Case Study 2: Focused Throat Exam

This week, you will explore how to assess the head, neck, eyes, ears, nose, and throat. Whether dealing with a detached retina, sinusitis, meningitis, or even cough, advanced practice nurses need to know the proper assessment techniques to form accurate diagnoses.

• 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.
• Provide a detailed assessment of affected system. Always include General, CV and Respiratory assessment in each Focus note.

Case Study 2: Focused Throat Exam

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. 

 

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