral pulses present and equal bilaterally. Extremities are perfused adequately with capillary refill of < 2 seconds and no cyanosis and edema. Lymphatics: Palpable cervical nodes on the right side, not on the left. No palpable nodes in the axillary region. No palpable nodes in the supraventricular region. No tenderness or pain in the examination.Psychiatric: No emotional concerns observed. Diagnostics/Labs: Chest X-Ray to rule out pneumonia, Covid swab to rule out Covid.ASSESSMENT: Diagnosis: Upper respiratory infection: URI common include symptoms of cough, sore throat, and runny nose, which is sufficiently diagnosed through assessment of these common symptoms, especially when more serious respiratory illness is absent such as color phlegm, difficulty breathing, fever, or chest congestion.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and ThroatDifferential diagnoses:Pharyngitis: Upper respiratory infections often involve the pharynx and cause irritations and inflammation of the pharynx. This is possible diagnoses due to the slight sore throat and redness, and cobblestoning noted on assessment. Allergic rhinitis: The reports of cough and runny nose with clear sputum coupled with red cobblestoningthroat, an abnormal assessment of finding with polygonal cells protrude from mucosal surfaces, could indicate allergic rhinitis due to various allergens.Covid: In the state of Covid pandemic, testing for Covid in light of minimal symptoms may be prudent to prevent the spread of the illness. While Covid cases report a wide range of clinical symptoms including cough, runny nose, and sore throat, they are often reported and common even in the absence of lung congestion, fever, or discomfort.NURS 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat    

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