01 Oct Health Assessment Nursing Patient Case – HEENT/Neck

Health Assessment Nursing

Patient Case – HEENT/Neck

 

Please refer to the Grading Rubric for details on how this activity will be graded.

 

The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria which exceed expectations.

 

Objective

 

The purpose of this discussion is to review assessment techniques, identify subjective and objective information related to a focused system, and introduce clinical reasoning. Please read through the entire discussion instructions and example posts prior to your initial post as you will be building on the responses of your peers.

 

Initial Post

 

Report to the virtual clinic and select ONE of the occupied exam rooms. Note that each exam room has its own thread for discussion. Read the chief complaint and review any information already shared by your peers to build on the identified patient case. Identify one additional unique health history or subjective symptom as well as one objective exam finding. Provide scholarly support to discuss the physical assessment technique used to identify the objective finding and compare and contrast characteristics of normal and abnormal findings. Each student will copy and paste the most recent developing case to build upon their initial post. Please do not copy the scholarly support. See Example.

 

Your initial post should include evidence of review of the course material, websites, and literature through proper citations using APA format.

 

Virtual Clinic Exam Rooms

 

Room 1: 2yo Richie is brought to the clinic by his mother Rachel Regis for nasal congestion and tugging at his left ear

 

Room 2: 47yo Roy Regis reports history of itching and irritation around his right eye

 

Room 3: 5yo Remy is brought to the clinic by his father Raphael Regis for a sore throat

 

(See Response Post Instructions and Example before beginning the Discussion.)

 

Response Posts

 

Return to the virtual clinic and select TWO of the occupied exam rooms. Review the documented subjective and objective history. Provide scholarly support to identify a differential diagnosis based on the reported findings. Include additional subjective or objective data that would support this diagnosis.

 

Example – Shows a developing case and does not include required scholarly support

 

Initial Post:

 

Room 1: 72yo Ralph Regis reports intermittent abdominal pain

 

Student 1:

 

HPI: 72yo Ralph Regis reports intermittent abdominal pain localized to the LLQ

 

PE: T-99.8; BP 148/86, P-84, R-16

 

Student 2:

 

HPI: 72yo Ralph Regis reports intermittent aching abdominal pain rated 5/10 localized to the LLQ

 

PE: T-99.8; BP 148/86, P-84, R-16

 

ABD: Bowel sounds active

 

Student 3:

 

HPI: 72yo Ralph Regis reports aching intermittent abdominal pain rated 5/10 localized to the LLQ. Pain started three days ago after eating popcorn.

 

PE: T-99.8; BP 148/86, P-84, R-16

 

ABD: Bowel sounds active; abdomen soft with tenderness to palpation in LLQ

 

Student 4:

 

HPI: 72yo Ralph Regis reports aching intermittent abdominal pain rated 5/10 localized to the LLQ. . Pain started three days ago after eating popcorn. Last BM two days ago.

 

PE: T-99.8; BP 148/86, P-84, R-16

 

ABD: Bowel sounds active; abdomen soft with tenderness to palpation in LLQ; LLQ dull to percussion

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