FULL CLASS:
NURS 6512 – Advanced Health Assessment and Diagnostic
To prepare:
- By Day 1 of this week, your Instructor will assign an i-Human Patients case for this Assignment. Note: Please see the Course Announcements section of the classroom for your i-Human Patients Assignment.
- Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with conditions of the head, neck, eyes, ears, nose, and/or throat.
- Access and review the assigned i-Human Patients case study. Based on the provided patient information, think about the health history you would need to collect from the patient.
- Consider what physical exams and diagnostic tests would be most appropriate to gather more information about the patient’s condition.
- Reflect on how the results would be used to make a diagnosis.
- Identify three to five (3–5)possible conditions that may be considered in a differential diagnosis for the patient.
- Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
- Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with conditions of the head, neck, eyes, ears, nose, and/or throat.
Assignment
As you interact with this week’s i-Human Patients patient, complete the assigned case study. For guidance on using i-Human Patients, refer to the i-Human Graduate Programs Help link within the i-Human Patients platform.
Solution
Problem Statement by Student’s Name on case William Fredericks
The patient is a 42-year old male who presented with 14 days hx of headache following URI who now complains of worsening headache, facial pain, intermittent right incisor tooth pain, sinus pressure, post-nasal drip with cough that worsens at night, the recent onset of stabbing right ear pain, and low grade fever. He finds moderate relief with a steaming shower, PMH is significant for newly DM2 and hyperlipidemia with poor follow up. RF includes DM and allergies.
Management Plan by Student’s Name on case William Fredericks
Diagnostic tests: CBC (slightly elevated), CMP (elevated glucose), Group A Streptococcal rapid antigen test (negative)
Medications: Amoxicillin 1000mg TID for 7-10 days
Referrals: None at this time
Client education: Patient should take a rest, steam head in shower daily, warm packs to facial sinus areas, and take medications as prescribed (Barry & Fahey, 2020). Additionally,
Electronic Health Record by Student’s Name on case William Fredericks
History of Present Illness
Category Data entered by Student’s Name
Reason for Encounter “I am here because I feel really sick and am not getting better. I have this
headache which started about 2 weeks ago. I was just getting over a cold at that time. Over the last 2 weeks my headache got……………………..$10