Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
- Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
- Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
- 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?
- Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing tReview the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
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?
Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat
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Episodic/Focused SOAP Note Exemplar Focused SOAP Note for a patient with chest pain S. HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years ROS O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”
General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard 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. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary— Lungs are clear to auscultation and percussion bilaterally
Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)
A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
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- This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
| Subjective Documentation in Provider Notes
Subjective narrative documentation in Provider Notes is detailed and organized and includes:
Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)
ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. |
5 (5%)
Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language. No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS). No documentation provided. |
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| Objective Documentation in Provider Notes – this is to be completed in Shadow Health
Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.
You only need to examine the systems that are pertinent to the CC, HPI, and History.
Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned
A. Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1). |
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When considering the ears, nose, and throat (ENT) in the context of a cough, it’s essential to understand the interconnectedness of these systems. A cough can be a symptom of various conditions affecting the respiratory system, including infections, allergies, asthma, or even issues related to the ears, nose, or throat.
In your review of the learning resources, you should focus on understanding how to conduct a thorough examination of the ENT system, including inspecting the ears for signs of infection or inflammation, assessing the nose for any congestion or discharge, and examining the throat for redness, swelling, or tonsillar enlargement.
Regarding diagnostic tests, for a patient presenting with a cough, several tests may be appropriate depending on the suspected underlying cause. These may include:
- Chest X-ray: To rule out pneumonia or other lung abnormalities.
- Pulmonary function tests: To assess lung function and identify conditions such as asthma or chronic obstructive pulmonary disease (COPD).
- Allergy testing: If allergies are suspected as a cause of the cough.
- Complete blood count (CBC): To check for signs of infection or inflammation.
- Throat swab or culture: If a bacterial infection such as strep throat is suspected.
Interpreting the results of these tests alongside the patient’s symptoms and physical exam findings can help in making a diagnosis. For example, if a chest X-ray shows signs of pneumonia, and the patient has a productive cough with fever and chest pain, pneumonia would be a likely diagnosis. Similarly, if pulmonary function tests reveal airflow obstruction and the patient has a history of wheezing and shortness of breath, asthma may be the underlying cause of the cough.
When documenting your findings using the DCE Documentation Template for Focused Exam: Cough, be sure to include relevant subjective and objective data gathered during the patient encounter, as well as your assessment and plan based on your findings and diagnostic considerations.
Lastly, when using the Shadow Health platform, ensure you’re familiar with its interface and documentation requirements to accurately record your encounter and interpretations within the platform. Reviewing tutorials and examples provided can help you navigate the platform effectively.
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