Case Study For Patient With Painful Swallowing

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 Case Study For Patient With Painful Swallowing.

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.

Assignment 1

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 (this means diagnoses related to EENT and the patient’s chief complaint)Case Study For Patient With Painful Swallowing.

You are to remain in the same group as you were previous assigned. This paper should include a separate title and reference page using APA format.
Jason, a 13 year old male comes in with Mom complaining of painful swallowing. Started yesterday as a “really bad sore throat” made worse with swallowing. He reports feeling very tired. His Mom gave him over-the-counter Children’s Motrin which made his fever better but did not help sore throat. He reports his symptoms are especially, worse during nighttime. His tonsils are 2+ and erythematous, tonsil stones are present on the right side. He has white patches on his tongue.

Subjective Data

Chief Complain: Painful swallowing

History of Presenting Illness

The patient is a 3-year-old male who reports painful swallowing that started yesterday as an awful sore throat and was aggravated with swallowing. The patient’s tonsils are 2+ and erythematous, and tonsil stones were noted on the right side. The tongue has white patches. The patient also states to be very tired. The symptoms aggravate at night, and despite the administration of children’s Motrin, only the fever was calmed but did not calm the sore throat.

Medications:

Motrin 100mg to relieve the inflammation and fever

Past Medical History

Positive history of aspiration pneumonia managed at six years.

Family History: The mother is asthmatic, and the father has a history of hypertension.

Social History: No history of alcohol or cigarette smoking

Allergies: No history of medicinal, environmental and food allergies

Immunizations: Up to date with immunizations Case Study For Patient With Painful Swallowing

Review of Systems

General Examination: Body fatigue and fever

Cardiovascular system: Negative for upper and lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnoea. The patient denies chest pain or palpitations.

Pulmonary system: Negative for hemoptysis, intermittent dyspnea on exertion, cough, sputum, and shortness of breath

Gastrointestinal system: Tonsils 2+, positive tonsil stones, white patches on the tongue. Denies anorexia, abdomen pain, nausea or vomiting and diarrhoea.

Lymphatics: Enlarged tonsils and cervical lymph nodes.

ORDER HERE

Objective Data

Blood Pressure: 109/76

Respiratory Rate: 15

Pulse Rate: 92 bpm

Temperature: 100.5 F

Weight: 107 lbs

Height: 62.3”

General: The patient appears weak and shaky

Cardiovascular: PMI at 4^th intercostal space at the left midclavicular line. No clubbing or cyanosis, and negative for edema.

Pulmonary: Clear to bilateral percussion and auscultation

Gastrointestinal: Normal quality and intensity of bowel sounds, Symmetrical and non-distended abdomen, no mass noted on palpation

Diagnostic Results

Reactive on the rapid strep test. Tonsilitis is diagnosed by observing the tonsil grade, pain in swallowing, and evidence of erythematous tonsil. The rapid strep test increases the molecular test sensitivity and specificity in the molecular tests. Besides, culture and sensitivity can take several days as opposed to the rapid test, which takes several minutes to identify the bacterial.     Weinzierl et al. (2018) advocated for a rapid antigen Group A streptococcus test kit for quick identification and treatment Case Study For Patient With Painful Swallowing

Assessment

Differential Diagnosis

1. Tonsilitis (Tonsilitis is diagnosed from enlarged lymph nodes (2+), erythematous tonsils, white patches on the tonsil, sore throat, painful swallowing and fever (Weinzierl et al., 2018)
2. Epstein Barr Virus (The patient was marked with fatigue, fever, swollen tonsils and lymph nodes and sore throat. However, mononucleosis from Epstein Barr Virus does not recover on antibiotic administration (Wilson & Wilson, 2021))

• Scarlet Fever (The patient had a fever associated with a sore throat and exhibited body malaise associated with Scarlet Fever. However, Scarlet fever is marked by a characteristic Scarlet spots, an initial sign of rash (Wilson & Wilson, 2021).

1. Peritonsillar Abscess (The patient reported painful swallowing, enlarged tonsils, fever and chills, which are characteristic of peritonsillar abscess (Galioto, 2017)
2. Tonsil cancer (The evidence of painful swallowing, chewing and speaking, sore throat that is not relieved. Tonsil cancer can lead to one enlarged tonsil or blood in saliva (Adil et al., 2018))Case Study For Patient With Painful Swallowing

Primary or Presumptive Diagnosis: Tonsilitis

References

Adil, E. A., Medina, G., & Cunningham, M. J. (2018). Pediatric tonsil cancer: a national and institutional perspective. The Journal of pediatrics, 197, 255-261. https://doi.org/10.1016/j.jpeds.2018.01.022

Galioto, N. J. (2017). Peritonsillar abscess. American family physician, 95(8), 501-506. https://www.aafp.org/pubs/afp/issues/2017/0415/p501.html

Weinzierl, E. P., Jerris, R. C., Gonzalez, M. D., Piccini, J. A., & Rogers, B. B. (2018). Comparison of Alere i Strep A rapid molecular assay with rapid antigen testing and culture in a pediatric outpatient setting. American Journal of Clinical Pathology, 150(3), 235-239. https://doi.org/10.1093/ajcp/aqy038

Wilson, M., & Wilson, P. J. (2021). Sore Throat. In Close Encounters of the Microbial Kind (pp. 197-212). Springer, Cham. https://doi.org/10.1007/978-3-030-56978-5_13

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 Patient With Painful Swallowing

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. Case Study For Patient With Painful Swallowing

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.

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)Case Study For Patient With Painful Swallowing

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.

ORDER TODAY

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 7^th edition formatting Case Study For Patient With Painful Swallowing