ASSESSING, DIAGNOSING, AND TREATING HEAD, NECK, AND FACE DISORDERS
Head, neck, and face disorders are common, and thus you will likely care for elderly patients with these disorders. In your role as an advanced practice nurse, you must be able not only to correctly assess and diagnose patients but also help patients manage the disorder by planning necessary treatments, assessments, and follow-up care.
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.Â
Â· Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Head, neck, and face disorders. InÂ
Advanced practice nursing in the care of older adultsÂ (2nd ed., pp. 127â€“151). F. A. Davis.
Â· Goldberg, C. (2018b).Â
The eye examLinks to an external site.. In C. Goldberg,Â
Practical guide to clinical medicine. Regents of the University of California. https://meded.ucsd.edu/clinicalmed/eyes.htm
Focused SOAP Note Template (Word Document)
Â· Review the case study provided by your Instructor.
Â· Reflect on the patientâ€™s symptoms and aspects of disorders that may be present.
Â· Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the case.
Â· Access the Focused SOAP Note Template in this weekâ€™s Resources.
Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:
Â· Subjective: What was the patientâ€™s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers CriteriaÂ®, and consider alternative drugs if appropriate.Â Provide a review of systems.
Â· Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?
Â· Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority.Â Compare the diagnostic criteria for each, and explain what rules each differential in or out. Exp
Focused SOAP Note Template
Initials, Age, Sex, Race
CC (chief complaint): a BRIEF statement identifying why the patient is here, stated in the patientâ€™s own words (for instance “headache,” NOT “bad headache for 3 daysâ€).
HPI (history of present illness): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was â€œheadacheâ€, the LOCATES for the HPI might look like the following example:
Â· Location: Head
Â· Onset: 3 days ago
Â· Character: Pounding, pressure around the eyes and temples
Â· Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia
Â· Timing: After being on the computer all day at work
Â· Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better
Â· Severity: 7/10 pain scale
Current Medications: Include dosage, frequency, length of time used, and reason for use; also include over the counter (OTC) or homeopathic products.
Allergies: Include medication, food, and environmental allergies separately, including a description of what the allergy is (i.e., angioedema, anaphylaxis, etc.). This will help determine a true reaction versus intolerance.
PMHx: Include immunization status (note date of
last tetanus for all adults), past major illnesses, and surgeries. Depending on the CC, more info is sometimes needed.
Soc and Substance Hx: Include occupation and major hobbies, family status, tobacco and alcohol use (previous and current use), and any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: Diagnosis and treatment. Current concerns (anxiety and/or depression). History of self-harm practices and/or suicida
Case Study 1:
A 76-year-old woman presents today with complaints of nasal drainage, clearing of throat, and occasional nasal congestion, especially on waking in the morning. She has recently moved into an independent living center after living in her home for 40 years. She states that, although she has had these symptoms before, generally the symptoms appeared in the spring, and she associated the nasal drainage with pollination. Because it is winter, she could not identify the trigger of her symptoms.
Chief complaint: Persistent â€œrunny noseâ€ for 3-week duration, associated clearing of throat, and nasal
congestion on awakening in the morning.
Objective data: Blood pressure (BP) 130/84, temperature 98.6, pulse 78, respiratory rate 20.
What further ROS questions will you want to ask her? List at least three.
What physical exam (PE) will you perform on this patient? List at least three.
What are the differential diagnoses that you are considering? Describe at least four.
What laboratory tests will help you rule out some of the differential diagnoses?
You have determined, by choosing your ROS, PE, and differential diagnosis, that this patient has allergic rhinitis (AR). Describe the treatment options for your diagnosis, and what specific information about the prescription will you give to this patient? List at least two treatment options: medications with dose, side effects and/or cautions in the older adult.
When will you have the patient follow up? Be specific.
Write a focused SOAP note for this case. Choose the ROS, PE, and medications you will use in your SOAP note.
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