CASE STUDY three: Focused Ear Exam
Martha brings her 11-year previous grandson, James, to your clinic to have his proper ear checked. He has complained to her a few gentle earache for the previous 2 days. His grandmother believes that he feels heat however didn’t confirm this with a thermometer. James states that the ache was worse whereas he was falling asleep and that it was more durable for him to listen to. Whenever you start fundamental assessments, you discover that James has a distinguished tan. Whenever you ask him how he is been spending his summer season, James responds that he is been spending plenty of time within the pool.
Assignment 1: Case Research Assignment: Assessing the Head, Eyes, Ears, Nostril, and Throat
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Most ear, nostril, and throat situations that come up in non-critical care settings are minor in nature. Nonetheless, delicate signs can generally escalate into life-threatening situations that require immediate Assessment and remedy.
Nurses conducting assessments of the ears, nostril, and throat should have the ability to determine the small variations between life-threatening situations and benign ones. For example, if a affected person with a sore throat and a runny nostril additionally has infected lymph nodes, the irritation might be because of the pathogen inflicting the sore throat quite than a case of throat most cancers. With this information and a enough affected person well being historical past, a nurse wouldn’t have to escalate the Assessment to a biopsy or an MRI of the lymph nodes however would in all probability carry out a easy strep check.
On this Case Research Assignment, you think about case research of irregular findings from sufferers in a medical setting. You establish what historical past ought to be collected from the sufferers, what bodily exams and diagnostic assessments ought to be carried out, and formulate a differential analysis with a number of attainable situations.
To Put together
By Day 1 of this week, you may be assigned to a particular case research for this Case Research Assignment. Please see the “Course Bulletins” part of the classroom on your assignment out of your Teacher.
Additionally, your Case Research Assignment ought to be within the Episodic/Focused SOAP Be aware format quite than the standard narrative fashion format. Confer with Chapter 2 of the Sullivan textual content and the Episodic/Focused SOAP Template within the Week 5 Studying Assets for steerage. Do not forget that all Episodic/Focused SOAP Notes have particular knowledge included in each affected person case.
With regard to the case research you had been assigned:
Assessment this week’s Studying Assets and think about the insights they supply.
Think about what historical past can be vital to gather from the affected person.
Think about what bodily exams and diagnostic assessments can be acceptable to collect extra details about the affected person’s situation. How would the outcomes be used to make a analysis?
Determine at the very least 5 attainable situations which may be thought-about in a differential analysis for the affected person.
The Assignment
Use the Episodic/Focused SOAP Template and create an episodic/centered be aware concerning the affected person within the case research to which you had been assigned utilizing the episodic/centered be aware template offered within the Week 5 assets. Present proof from the literature to help diagnostic assessments that might be acceptable for every case. Record 5 completely different attainable situations for the affected person’s differential analysis and justify why you chose every.
Rubric
Grid View
Record View
ExcellentGoodFairPoorUsing the Episodic/Focused SOAP Template:
· Create documentation or an episodic/centered be aware in SOAP format concerning the affected person within the case research to which you had been assigned.
· Present proof from the literature to help diagnostic assessments that might be acceptable on your case.45 (45%) – 50 (50%)The response clearly, precisely, and totally follows the SOAP format to doc the affected person within the assigned case research. The response totally and precisely supplies detailed proof from the literature to help diagnostic assessments that might be acceptable for the affected person within the assigned case research.39 (39%) – 44 (44%)The response precisely follows the SOAP format to doc the affected person within the assigned case research. The response precisely supplies detailed proof from the literature to help diagnostic assessments that might be acceptable for the affected person within the assigned case research.33 (33%) – 38 (38%)The response follows the SOAP format to doc the affected person within the assigned case research, with some vagueness and inaccuracy. The response supplies proof from the literature to help diagnostic assessments that might be acceptable for the affected person within the assigned case research, with some vagueness or inaccuracy within the proof chosen.zero (zero%) – 32 (32%)The response incompletely and inaccurately follows the SOAP format to doc the affected person within the assigned case research. The response supplies incomplete, inaccurate, and/or lacking proof from the literature to help diagnostic assessments that might be acceptable for the affected person within the assigned case research.· Record 5 completely different attainable situations for the affected person’s differential analysis, and justify why you chose every.30 (30%) – 35 (35%)The response lists 5 distinctly completely different and detailed attainable situations for a differential analysis of the affected person within the assigned case research, and supplies an intensive, correct, and detailed justification for every of the 5 situations chosen.24 (24%) – 29 (29%)The response lists 4 or 5 completely different attainable situations for a differential analysis of the affected person within the assigned case research and supplies an correct justification for every of the 5 situations chosen.18 (18%) – 23 (23%)The response lists three to 5 attainable situations for a differential analysis of the affected person within the assigned case research, with some vagueness and/or inaccuracy within the situations and/or justification for every.zero (zero%) – 17 (17%)The response lists two or fewer, or is lacking, attainable situations for a differential analysis of the affected person within the assigned case research, with inaccurate or lacking justification for every situation chosen.Written Expression and Formatting – Paragraph Growth and Group:
Paragraphs clarify factors that help well-developed concepts, stream logically, and reveal continuity of concepts. Sentences are fastidiously focused–neither lengthy and rambling nor brief and missing substance. A transparent and complete function assertion and introduction are offered that delineate all required standards.5 (5%) – 5 (5%)Paragraphs and sentences observe writing requirements for stream, continuity, and readability. A transparent and complete function assertion, introduction, and conclusion are offered that delineate all required standards.four (four%) – four (four%)Paragraphs and sentences observe writing requirements for stream, continuity, and readability 80% of the time. Function, introduction, and conclusion of the assignment are acknowledged, but are transient and never descriptive.three (three%) – three (three%)Paragraphs and sentences observe writing requirements for stream, continuity, and readability 60%–79% of the time. Function, introduction, and conclusion of the assignment are obscure or off matter.zero (zero%) – 2 (2%)Paragraphs and sentences observe writing requirements for stream, continuity, and readability < 60% of the time. No function assertion, introduction, or conclusion had been offered.Written Expression and Formatting – English writing requirements:
Appropriate grammar, mechanics, and correct punctuation5 (5%) – 5 (5%)Makes use of appropriate grammar, spelling, and punctuation with no errors.four (four%) – four (four%)Accommodates a couple of (1 or 2) grammar, spelling, and punctuation errors.three (three%) – three (three%)Accommodates a number of (three or four) grammar, spelling, and punctuation errors.zero (zero%) – 2 (2%)Accommodates many (≥ 5) grammar, spelling, and punctuation errors that intervene with the reader’s understanding.Written Expression and Formatting – The paper follows appropriate APA format for title web page, headings, font, spacing, margins, indentations, web page numbers, working heads, parenthetical/in-text citations, and reference checklist.5 (5%) – 5 (5%)Makes use of appropriate APA format with no errors.four (four%) – four (four%)Accommodates a couple of (1 or 2) APA format errors.three (three%) – three (three%)Accommodates a number of (three or four) APA format errors.zero (zero%) – 2 (2%)Accommodates many (≥ 5) APA format errors.Whole Factors: 100ReplyForward
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