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NURS 5220 – Advanced Health Assessment – University of Texas at Arlington You will complete the learning module for Ear (capstone case study (ear) 85-year-old woman with hearing loss 1. You will access the assigned case study: HEENT: Capstone Case Study the Capstone that is located in your Evolve Online Book b. Access the Evolve Chapter 13: Ears, Nose, and Throat, then self-paced learning modules, capstone case study Ear, Kathryn U, 85-year-old with hearing loss 2. You will complete the case study (there is no verification that you completed the scenario), but you obtain information from the scenario to complete the soap note 3. You will need to pose additional questions on your soap note, the scenario will supply some, but not all the history required Utilize the Soap Note Form with the information that you obtained in completion of the assigned case study. a. Think objectively, you will be given a diagnosis but is there another diagnosis or differential to consider and what information would be required to help you rule in/out a differential or to develop a plan of care. Scenario: Mrs. Kathryn U., 85 years old, lives in the retirement community served by your clinic. She comes in during drop-in hours early one Saturday morning and asks to speak with you in private. She tells you, “My husband says he has to repeat himself too many times when he talks to me and that I should get my hearing checked. I don’t think I’m hard of hearing, but he keeps pestering me. I want you to check my hearing so that I can go back and tell him that he’s making it all up.” 7. In light of Mrs. Unterreiner’s husband’s comments, you will consider various types of hearing loss that may be affecting her. Onset—”He [her husband] has been pestering me about it for about 2 months. I’d never had any trouble before then, and I didn’t want to believe him at first.” · Character—”Everything sounds funny. I can hear noises, but speech isn’t clear. It’s worse on my right side.” · Context—”I have the most trouble when we’re in the dining hall in the evening, but I think everyone has a little trouble hearing in situations like that, don’t you?” · Shouting—”No, sometimes my husband—and, lately, my best friend—repeat themselves, but no one has been shouting at me.” · Hollowness—”Yes, funny that you should mention it. Things do sound rather hollow—a little like international phone calls used to sound.” · Air travel—”No, I haven’t been on a plane since last year, when we went to see our grandchildren.” · Efforts to treat the problem—”I used a cotton swab in case there was some wax in there, but nothing came out on the swab and the problem didn’t get better.” · Coping strategies—”I’ve found myself watching people’s lips when they talk; in noisy restaurants, I sometimes just don’t listen to the conversation going on around me. It can be frustrating.” Findings: Found cerumen, describes conduction hearing loss. Will test with: Weber and Rinne test. Completion of your soap note will include Subjective AND Objective components as well as: Medical Diagnosis (Formulate 2 (two) Primary Diagnoses) Decide what is pertinent and then place the components in the correct sections of subjective and objective components Use appropriate abbreviations and concise terminology if appropriate If you are lacking pertinent information supply the questions that you would ask the patient (pretend you are completing the visit, how would you phrase the questions) Consider What type of history will you obtain for this visit? (The SOAP note Template is a Template used in multiple courses, some of the boxes may not be applicable to your assignment) What additional history would you obtain from the family that is significant to Kathryn’s situation? Practice using clinical reasoning and list possible diagnoses for Kathryn based on the subjective information provided The Following must be included in your SOAP submission Subjective Content Identifying Information Chief Complaint HPI Family, Personal/Social Current Health PHM Review of Systems Primary Medical Diagnosis ICD 10 code (you may do a simple google search) Provide pathophysiology for each diagnosis (1 paragraph) The rationale for each diagnosis Plan for each diagnosis Pertinent positives for each diagnosis (list 2) Pertinent negatives for each diagnosis (list 2) 3-5 Differential diagnosis ICD 10 code (you may do a simple google search) Provide pathophysiology for each diagnosis (1 paragraph) The rationale for each diagnosis Plan for each diagnosis Pertinent positives for each diagnosis (list 2) Pertinent negatives for each diagnosis (list 2) Other Health maintenance/risk profile Reference List (you are researching your diagnosis, you should have at least 2 references) APA format Form: S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx: Pesonal/Social Hx: Chief Complaint: Hx of present illness” CURRENT HEALTH Medications: Allergies: Last PE & Screenings: Immunization Status: LMP & Birth Control (if applicable) PMH Illnesses & Trauma: Hospitalizations/Surgeries: OB Hx/Sexual Hx: Emotional/Psy Hx: REVIEW OF SYSTEMS General Nutrition Skin/Hair/Nails HEENT Breasts Respiratory GI GU MSK Psych Neuro Lymph/Heme/Endocrine O/ Physical Exam: T: P: R: BP: HT: WT: BMI: General Skin Head EENT Neck Breasts/Chest Lungs Heart/ perip vascular Abdomen Genitalia/Rectum Lymph MSK Neuro Medical Dx: (2max) Rule Outs (only if applicable): Health Profile: age/gender/racial risks: Pertinent Positives:(1DX) personal/family: screening needs: Pertinent Negatives: counseling needs: Immunization/chemo needs: Differential DX:(3-5) Alteration in Health Prevention R/T: Screening deficits: Counseling deficits: Nursing Dx: Immunization/chemo deficits: I. PLAN: Do separate sections in the plan to include: Max 1-2 pages Diagnostics: Medications/Treatments: Education: Follow-up: Referrals: Prevention Plan: II. Rationale: ( Max 2 pages) III. Patho: (Max 2 pages)
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