Case Study Assignment: Assessing the Head Eyes Ears Nose and Throat.

Case Study Assignment: Assessing the Head Eyes Ears Nose and Throat.

Case Study Assignment: Assessing the Head Eyes Ears Nose and Throat.

Assignment 1: Case Study Assignment:
Assessing the Head, Eyes, Ears, Nose, and
Throat

Photo Credit: Getty Images/Blend Images
Most 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.
Nurses 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 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.
By Day 6 of Week 5
Submit your Assignment.

Submission and Grading Information
To 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.
 Click 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.
Grading Criteria

To access your rubric:
Week 5 Assignment 1 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:
Submit your Week 5 Assignment 1 draft and review the originality report.

Submit Your Assignment by Day 6 of Week 5

To participate in this Assignment:
Week 5 Assignment 1

Learning Resources

Required 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.

 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”
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.

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., 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.

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). 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/S0042698913000217

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/S0042698913000436

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).

Document: 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 Resources

Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY

Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us

Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)

Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to Walden
University’s Code of Conduct.

Document: DCE (Shadow Health) Documentation Template for Focused Exam:
Cough (Word document)
Use this template to complete your Assignment 2 for this week.

Optional Resource
Use 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. (2014). DeGowin’s diagnostic
examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 7, “The Head and Neck” (pp. 178–301)

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)

Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 (29m)
Online media for Seidel's Guide to Physical Examination
It is highly recommended that you access and view the resources included with the course
text, Seidel's Guide to Physical Examination. Focus on the videos and animations in
Chapters 10, 11, and 12 that relate to the assessment of the head, neck, eyes, ears, nose,
and throat. Refer to the Week 4 Learning Resources area for access instructions on
https://evolve.elsevier.com/.

University of Iowa Ophthalmology. (2016, December 19). Fluorescein staining of
the cornea. Retrieved from https://vimeo.com/198695974
Credit Line: University of Iowa Ophthalmology. (n.d.). Fluorescein staining of the
cornea [Video file]. Retrieved from ​https://vimeo.com/198695974. The author(s)
and publishers acknowledge the University of Iowa and EyeRounds.org for
permission to reproduce this copyrighted material.

Note: Approximate length of this media program is 25 seconds.