CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT

Week 5 Assignment: HEENT Episodic/Focused SOAP Note

Patient Information:

Initials: Kali Age: 44 years

Sex: Female Race: White

CC: “My eyes are bulging and I feel fatigued.”

HPI:

Kali is a 44-year-old White woman on physical exam with primary symptoms of protruding eyes and fatigue. The symptoms began about four months ago, and the fatigue has worsened. The fatigue has no aggravating factors, but resting alleviated it to some degree. The symptoms have significantly affected her occupational functioning since she always feels tired.

Current Medications: Atorvastatin 40 mg OD for hyperlipidemia.

Allergies: No allergies.

PMHx: Vaccination is current. The last TT was four years ago, and she received a FLU shot 5 months ago. Positive history of dyslipidemia diagnosed 12 months ago. No history of surgery.

Soc Hx: Kali is a corporate secretary working in an insurance firm. She is a Certified Professional Secretary and has a Diploma in Business Administration. She is married and has two children, 20 and 17 years old. Her hobbies include baking and reading magazines. She takes 3-4 beers on weekends but denies smoking or using illicit substances. Her souse and sister are the support system.

Fam Hx: The grandmother had Diabetes, and the grandfather succumbed to Lung cancer. Her elder sister also has Diabetes. The children are well.

ROS:

Vital signs: BP- 132/84; HR-94; RR- 20; Temp- 98.4F

Wt-188 lbs; Ht-5’6; BMI- 30.3

GENERAL: Reports fatigue and weight gain. Denies fever/chills.

HEENT: Eyes: Positive for bulged eyes. Negative for other eye symptoms. Ears: Denies ear symptoms. Nose: Negative for sneezing, nose bleed, nasal discharge. Throat: Negative for sore throat or swallowing difficulties.

SKIN: Negative for skin symptoms.

CARDIOVASCULAR: Negative for edema, neck vein distension, chest pain, palpitations, or SOB.

RESPIRATORY: Negative for respiratory symptoms.

GASTROINTESTINAL: Denies abdominal symptoms.

GENITOURINARY: Denies genitourinary symptoms.

NEUROLOGICAL: Positive for fatigue. Negative for headaches, dizziness, muscle weakness, syncope, or burning sensations.

MUSCULOSKELETAL: Denies musculoskeletal symptoms.

HEMATOLOGIC: Denies hematologic symptoms.

LYMPHATICS: Denies lymphatic symptoms.

PSYCHIATRIC: Negative for mood symptoms.

ENDOCRINOLOGIC: Denies endocrine symptoms.

ALLERGIES: Negative for allergic symptoms.

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Physical exam:

GENERAL: Female patient in her early 40s. She appears overweight, alert, and oriented. Her speech is clear and goal-directed, and she maintains eye contact throughout the session.

HEENT: Head: Atraumatic and normocephalic. Eyes: Bulging eyes bilaterally, lid lag, lid retraction, PERRLA. Ears: Tympanic membranes are intact and shiny, with minimal pus. Nose: Moist mucous membranes, patent nostrils. Throat: Tongue is midline, and tonsillar glands are non-inflamed.

NECK: Swollen; The thyroid gland is smooth and; thyroid bruits present.

CARDIOVASCULAR: Regular heart rate and rhythm. Audible S1 and S2 with no murmurs.

RESPIRATORY: Uniform chest rise and fall; smooth respirations; Chest is clear.

Diagnostic results:

TSH levels- elevated.

Differential Diagnoses

Graves disease: Grave’s disease is the most prevalent form of hyperthyroidism. The typical clinical features of Grave’s disease are increased levels of Thyroxine (T4) and enlargement of the thyroid gland. Ophthalmopathy is the hallmark of Graves disease and manifests with eye redness, swelling, upper eyelid retraction, lid lag, conjunctivitis, and bulging eyes Davies et al., 2020). Clinical symptoms include fatigue, general body weakness, sweating, warm, moist, fine skin, eye pain, photophobia, protruding eyes, double vision, heat intolerance, and weight loss despite increased appetite (Davies et al., 2020). Physical exam of the neck reveals a diffusely enlarged and smooth thyroid gland. Graves disease is a presumptive diagnosis based on positive symptoms of bulging eyes, fatigue, elevated TSH levels, thyroid bruits, and diffusely enlarged and smooth thyroid gland.

Subacute thyroiditis: Subacute thyroiditis is diagnosed based on a history of neck tenderness, respiratory tract infection, increased sedimentation rate, and inadequate or absent radioactive iodine consumption. It has a self-limited course. Local thyroid symptoms include dysphagia, pain over the thyroid area (gradual or sudden onset), and hoarseness (Stasiak & Lewiński, 2021). Constitutional clinical symptoms include fever, anorexia, malaise, fatigue, and myalgia. In stage three of the disease, TSH levels are usually elevated. Subacute thyroiditis is a differential diagnosis based on positive symptoms of swollen neck, fatigue, and elevated TSH levels.

Hashimoto Thyroiditis: Hashimoto Thyroiditis occurs due to the damage of thyroid cells by immune processes mediated by cells and antibodies. It is the most common cause of hypothyroidism. Symptoms include fatigue, energy loss, constipation, dry skin, weight gain, and bulging/protruding eyes (Ragusa et al., 2019). In addition, the TSH levels are invariably elevated. Positve clinical features of fatigue, bulging eyes, weight gain, and increased TSH levels support Hashimoto Thyroiditis as a differential diagnosis.

Goiter: Goiter presents with a distended thyroid gland (diffuse or nodular). The thyroid gland causes compresses adjacent organs causing shortness of breath, painful swallowing, stridor, nd voice hoarseness (Ragusa et al., 2019). The findings of a distended thyroid gland mae==ke Goiter a possible diagnosis.

Exophthalmos: Exophthalmos is an abnormal bulging of the eyeball. It is characterized by pupillary abnormalities. Patients also report pain, double vision, pulsation, change in effect or size with position, and disturbance in visual acuity (Topilow et al., 2020). Exophthalmos is a likely diagnosis owing to protruding eyes.

CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT References

Davies, T. F., Andersen, S., Latif, R., Nagayama, Y., Barbesino, G., Brito, M., Eckstein, A. K., Stagnaro-Green, A., & Kahaly, G. J. (2020). Graves’ disease. Nature reviews. Disease primers, 6(1), 52. https://doi.org/10.1038/s41572-020-0184-y

Ragusa, F., Fallahi, P., Elia, G., Gonnella, D., Paparo, S. R., Giusti, C., Churilov, L. P., Ferrari, S. M., & Antonelli, A. (2019). Hashimotos’ thyroiditis: Epidemiology, pathogenesis, clinic, and therapy. Best practice & research. Clinical endocrinology & metabolism, 33(6), 101367. https://doi.org/10.1016/j.beem.2019.101367

Stasiak, M., & Lewiński, A. (2021). New aspects in the pathogenesis and management of subacute thyroiditis. Reviews in Endocrine and Metabolic Disorders, 1-13. https://doi.org/10.1007/s11154-021-09648-y

Topilow, N. J., Tran, A. Q., Koo, E. B., & Alabiad, C. R. (2020). Etiologies of Proptosis: A review. Internal medicine review (Washington, D.C.: Online), 6(3), 10.18103/imr.v6i3.852. https://doi.org/10.18103/imr.v6i3.852

CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT Grading Rubric

Performance Category	100% or highest level of performance 100% 16 points	Very good or high level of performance 88% 14 points	Acceptable level of performance 81% 13 points	Inadequate demonstration of expectations 68% 11 points	Deficient level of performance 56% 9 points	Failing level of performance 55% or less 0 points
Total Points Possible= 50	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Scholarliness Demonstrates achievement of scholarly inquiry for professional and academic topics.	Presentation of information was exceptional and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was good, but was superficial in places and included all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information was minimally demonstrated in all of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in one of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in two of the following elements: Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information.	Presentation of information is unsatisfactory in three or more of the following elements Provides evidence of scholarly inquiry relevant to required TD topic(s). Presents specific information from scholarly sources to develop a comprehensive presentation of facts. Uses at least one outside scholarly reference that is relevant, less than 5 years old (use of older references requires instructor permission) and reliable for the required topic.* Uses in-text citation and full reference at end of posting when presenting another person’s thoughts as quotes or paraphrase of information
	16 Points	14 Points	13 Points	11 Points	9 Points	0 Points
Application of Course Knowledge Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations	Presentation of information was exceptional and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was good, but was superficial in places and included all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information was minimally demonstrated in the all of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in one of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from and scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in two of the following elements: Applies principles, knowledge and information from scholarly resources to the required topic. Applies facts, principles or concepts learned from scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.	Presentation of information is unsatisfactory in three of the following elements Applies principles, knowledge and information and scholarly resources to the required topic. Applies facts, principles or concepts learned scholarly resources to a professional experience. Application of information is comprehensive and specific to the required topic.
	10 Points	9 Points			6 Points	0 Points
Interactive Dialogue Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic.	Demonstrated all of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 3 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.			Demonstrated 2 of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.	Demonstrated 1 or less of the following: Initial post must be a minimum of 300 words. The peer and instructor responses must be a minimum of 150 words each. Responses are substantive Responses are related to the topic of discussion.
	8 Points	7 Points	6 Points	5 Points	4 Points	0 Points
Grammar, Syntax, APA Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error.	The following was present: 0-3 errors in APA format AND Responses have 0-3 grammatical, spelling or punctuation errors AND Writing style is generally clear, focused on topic,and facilitates communication.	The following was present: 4-6 errors in APA format. AND/OR Responses have 4-5 grammatical, spelling or punctuation errors AND/OR Writing style is somewhat focused on topic.	The following was present: 7-9 errors in APA format. AND/OR Responses have 6-7 grammatical, spelling or punctuation errors AND/OR Writing style is slightly focused on topic making discussion difficult to understand.	The following was present: 10- 12 errors in APA format AND/OR Responses have 8-9 grammatical, spelling and punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand.	The following was present: 13 – 15 errors in APA format AND/OR Responses have 8-10 grammatical, spelling or punctuation errors AND/OR Writing style is not focused on topic, making discussion difficult to understand. AND/OR The student continues to make repeated mistakes in any of the above areas after written correction by the instructor.	The following was present: 16 to greater errors in APA format. AND/OR Responses have more than 10 grammatical, spelling or punctuation errors. AND/OR Writing style does not facilitate communication
	0 Points Deducted					5 Points Lost
Participation Requirements	Demonstrated the following: Initial, peer, and faculty postings were made on 3 separate days					Failed to demonstrate the following: Initial, peer, and faculty postings were made on 3 separate days
	0 Points Lost					5 Points Lost
Due Date Requirements	Demonstrated all of the following: The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.					Demonstrates one or less of the following. The initial posting to the graded threaded discussion topic is posted within the course no later than Wednesday, 11:59 pm MT. A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT.