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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.

USW1.575.202130 – NURS-6512C-1/NURS-6512D-1/NURS-6512N-1-Advanced Health Assessment2020 Winter Qtr 11/30-02/21-PT27

SafeAssign Drafts

Monica Castelao
on Wed, Jan 06 2021, 3:32 AM

68% highest match

Submission ID: bb56b440-40e4-4e90-8c80-18bff0b840f6

Week5Castelao.M.extention x

Word Count: 907

Attachment ID: 3891174207

68%

Citations (19/19)

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Another student’s paper

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https://besthomeworkhelp.org/assessing-neurological-symptoms/

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Another student’s paper

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Another student’s paper

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Another student’s paper

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Another student’s paper

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Another student’s paper

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Another student’s paper

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Running head: FOCUSED EAR EXAMINATION 1
FOCUSED EAR EXAMINATION 5
Focused Ear Examination Monica Castelao Walden University

1
Focused Ear Examination

Suspected Entry: 63% match

Uploaded – Week5Castelao.M.extention x
Focused Ear Examination

Source – Another student’s paper
Focused Ear Exam

Patient Information:

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JK is an 11 year old male African American

Suspected Entry: 65% match

Uploaded – Week5Castelao.M.extention x
JK is an 11 year old male African American

Source – Another student’s paper
The patient is an 11-year-old African American male brought into the clinic by his grandmother

S

3
Chief Complaint (CC):

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
Chief Complaint (CC)

Source – Another student’s paper
CC (chief complaint)

4
I have had a mild earache for the past 2 days

Suspected Entry: 68% match

Uploaded – Week5Castelao.M.extention x
I have had a mild earache for the past 2 days

Source – Another student’s paper
“Mild earache for the past two days”

HPI:
Location: Right ear
Onset:

3
2 days ago

Suspected Entry: 99% match

Uploaded – Week5Castelao.M.extention x
2 days ago

Source – Another student’s paper
2 days ago

Character: Aching

3
Associated signs and symptoms:

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
Associated signs and symptoms

Source – Another student’s paper
Associated signs and symptoms

5
Pain when falling asleep and hearing difficulty.

Suspected Entry: 89% match

Uploaded – Week5Castelao.M.extention x
Pain when falling asleep and hearing difficulty

Source – Another student’s paper
difficulty hearing, pain worsen when falling asleep

Timing:

5
Troubling all the time

Suspected Entry: 64% match

Uploaded – Week5Castelao.M.extention x
Troubling all the time

Source – Another student’s paper
all the time

6
Exacerbating/ relieving factors:

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
Exacerbating/ relieving factors

Source – Another student’s paper
Exacerbating/ relieving factors

Going to sleep worsens the situation. Paracetamol relieves the pain.
Severity:

1
5/10 pain scale

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
5/10 pain scale

Source – Another student’s paper
5/10 pain scale

Current Medication:

7
Over the counter paracetamol 200 mg, 1 tablet after every 8 hours for pain relief.

Suspected Entry: 67% match

Uploaded – Week5Castelao.M.extention x
Over the counter paracetamol 200 mg, 1 tablet after every 8 hours for pain relief

Source – Another student’s paper
Ibuprofen 200 mg, 1 tablet every 8 hours

Allergies: None
PMHx: All immunizations up-to-date, including recent tetanus and influenza shots received in November 2020.

5
No previous hospitalizations except at birth, which was uneventful.

Suspected Entry: 63% match

Uploaded – Week5Castelao.M.extention x
No previous hospitalizations except at birth, which was uneventful

Source – Another student’s paper
no previous hospitalizations except for birth (no complications)

No surgeries.
Soc Hx: Lives with grandmother alongside his brother after the loss of his parents in 2017 due to car accident. The grandmother is a retired k-12 teacher. He enjoys swimming and outdoor games. He is not exposed to secondhand cigarette smoke. The grandmother quit drinking alcohol in 2016 after a long history of alcoholism. James usually wears seat belt and does not need booster seat when travelling. He only uses the back seat of a car when travelling in their family car. The grandmother does not use text or mobile phone while driving.

8
The family has working smoke and carbon dioxide detectors.

Suspected Entry: 62% match

Uploaded – Week5Castelao.M.extention x
The family has working smoke and carbon dioxide detectors

Source – Another student’s paper
Working smoke and carbon monoxide detectors in house

They live in a quiet middle class neighborhood and take part in local activities such as cleaning their church compound.
Fam Hx: Older brother died in 2015 at age of 9 years due to malignant neoplasm. Grandfather died in 2010 aged 60 years due to type 2 diabetes.
ROS
General:

9
No fatigue, weakness, fever, and weight loss

Suspected Entry: 84% match

Uploaded – Week5Castelao.M.extention x
No fatigue, weakness, fever, and weight loss

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No weight loss, fever, chills, weakness or fatigue

HEENT:
Eyes:

3
no blurred vision, yellow sclera, loss of sight or double vision.

Suspected Entry: 87% match

Uploaded – Week5Castelao.M.extention x
no blurred vision, yellow sclera, loss of sight or double vision

Source – Another student’s paper
No visual loss, blurred vision, double vision or yellow sclera

9
Ears, Nose, Throat:

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
Ears, Nose, Throat

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
Ears, Nose, Throat

8
Hearing difficulty in the right ear for the past 2 days.

Suspected Entry: 70% match

Uploaded – Week5Castelao.M.extention x
Hearing difficulty in the right ear for the past 2 days

Source – Another student’s paper
Difficulty hearing to right ear x2 days

1
No sneezing, sore throat, runny nose, and/or congestion.

Suspected Entry: 98% match

Uploaded – Week5Castelao.M.extention x
No sneezing, sore throat, runny nose, and/or congestion

Source – Another student’s paper
no sneezing, congestion, runny nose or sore throat

SKIN:

9
No itching or rashes

Suspected Entry: 64% match

Uploaded – Week5Castelao.M.extention x
No itching or rashes

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No rash or itching

CARDIOVASCULAR:

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No chest discomfort, chest pain, and chest pressure.

Suspected Entry: 94% match

Uploaded – Week5Castelao.M.extention x
No chest discomfort, chest pain, and chest pressure

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No chest pain, chest pressure or chest discomfort

4
No edema and palpitation.

Suspected Entry: 86% match

Uploaded – Week5Castelao.M.extention x
No edema and palpitation

Source – Another student’s paper
No palpitation or edema

RESPIRATORY:

4
No cough or shortness of breath

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
No cough or shortness of breath

Source – Another student’s paper
No shortness of breath or cough

GASTROINTESTINAL:

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No nausea, diarrhea, vomiting, and anorexia.

Suspected Entry: 92% match

Uploaded – Week5Castelao.M.extention x
No nausea, diarrhea, vomiting, and anorexia

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No anorexia, nausea, vomiting or diarrhea

10
No abdominal pain GENITOURINARY:

Suspected Entry: 80% match

Uploaded – Week5Castelao.M.extention x
No abdominal pain GENITOURINARY

Source – Another student’s paper
No abdominal pain

9
No burning urination

Suspected Entry: 89% match

Uploaded – Week5Castelao.M.extention x
No burning urination

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No burning on urination

MUSCULOSKELETAL:

3
No muscle, back pain, joint pain, and stiffness.

Suspected Entry: 93% match

Uploaded – Week5Castelao.M.extention x
No muscle, back pain, joint pain, and stiffness

Source – Another student’s paper
No muscle, back pain, joint pain or stiffness

HEMATOLOGIC: No bleeding. Minor bruising to right elbow
LYMPHATICS:

11
No enlarged nodes and history of splenectomy

Suspected Entry: 82% match

Uploaded – Week5Castelao.M.extention x
No enlarged nodes and history of splenectomy

Source – Another student’s paper
No history of splenectomy or enlarged nodes · ENDOCRINOLOGIC

PSYCHIATRIC:

9
No history of depression and anxiety

Suspected Entry: 88% match

Uploaded – Week5Castelao.M.extention x
No history of depression and anxiety

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No history of depression or anxiety

ENDOCRINOLOGIC:

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No reports of cold, heat intolerance, and sweating.

Suspected Entry: 93% match

Uploaded – Week5Castelao.M.extention x
No reports of cold, heat intolerance, and sweating

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No reports of sweating, cold or heat intolerance

No reports of polyuria or polydipsia.

Suspected Entry: 84% match

Uploaded – Week5Castelao.M.extention x
No reports of polyuria or polydipsia

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No polyuria or polydipsia

ALLERGIES:

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No history of rhinitis, eczema, and asthma as well as hives.

Suspected Entry: 82% match

Uploaded – Week5Castelao.M.extention x
No history of rhinitis, eczema, and asthma as well as hives

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
No history of asthma, hives, eczema or rhinitis

O Physical Examination:
EENT:

1
Non reddened eyes and normal sclera.

Suspected Entry: 97% match

Uploaded – Week5Castelao.M.extention x
Non reddened eyes and normal sclera

Source – Another student’s paper
Eyes non reddened, normal sclera

5
Visualize external auditory canal and the middle ear using otoscope, with results showing mild redness with serous fluid and no pearly white lesions.

Suspected Entry: 84% match

Uploaded – Week5Castelao.M.extention x
Visualize external auditory canal and the middle ear using otoscope, with results showing mild redness with serous fluid and no pearly white lesions

Source – Another student’s paper
use otoscope visualized external auditory canal and middle ear showing mild redness and bulging, with serous fluid, no pearly white lesions

12
No facial grimace and drainage from ears.

Suspected Entry: 69% match

Uploaded – Week5Castelao.M.extention x
No facial grimace and drainage from ears

Source – Another student’s paper
Upon further investigation, no signs of facial grimace and no drainage from his ears

3
The patient is not tugging on his ears or demonstrating signs of distress.

Suspected Entry: 66% match

Uploaded – Week5Castelao.M.extention x
The patient is not tugging on his ears or demonstrating signs of distress

Source – Another student’s paper
Patient is not pulling or tugging on ear, or showing signs of distress

Nose:

5
No congestion, drainage, soreness, or redness.

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
No congestion, drainage, soreness, or redness

Source – Another student’s paper
No redness, congestion, drainage or soreness

3
No enlarged nodes or sore throat with swallowing.

Suspected Entry: 88% match

Uploaded – Week5Castelao.M.extention x
No enlarged nodes or sore throat with swallowing

Source – Another student’s paper
No sore throat with swallowing, or enlarged nodes, no redness

Diagnostic results:
The patient is not feverish at 37.20 c. Though not breastfed, he takes pacifiers

13
Otoscope used to visualize external auditory canal and the middle ear.

Suspected Entry: 95% match

Uploaded – Week5Castelao.M.extention x
Otoscope used to visualize external auditory canal and the middle ear

Source – Another student’s paper
Otoscope to visualize external auditory canal, and middle ear

14
The patient has intact hearing after checking cranial nerve V111.

Suspected Entry: 66% match

Uploaded – Week5Castelao.M.extention x
The patient has intact hearing after checking cranial nerve V111

Source – Another student’s paper
Hearing evaluated to check cranial nerve V111:intact

15
Results from Weber and Rinne tests showed that the patient could hear whispered sound.

Suspected Entry: 63% match

Uploaded – Week5Castelao.M.extention x
Results from Weber and Rinne tests showed that the patient could hear whispered sound

Source – Another student’s paper
Patient was able to hear whispered voice according Weber and Rinne tests

Left Weber had better hearing.

12
Rinne tests demonstrated air heard longer with slight variation to the right side.

Suspected Entry: 64% match

Uploaded – Week5Castelao.M.extention x
Rinne tests demonstrated air heard longer with slight variation to the right side

Source – Another student’s paper
Rinne test (positive) showed air heard longer, a slight difference to the right side

Weber and Rinne tests help in detecting hearing problems (Ball et al., 2015).

7
Pneumatic otoscopy Tympanogram tests carried out to detect otitis media with effusion

Suspected Entry: 71% match

Uploaded – Week5Castelao.M.extention x
Pneumatic otoscopy Tympanogram tests carried out to detect otitis media with effusion

Source – Another student’s paper
Pneumatic otoscopy Tympanogram used to check for otitis media with effusion

3
Answers to Key Questions:

Suspected Entry: 91% match

Uploaded – Week5Castelao.M.extention x
Answers to Key Questions

Source – Another student’s paper
Key questions and answers

Patient reported swimming at least three times a day, hitting the water hard a few times, and landing on his right side quite often. He denied cleaning and swabbing his ears, without the help of his grandmother.

1
No history of excessive earwax and putting objects in the ear.

Suspected Entry: 66% match

Uploaded – Week5Castelao.M.extention x
No history of excessive earwax and putting objects in the ear

Source – Another student’s paper
No history of placing objects in ears, or excessive earwax

16
He reports muffed sounds on right ear but can hear well and denies dizziness.

Suspected Entry: 68% match

Uploaded – Week5Castelao.M.extention x
He reports muffed sounds on right ear but can hear well and denies dizziness

Source – Another student’s paper
He reports that ear sounds are slightly more muffled on the right side, but he can hear good, denies ringing, dizziness

He can repeat simple sentences without any hesitation and does not appear to have hearing difficulties.

Suspected Entry: 64% match

Uploaded – Week5Castelao.M.extention x
He can repeat simple sentences without any hesitation and does not appear to have hearing difficulties

Source – Another student’s paper
Does not turn head when listening or appear to have difficulty hearing and can repeat back simple sentences without hesitation (Dains et al., 2016)

A
Differential Diagnosis
Primary Diagnosis:

3
Acute otitis media.

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
Acute otitis media

Source – Another student’s paper
Acute Otitis Media

Although he is not feverish, Marchisio et al. (2019) associate acute otitis media with symptoms such as reddening of ears and ear pains.
Differential Diagnosis:
Ear trauma: While there is no perforation, this may have occurred during swimming. Dains, Baumann, and Scheibel (2016) indicate that blunt trauma and no vertigo can lead to ear trauma

3
Middle ear effusion:

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
Middle ear effusion

Source – Another student’s paper
Middle ear effusion

Common symptoms of middle ear effusion include serous fluid and rightward lateralization, which can occur due to occluded ear (Ball et al., 2015).
Cholesteatoma: This infection is associated with hearing difficulties but no loss of hearing and perforations (Gulati et al., 2019).
References
Ball, J.

14
W., Dains, J.

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
W., Dains, J

Source – Another student’s paper
W., Dains, J

E., Flynn, J.

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
E., Flynn, J

Source – Another student’s paper
E., Flynn, J

A., Solomon, B.

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
A., Solomon, B

Source – Another student’s paper
A., Solomon, B

S., & Stewart, R.

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
S., & Stewart, R

Source – Another student’s paper
S., Stewart, R

W. (2015).

14
Siedel’s guide to physical examinations (8th ed.).

Suspected Entry: 64% match

Uploaded – Week5Castelao.M.extention x
Siedel’s guide to physical examinations (8th ed.)

Source – Another student’s paper
Seidel’s guide to physical examination (8th ed.)

St. Louis, MO: Elsevier Mosby.
Dains, J.

17
E., Baumann, L.C., & Scheibel, P.

Suspected Entry: 66% match

Uploaded – Week5Castelao.M.extention x
E., Baumann, L.C., & Scheibel, P

Source – Another student’s paper
Dains, J., Baumann, L., & Scheibel, P

(2016).

9
Advanced health assessment and clinical diagnosis in primary care (5th ed.).

Suspected Entry: 100% match

Uploaded – Week5Castelao.M.extention x
Advanced health assessment and clinical diagnosis in primary care (5th ed.)

Source – https://besthomeworkhelp.org/assessing-neurological-symptoms/
Advanced health assessment and clinical diagnosis in primary care (5th ed.)

St. Louis, MO: Elsevier Mosby Gulati, M., Gupta, S., Prakash, A., Garg, A., & Dixit, R. (2019). HRCT imaging of acquired cholesteatoma: A pictorial review. Insights into Imaging, 10(1), 1-8.
Marchisio, P., Bortone, B., Ciarcià, M., Motisi, M. A., Torretta, S., Gattinara, G. C.,. & Varricchio, A. (2019).

18
Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics:

Suspected Entry: 95% match

Uploaded – Week5Castelao.M.extention x
Updated Guidelines for the Management of Acute Otitis Media in Children by the Italian Society of Pediatrics

Source – Another student’s paper
Updated guidelines for the management of acute otitis media in children by the Italian society of pediatrics diagnosis

Prevention.

19
The Pediatric Infectious Disease Journal, 38(12), 22-36.

Suspected Entry: 64% match

Uploaded – Week5Castelao.M.extention x
The Pediatric Infectious Disease Journal, 38(12), 22-36

Source – Another student’s paper
Pediatric Infectious Disease Journal, 38, S3-S9

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