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Week 5 Assignment Sample Paper
Week 5 Assignment Sample Paper
Episodic/Focused SOAP Note
NURS 6512 Week 5 Assignment Sample Paper Assignment – Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Episodic/Focused SOAP Note Template
Patient Information:
65 year Old AA male
S.
CC Chest pain.
HPI: The individual in this case is a 65 year Old AA male. The patient indicates that he developed an abrupt commencement of chest pain that commenced early in the morning. The patient indicates the pain as crushing and is ranked 9/10 in pain scale. The aching’s location is in the interior of the ribcage, and this is complemented by shortness of breath. On probing, the individuals indicated feeling nauseated. The individual has also tried medication such as antacid with negligible reprieve of his signs. The patient has a positive history of GERD and hypertension that have previously been controlled.
The patient also indicates the mother passed on at 78 of breast cancer, Father at 75 of CVA. The patient does not exhibit an account of untimely cardiac disease in first degree relations. The patient has been married for the last 39 years. Week 5 Assignment Sample Paper
Location: Chest.
Onset: early in the morning.
Character: Crushing pain in the middle of the chest.
Associated signs and symptoms: nauseous without vomiting.
Timing: no sufficient information.
Exacerbating/ relieving factors: antacid with minimal relief of the symptoms.
Severity: 9/10 pain scale
Current Medications: antacids with minimal relief on the symptoms.
Allergies: No known allergies.
PMHx: positive history of GERD and hypertension is controlled.
Soc Hx: currently consumes moderate alcohol and negative for tobacco use.
Fam Hx: The mother passed on at 78 of breast cancer, Father at 75 of CVA. There is no account of untimely cardiac ailment in first degree.
ROS:
GENERAL: negative for fever, chills, fatigue.
HEENT: No evidence of HEENT examination.
SKIN: No evidence of skin examination.
CARDIOVASCULAR: negative for orthopnea, PND, positive for sporadic lower extremity edema.
RESPIRATORY: no evidence of respiratory examination.
GASTROINTESTINAL: positive for nausea without vomiting, negative for diarrhea, abdominal pain.
GENITOURINARY: not applicable.
NEUROLOGICAL: no evidence of neurological examination.
MUSCULOSKELETAL: no evidence of musculoskeletal examination.
HEMATOLOGIC: no evidence of hematologic examination.
LYMPHATICS: no report of lymphatic examination.
PSYCHIATRIC: no report of psychiatric examination.
ENDOCRINOLOGIC: no report of endocrinologic examination.
ALLERGIES: no report of allergies.
O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
Physical exam: The results of electrocardiography (EKG), chest radiograph (CXR), and CK-MB test, indicate that the lungs are clear to auscultation and percussion bilaterally. The Pt looks diaphretic and restless. PMI is in the 5th inter costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is perceived best at the second right inner costal space that discharges to the neck. A third heart 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.
The abdomen is proportioned devoid of distention, bowel noises are ordinary quality and concentration in all parts, a bruit is heard in the right para umbilical area. No masses or splenomegaly are eminent. Positive for mid-epigastric inflammation with profound palpation. The lungs are flawless to auscultation and percussion jointly. Week 5 Assignment Sample Paper
Diagnostic results: EKG, CXR, CK-MB.
A.
Differential Diagnoses
The physical exam comprises of an active observational examination of the individual. According to Balogh, Miller, and Ball (2015), the nurse should first observe the patient’s behavior, complexion, posture, level or distress, and any other signs which might contribute to the understanding of the health of the patient. A physical exam can include the entire HEENT examination, which can assist the nurse to enhance the steps taken in the diagnostic process. In the long run, this can avert unnecessary diagnostic testing and build trust with the patient (Balogh, Miller & Ball, 2015). Some of the physical examinations that should be conducted on the patient can include the following.
First, inspection where the clinician can look at or inspect specific areas for abnormalities. Second, palpation where the nursing practitioner can use their hands to feel for abnormalities during the health assessment (“Techniques of Physical Assessment: NCLEX-RN”, 2020). In the basic HEENT examination, the nursing practitioner can commence by checking for any deformities or asymmetry. After completing the head, the clinician should proceed to the eyes, ears, nose, and mouth. In checking the eyes, the nurse should assess for eye movement (Haber et al., 2015). For this patient experiencing chest pains, one of the most recommended tests is the ECG/EKG, CXR, CK-MB test that can determine if the patient suffers from a heart-related issue (Chamley, Holdsworth, Rajappan & Nicol, 2019).
Based on the symptoms depicted by the patient, they most probably have the following illnesses.
GERD: GERD is also known as gastroesophageal reflux disease. The patient has a past history of GERD. GERD is chronic acid reflux, and it makes the patients experience pain in the chest.
Hypertrophic cardiomyopathy: this occurs when the heart grows too thick because of genetic factors (Marian & Braunwald, 2017). The thickening of the heart can can prevent blood from flowing from the heart properly. Some of the symptoms include chest pains, shortness of breath, and dizziness. Week 5 Assignment Sample Paper
Myocardial ischemia: occurs when there is little blood flow to the heart muscles, thereby preventing the heart from receiving enough oxygen (Heusch, 2016). Some of the symptoms of myocardial ischemia include shortness of breath and pain in the chest.
Pulmonary embolism: this entails the blockage of the pulmonary arteries in the lungs. It is caused by blood clots that travel to the lungs from deep veins in the legs. Some of the symptoms include shortness of breath and chest pain.
Chronic obstructive pulmonary disease (COPD): this is a chronic inflammatory lung disease that causes obstructed airflow from the lung (Qureshi, Sharafkhaneh & Hanania, 2014). COPD also has distinct symptoms that cause shortness of breath and chest pain.
For the nursing practitioner to understand the root cause of the pain in the chest this necessitates an ECG test that can check all the underlying patient conditions.
References
Balogh, E., Miller, B., & Ball, J. (2015). The Diagnostic Process. Retrieved 26 December 2020, from https://www.ncbi.nlm.nih.gov/books/NBK338593/
Chamley, R., Holdsworth, D., Rajappan, K., & Nicol, E. (2019). ECG interpretation. European Heart Journal, 40(32), 2663-2666. doi: 10.1093/eurheartj/ehz559
Haber, J., Hartnett, E., Allen, K., Hallas, D., Dorsen, C., & Lange-Kessler, J. et al. (2015). Putting the Mouth Back in the Head: HEENT to HEENOT. American Journal Of Public Health, 105(3), 437-441. doi: 10.2105/ajph.2014.302495 Week 5 Assignment Sample Paper
Heusch, G. (2016). Myocardial Ischemia. Circulation Research, 119(2), 194-196. doi: 10.1161/circresaha.116.308925
History & Physical Exam | SEER Training. (2020). Retrieved 26 December 2020, from https://training.seer.cancer.gov/diagnostic/history.html
Marian, A., & Braunwald, E. (2017). Hypertrophic Cardiomyopathy. Circulation Research, 121(7), 749-770. doi: 10.1161/circresaha.117.311059
Qureshi, H., Sharafkhaneh, A., & Hanania, N. (2014). Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications. Therapeutic Advances In Chronic Disease, 5(5), 212-227. doi: 10.1177/2040622314532862
Techniques of Physical Assessment: NCLEX-RN. (2020). Retrieved 26 December 2020, from https://www.registerednursing.org/nclex/techniques-physical-assessment/
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