Make a SOAP Note Not an Essay: Focused Throat Exam

Make a SOAP Note Not an Essay: Focused Throat Exam

The majority of ear, nose, and throat conditions that arise in non-critical care settings are minor. However, subtle symptoms can sometimes progress to life-threatening conditions that necessitate immediate evaluation and treatment. Nurses performing assessments of the ears, nose, and throat must be able to distinguish between life-threatening and benign conditions. For example, if a patient has a sore throat, a runny nose, and inflamed lymph nodes, the inflammation is most likely caused by the pathogen causing the sore throat rather than throat cancer. With this knowledge and a sufficient patient health history, a nurse would probably perform a simple strep test rather than escalating the assessment to a biopsy or an MRI of the lymph nodes.

You will look at case studies of abnormal findings from patients in a clinical setting in this Discussion. You decide what history to take from the patients, what physical exams and diagnostic tests to perform, and how to formulate a differential diagnosis with several possible conditions.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

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Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

• Your response needs to be a minimum of 150 words (not including your list of references)
• There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
• Include in-text citations in your response
• Do not include quotes—instead summarize and paraphrase the information
• Follow APA-7th edition
• Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

• A minimum of 6 responses per week, on at least 3 days of the week.
• Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
• Each response needs to be at least 75 words in length (does not include your list of references)
• Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
• Follow APA 7th edition
• Points will be deducted if the above is not followed

• Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
• Here are some helpful links
• The is a great resource

Please keep in mind that by the first day of this week, your instructor will have assigned you to one of the following case studies to review for this Discussion. Also, rather than the traditional narrative style Discussion posting format, your Discussion post should be in the SOAP Note format. For more information, see Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in the Week 4 Learning Resources. Keep in mind that not all comprehensive SOAP data is included in each patient case.

Case Study: Focused Throat Exam

Lily, a 20-year-old student at a nearby community college, When some of Lily’s friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus over the last two weeks, she decided she shouldn’t dismiss her three-day sore throat. Your clinic has seen a few cases like Lily’s. All of the patients reported a loss of appetite, headaches, and swallowing pain. As Lily describes her symptoms, you notice that she has a runny nose and a slight hoarseness in her voice, but she does not appear congested.

To get ready:

Concerning the case study you were assigned:

Examine this week’s Learning Resources and consider the insights they offer.

Consider what information you will need to obtain from the patient.

Consider what physical exams and diagnostic tests would be necessary to learn more about the patient’s condition. How would the findings be used to make a decision?

Identify at least ten possible conditions that could be considered in the patient’s differential diagnosis.

Note: Before you submit your first post, change the subject line from “Week 5 Discussion” to “Review of Case Study ___,” indicating the case study number you were assigned.

In the SOAP Note, address the following:

1. A description of the health history you will need to obtain from the patient in the case study to which you have been assigned.

2. Describe the appropriate physical exams and diagnostic tests, as well as how the results will be used to make a diagnosis.

3. Explain why you chose each of the five possible conditions for the patient’s differential diagnosis.

REFERENCES:

Readings

J. W. Ball, J. E. Dains, J. A. Flynn, B. S. Solomon, and R. W. Stewart (2015).

Seidel’s Physical Examination Manual (8th ed.). Elsevier Mosby, St. Louis, MO.