Chat with us, powered by LiveChat This is just a discussion no soap note focus is ca - Writedi

This is just a discussion no soap note focus is ca

This is just a discussion no soap note focus is case study 3. A diagnosis could be any of the following: tonsillitis, mononucleosis, or tonsillar abscess. Will, upload an example of discussion. Discussion: Diagnosing HEENT Disorders In clinical settings, advanced practice nurses may initiate a physical examination of a patient by examining the components of the HEENT system. Assessing primary diagnoses and differential diagnoses as they concern the HEENT system are important in informing your practice in providing optimal care. For this Discussion, consider the following three case studies of patients presenting with head, eyes, ears, nose, and throat disorders. Case Study 1 An 86-year-old widowed female is brought to the office by her daughter-in-law. The patient complains of constant tearing and an itchy, burning sensation in both eyes. The patient states this is not a new problem, but it has worsened in the past week and is affecting her vision. The patient complains that her eyes are dry. She thinks the problem must be caused by one of her medications. Her patient medical history is positive for hypertension, atrial fibrillation, and heart failure. She has an allergy to erythromycin that causes rash and elevated liver enzymes. Medications currently prescribed include Furosemide 40 milligrams po twice a day, diltiazem 240 milligrams po daily, lisinopril 20 milligrams po daily, and warfarin 3 milligrams po daily. The physical examination reveals a frail older female with some facial dryness and slight scaling. Her visual acuity is 20/60 OU, 20/40 OD, 20/60 OS. The eyelids are erythematous and edematous with yellow crusting around the lashes. Sclera are injected, conjunctiva are pale, and pupils are equal and reactive to light and accommodation. Case Study 2 A middle-aged male presents to the office complaining of a two-day history of a left earache. The onset was gradual, but has steadily been increasing. It has been constantly aching since last night, and his hearing seems diminished to him. Today he thinks the left side of his face may even be swollen. He denies upper respiratory infection, known fever, or chills. His patient medical history is positive for Type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient has a known allergy to Amoxicillin that results in pruritus. Medications currently prescribed include Metformin 1,000 milligrams po twice a day, lisinopril 20 milligrams po daily, Aspirin 81 milligrams po daily, and simvastatin 40 milligrams po daily. The physical exam reveals a middle aged male at a weight of 160 pounds, height of 5’8”, temperature of 98.8 degrees Fahrenheit, heart rate of 88, respiratory rate of 18, and blood pressure of 138/76. Further examination reveals the following: • Face: Faint asymmetry with left periauricular area slightly edematous • Eyes: sclera clear, conj wnl • L ear: + tenderness L pinna, + edema, erythema, exudates left external auditory canal, TM not visible • R ear: no tenderness, R external auditory canal clear without edema, erythema, exudates • + tenderness L preauricular node, otherwise no lymphadenopathy • Cardiac: S1 S2 regular. No S3 S4 or murmur. • Lungs: CTA w/o rales, wheezes, or rhonchi. Case Study 3 A middle-aged female presents to the office complaining of strep throat. She states she suddenly developed a sore throat yesterday afternoon, and it has gotten worse since then. During the night she felt like she was chilled and feverish. She denies known recent contact with anyone else who had strep throat, but states she has had strep before and it feels like she has strep now. She takes no medications, but is allergic to penicillin. The physical examination reveals a slender female lying on the examination table. She has a temperature of 101 degrees Fahrenheit, heart rate of 112, respiratory rate of 22, and blood pressure of 96/64. The head, eyes, ears, nose, and throat evaluation is positive for bilateral tonsillar swelling without exudates. Her neck is supple with bilateral, tender, enlarged anterior cervical nodes. To prepare: • Review the case studies provided in this week’s Resources. • You will either select or be assigned one of the three case studies provided. • Reflect on the provided patient information including history and physical exams. • Think about a differential diagnosis. Consider the role the patient history and physical exam played in your diagnosis. • Reflect on potential treatment options based on your diagnosis. Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! By Day 3 Post an explanation of the primary diagnosis, as well as 3 differential diagnoses, for the patient in the case study you selected. Describe the role of the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis. Rubric Detail Select Grid View or List View to change the rubric’s layout. Name: NURS_6531_Week_3_Discussion_Rubric • Grid View • List View Outstanding Performance Excellent Performance Competent Performance Proficient Performance Room for Improvement Main Posting: Response to the discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources. 44 (44%) – 44 (44%) Thoroughly responds to the discussion question(s) is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources. supported by at least 3 current, credible sources 40 (40%) – 43 (43%) Responds to the discussion question(s) is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. 75% of post has exceptional depth and breadth supported by at least 3 credible references 35 (35%) – 39 (39%) Responds to most of the discussion question(s) is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. 50% of post has exceptional depth and breadth supported by at least 3 credible references 31 (31%) – 34 (34%) Responds to some of the discussion question(s) one to two criteria are not addressed or are superficially addressed is somewhat lacking reflection and critical analysis and synthesis somewhat represents knowledge gained from the course readings for the module. post is cited with fewer than 2 credible references 0 (0%) – 30 (30%) Does not respond to the discussion question(s) lacks depth or superficially addresses criteria lacks reflection and critical analysis and synthesis does not represent knowledge gained from the course readings for the module. contains only 1 or no credible references Main Posting: Writing 6 (6%) – 6 (6%) Written clearly and concisely Contains no grammatical or spelling errors Fully adheres to current APA manual writing rules and style 5.5 (5.5%) – 5.5 (5.5%) Written clearly and concisely May contain one or no grammatical or spelling error Adheres to current APA manual writing rules and style 5 (5%) – 5 (5%) Written concisely May contain one to two grammatical or spelling error Adheres to current APA manual writing rules and style 4.5 (4.5%) – 4.5 (4.5%) Written somewhat concisely May contain more than two spelling or grammatical errors Contains some APA formatting errors 0 (0%) – 4 (4%) Not written clearly or concisely Contains more than two spelling or grammatical errors Does not adhere to current APA manual writing rules and style Main Posting: Timely and full participation 10 (10%) – 10 (10%) Meets requirements for timely and full participation posts main discussion by due date 0 (0%) – 0 (0%) NA 0 (0%) – 0 (0%) NA 0 (0%) – 0 (0%) NA 0 (0%) – 0 (0%) Does not meet requirement for full participation First Response: Post to colleague’s main post that is reflective and justified with credible sources. 9 (9%) – 9 (9%) Response exhibits critical thinking and application to practice settings responds to questions posed by faculty the use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives 8.5 (8.5%) – 8.5 (8.5%) Response exhibits critical thinking and application to practice settings 7.5 (7.5%) – 8 (8%) Response has some depth and may exhibit critical thinking or application to practice setting 6.5 (6.5%) – 7 (7%) Response is on topic, may have some depth 0 (0%) – 6 (6%) Response may not be on topic, lacks depth First Response: Writing 6 (6%) – 6 (6%) Communication is professional and respectful to colleagues Response to faculty questions are fully answered if posed Provides clear, concise opinions and ideas that are supported by two or more credible sources Response is effectively written in Standard Edited English 5.5 (5.5%) – 5.5 (5.5%) Communication is professional and respectful to colleagues Response to faculty questions are answered if posed Provides clear, concise opinions and ideas that are supported by two or more credible sources Response is effectively written in Standard Edited English 5 (5%) – 5 (5%) Communication is mostly professional and respectful to colleagues Response to faculty questions are mostly answered if posed Provides opinions and ideas that are supported by few credible sources Response is written in Standard Edited English 4.5 (4.5%) – 4.5 (4.5%) Responses posted in the discussion may lack effective professional communication Response to faculty questions are somewhat answered if posed Few or no credible sources are cited 0 (0%) – 4 (4%) Responses posted in the discussion lack effective Response to faculty questions are missing No credible sources are cited First Response: Timely and full participation 5 (5%) – 5 (5%) Meets requirements for timely and full participation posts by due date 0 (0%) – 0 (0%) NA 0 (0%) – 0 (0%) NA 0 (0%) – 0 (0%) NA 0 (0%) – 0 (0%) Does not meet requirement for full participation Second Response: Post to colleague’s main post that is reflective and justified with credible sources. 9 (9%) – 9 (9%) Response exhibits critical thinking and application to practice settings * responds to questions posed by faculty the use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives 8.5 (8.5%) – 8.5 (8.5%) Response exhibits critical thinking and application to practice settings 7.5 (7.5%) – 8 (8%) Response has some depth and may exhibit critical thinking or application to practice setting 6.5 (6.5%) – 7 (7%) Response is on topic, may have some depth 0 (0%) – 6 (6%) Response may not be on topic, lacks depth Second Response: Writing 6 (6%) – 6 (6%) Communication is professional and respectful to colleagues Response to faculty questions are fully answered if posed Provides clear, concise opinions and ideas that are supported by two or more credible sources Response is effectively written in Standard Edited English 5.5 (5.5%) – 5.5 (5.5%) Communication is professional and respectful to colleagues Response to faculty questions are answered if posed Provides clear, concise opinions and ideas that are supported by two or more credible sources Response is effectively written in Standard Edited English 5 (5%) – 5 (5%) Communication is mostly professional and respectful to colleagues Response to faculty questions are mostly answered if posed Provides opinions and ideas that are supported by few credible sources Response is written in Standard Edited English 4.5 (4.5%) – 4.5 (4.5%) Responses posted in the discussion may lack effective professional communication Response to faculty questions are somewhat answered if posed Few or no credible sources are cited 0 (0%) – 4 (4%) Responses posted in the discussion lack effective Response to faculty questions are missing No credible sources are cited Second Response: Timely and full participation 5 (5%) – 5 (5%) Meets requirements for timely and full participation Posts by due date 0 (0%) – 0 (0%) NA 0 (0%) – 0 (0%) NA 0 (0%) – 0 (0%) NA 0 (0%) – 0 (0%) Does not meet requirement for full participation Total Points: 100 Name: NURS_6531_Week_3_Discussion_Rubric

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