Episodic Note

Renee is a 47-year-old female with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Renee has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check her ears and throat for redness and inflammation, you notice her touch his fingers to the bridge of her nose to press and rub there. She says she has taken Mucinex OTC the past 2 nights to help her breathe while she sleeps. When you ask if the Mucinex has helped at all, she sneers slightly and gestures that the improvement is only minimal. Renee is alert and oriented. She has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinate’s, which obstruct airway flow but her lungs are clear. Her tonsils are not enlarged but his throat is mildly erythematous.

Assignment 1 is a SOAP note. Your case assignment is listed in the Announcements area. Please remember to post your response in a SOAP note format. You will need to make up some of the details for the SOAP if they are not given to you. The template for the SOAP note is located in the Week 5 Resource area. I also encourage all of you to review the SOAP note exemplar to see how to word items. 
An important point to remember is that the subjective section is what the patient tells you and the objective section is your exam (what do you see or hear). It is important to not mix this information up.

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Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

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Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.
Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.
In this Case Study Assignment, 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.
To Prepare
 
By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
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 five possible conditions that may be considered in a differential diagnosis for the patient.
The Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

Rubric Detail

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Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.

·  Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.–
Excellent 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Good 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Fair 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.
Poor 0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.–
Excellent 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected.
Good 24 (24%) – 29 (29%)
The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.
Fair 18 (18%) – 23 (23%)
The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
Poor 0 (0%) – 17 (17%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–
Excellent 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Good 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
Fair 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
Poor 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation–
Excellent 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Good 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
Fair 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Poor 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.–
Excellent 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Good 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
Fair 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
Poor 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting. For more information on Episodic Note see this: https://www.dictionary.com/browse/episodic

Episodic Note

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