Review of Case Study:
In this Discussion, 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.
Note: Discussion post should be in the SOAP Note format, rather than the traditional narrative style Discussion posting format. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Case: Focused Throat Exam
Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus over the past two weeks, Lily figured she shouldn't take her three-day sore throat lightly. Your clinic has treated a few cases similar to Lily's. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn't sound congested.
To prepare:
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 10 possible conditions that may be considered in a differential diagnosis for the patient.
Post 2 page discussion SOAP NOTE on:
A description of the health history you would need to collect from the patient in the case study to which you were assigned.
Explain what physical exams and diagnostic tests would be appropriate and how the results would be used to make a diagnosis.
List five different possible conditions for the patient's differential diagnosis and justify why you selected each.
REFERENCE
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
?Chapter 10, "Head and Neck" (pp. 184-203)
Chapter 12, "Ears, Nose, and Throat" (pp. 231-259)
Chapter 21, "Hoarseness" (pp. 248-256
Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2009). DeGowin's diagnostic examination (9th ed.). New York, NY: McGraw Hill Medical. ?Chapter 7, "The Head and Neck" (pp. 178-301)