Case Study For HEENT Focused SOAP Note Assignment
Case Study For HEENT Focused SOAP Note Assignment
Patient Information:
Initials – Kali Age – 44 Sex – Female Race – African American
S.
CC: Proptosis and fatigue
HPI: Kali, a 44-year-old African American female presents in the office for a complete physical examination. She complains of proptosis and feeling fatigued. Her neck appears swollen with a little pain on the swollen part for the last three days. She also has puffy eyes in the periorbital region. She has also complained of constipation for the last three days. The severity of the pain is rated four out of ten. The patient has used laxatives and paracetamol but has achieved minimal relief of her symptoms. Case Study For HEENT Focused SOAP Note Assignment
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Current Medications: Rub Ibuprofen gel on the swollen part of the neck twice a day for three days to relieve pain; Paracetamol 1000mg three times a day for three days; Dulcolax 5mg once daily for three days
Allergies: Sulfa drugs – skin rash and itching; Penicillin – skin rash and itching; dairy products – stomach upset and vomiting; environmental – none
PMHx:
Immunization History:
Covid Vaccine #1 2/6/2021 #2 8/8/2021 Pfizer BioNTech – Comirnaty
Booster shot 16/10/2021 Pfizer BioNTech – Comirnaty
Influenza Vaccination 14/5/2020 Case Study For HEENT Focused SOAP Note Assignment
PNV 26/5/2017
Yellow fever 23/3/2017
DPT 1983
Last tetanus vaccine 2010
Past Medical History (PMH):
1.) Overweight
2.) Anemia
3.) Hyperlipidemia
Past Surgical History (PSH): No past surgical history
Soc Hx: Born of African American parents, second born in a family of two, lived with both parents, holds a bachelor’s degree, married to one partner, works FT as a human resource manager in a food processing company; lives in her home in the city in a serene environment with moderate crime, with good public transportation and she is financially stable. She has a primary care nurse practitioner provider and goes for annual routine care every six months. She has medical insurance. She has a healthy diet and lifestyle. She enjoys dancing and walking. Her family and friends who make a good support system make her satisfied with her life.
Never smoked; denied ETOH or illicit drug use
Fam Hx:
Father – obese, hypertension dx at age 50, died at 56
Mother – hyperthyroidism, dx at age of 25, still alive
Brother – overweight, dx at 44
She has one son and one daughter aged 16, and 14 years respectively. No record of overweight/obese or hyperthyroidism in all the children Case Study For HEENT Focused SOAP Note Assignment.
ROS:
GENERAL: Positive for weight gain, fatigue, swollen neck; no fever, chills.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: no rash or itching.
CARDIOVASCULAR: Negative for chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Positive for constipation; denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Denies change in her urinary pattern, dysuria, or incontinence. Normal urination urgency, hesitancy, odor, and color.
NEUROLOGICAL: Positive for headache, dizziness; denies syncope, paralysis, ataxia, numbness, or tingling in the extremities. Positive for slow bowel movement; no change in bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, positive for cold intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Physical exam:
Vital signs: B/P 132/90, left arm, sitting, regular cuff; P 90 and regular; T 98.8 Orally; RR 12; non-labored; Wt: 159 lbs; Ht: 5’2; BMI 29.2
General: A&O x4, NAD, appears comfortable
HEENT: PERRLA, EOMI, no nystagmus and optical disks sharp, oronasopharynx is clear
Neck: Carotids no bruit, jvd or thyromegaly
Chest/Lungs: Lungs no wheezing, negative for scattered rhonchi
Heart/Peripheral Vascular: RRR without murmur, rub or gallop; pulses +3 bilat pedal and +3 radial
ABD: Nabs x 4, no organomegaly; no suprapubic pain or tenderness Case Study For HEENT Focused SOAP Note Assignment
Diagnostic results:
TSH test – Elevated TSH levels (Duntas & Yen, 2019)
CBC – Leukopenia; Hb – 14.2 g/dl
Lipid profile test – 248 mg/dL
RBS – 7.2 mmol/L (Tvedten, 2022)
Neck MRI scan – No abnormal growth seen
A.
Differential Diagnoses
- Hypothyroidism
- Hyperthyroidism
- Anemia
Primary Diagnoses:
1.) Hypothyroidism
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Differential Diagnoses
The patient presents with swollen neck accompanied with little pain on the swollen part for the last three days. She complains of proptosis and feeling fatigued. Also, she has puffy eyes in the periorbital region. She has also complained of constipation for the last three days. Despite using painkillers and laxatives to increase bowel movement, the outcome has been very minimal. Three different diagnoses that can be considered in this case are hypothyroidism, hyperthyroidism, and anemia (Ball et al., 2019). Swelling in the neck is clinically associated with hyperthyroidism. The patient presented with a swollen neck therefore hyperthyroidism would be considered a possible diagnosis. However, hyperthyroidism is associated with other symptoms such as increased frequency of bowel movements, weight loss, and lid retraction with double vision, which contradicts the symptoms presented by the patient such as reduced frequency of bowel movements, weight gain, and puffiness in the periorbital area with no double vision (LiVolsi & Baloch, 2018; Chiovato et al., 2019). Further, the TSH test results revealed elevated levels of TSH ruling out hyperthyroidism which is associated with lower levels of TSH (LiVolsi & Baloch, 2018). This finally confirms the primary diagnosis of hypothyroidism. For anemia, the CBC results indicate normal levels of hemoglobin and hematocrit therefore anemia is also ruled out (Tvedten, 2022).
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.). Elsevier.
Chiovato, L., Magri, F., & Carlé, A. (2019). Hypothyroidism in context: Where we’ve been and where we’re going. Advances in Therapy, 36(S2), 47-58. https://doi.org/10.1007/s12325-019-01080-8
Duntas, L. H., & Yen, P. M. (2019). Diagnosis and treatment of hypothyroidism in the elderly. Endocrine, 66(1), 63-69. https://doi.org/10.1007/s12020-019-02067-9
LiVolsi, V. A., & Baloch, Z. W. (2018). The pathology of hyperthyroidism. Frontiers in Endocrinology, 9. https://doi.org/10.3389/fendo.2018.00737
Tvedten, H. (2022). Classification and laboratory evaluation of anemia. Schalm’s Veterinary Hematology, 198-208. https://doi.org/10.1002/9781119500537.ch25 Case Study For HEENT Focused SOAP Note Assignment
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| Episodic/Focused SOAP Note Exemplar
Focused SOAP Note for a patient with chest pain S. HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.
Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years
Allergies: PCN-rash; food-none; environmental- none
Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna ROS O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary— Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)Case Study For HEENT Focused SOAP Note Assignment
A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
|
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
- This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
As we move to week 5, we will begin assessment of the Head, Neck, Eyes, Ears, Nose and Throat. It is imperative that we learn proper assessment of these areas to form proper diagnoses.
Your first assignment this week will be a case study. 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. You will need to put in the missing information in the note (some may be made up ie meds, hx, parts of the ROS and PE). I’m looking to make sure you know what information to include. In the Assessment/Plan, you will document your differential diagnoses as per the assignment. Document the assignment on the Episodic/focused SOAP note exemplar located in the Resource list.
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: Case Study For HEENT Focused SOAP Note Assignment
By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment.
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.
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example: Case Study For HEENT Focused SOAP Note Assignment
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis 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.
Example of Complete ROS:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. Case Study For HEENT Focused SOAP Note Assignment
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
*The Assignment 1:
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 (this means diagnoses related to EENT and the patient’s chief complaint)Case Study For HEENT Focused SOAP Note Assignment. You are to remain in the same group as you were previously assigned.
*This paper should include a separate title and reference page.
*CASE STUDY 3: Focused Thyroid Exam (Students in Group C): *Please use the case study below to write this assignment:
*Kali, a 44-year-old female is in the office for a complete physical examination. She complains of proptosis and feeling fatigued. Her TSH levels are elevated, she has hyperlipidemia, her neck appears swollen, and is overweight.
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.
Chapter 11, “Head and Neckâ€
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, “Eyesâ€
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 Throatâ€
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 Case Study For HEENT Focused SOAP Note Assignment.
Chapter 15, “Earacheâ€
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, “Hoarsenessâ€
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 Congestionâ€
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 Eyeâ€
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 Throatâ€
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 Lossâ€
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. Case Study For HEENT Focused SOAP Note Assignment
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). 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.2020.05.019
Mustafa, 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.2020.563627
Patel, 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.2020.01.031
Rubrics:
Rubric Detail:
Name: NURS_6512_Week_5_Assignment_1_Rubric
Excellent Good Fair Poor
Using 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.
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.
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.
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.
0 (0%) – 32 (32%)Case Study For HEENT Focused SOAP Note Assignment
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.
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.
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.
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.
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.
Written 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.
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.
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.
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.
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 punctuation
5 (5%) – 5 (5%) Case Study For HEENT Focused SOAP Note Assignment
Uses correct grammar, spelling, and punctuation with no errors.
4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
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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.
5 (5%) – 5 (5%)
Uses correct APA format with no errors.
4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Total Points: 100 Case Study For HEENT Focused SOAP Note Assignment