Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests appropriate for each case. List five conditions for the patient’s differential diagnosis and justify why you selected each.
For this Assignment, you must make up information to complete the entire soap note. Please use the soap note exemplar example as a guide. I think it is essential to document a detailed HEENT exam and HEENT ROS for this Assignment. Writing a heart and lung exam on each patient is also necessary. For the Subjective Data (document constitutional/general ROS) on all patients and Psych. Please use your clinical guide to documentation textbook as a guide as needed for documentation purposes.
Thyroid Disorders-Symptoms, Diagnosis, and Differential Analyses
Case study
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 she is overweight.
Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Nurses conducting assessments of the ears, nose, and throat must be able to identify the minor 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.
Most non-critical care settings have minor ear, nose, and throat conditions. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.
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 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.
About 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.