NR511 SNAPPS ORAL PRESENTATION TEMPLATE Week 2 Complete Solution
This template should only be used to organize your oral presentation, IT SHOULD NOT BE
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SUMMARIZE
Using a patient seen in the practicum setting, summarize the H&P into an organized and concise format.
CC
Nasal congestion and headache
HPI statement using OLDCARTS data
SA is a 46-year-old Caucasian female that presents to the office with complaints of nasal congestion with drainage, headache, right ear pain, and intermittent cough.
Onset: 3 days ago
Location: nose, head, face, and right ear
Duration: nasal congestion and pain has been persistent and constant for the past 3 days
Characteristics: nasal congestion is mild to moderate alternating with clear to yellow drainage, headache is dull, right ear pain is reported as dull with a significant amount of pressure, and intermittent cough. Reports pain 2 out of 10
Aggravating factors: more severe when bending or leaning
over
Relieving factors: Rest and warm rice sock to face and right ear
Treatment: Ibuprofen and Tylenol cold
Denies history of allergies to drugs, foods, latex, animals, or environmental factors
Denies: use of tobacco products or vaping products
Pertinent ROS
Denies: fever/ chills/night sweats
Denies: watery, itchy or painful eyes
Denies: sore throat, difficulty swallowing, shortness of breath, or sneezing.
Patient does report: Body aches, nasal congestion, clear to yellow nasal drainage, anosmia, headache, facial pain, right ear pain and pressure, as well as an intermittent non-productive cough especially at night
Pertinent PE
HEENT: Maxillary sinuses are tender upon palpation
Clear fluid is noted in the right ear, however, there is no erythema or edema
Nasal turbinates’ are erythematous with edema and clear to yellow Drainage noted bilaterally
Post nasal pharynx is pink and moist with the presence of
Drainage
Halitosis noted
Cardiopulmonary: S1S2 heard with no additional heart sounds
Bilateral breath sounds clear and equal in all lobes
NARROW
Based on the H&P key findings, identify an appropriate differential.
Influenza
Dental infection
Acute Sinusitis
ANALYZE
Analyze the differential by comparing and contrasting the possibilities. Use pertinent positive and negative findings to argue for or against each diagnosis in your differential. Rank your diagnoses in order of most likely to least likely.
Out of the differential diagnosis:
First would be: Acute Sinusitis:
Because it involves inflammation of the paranasal sinuses and the nasal cavity and interferes with the ability to drain mucus from the nasal cavity and sinuses, leading to congestion and infection
Suggestive positive findings are the presence of facial pain, pressure, clear to yellow drainage, headache, cough, anosmia, post-nasal drainage, and maxillary tenderness upon palpation
Pain in worse when patient bends or leans over
Second would be: Dental infection:
Symptoms of dental infection include fever, halitosis, facial pain, and edema
Positive findings are that patient exhibit halitosis, facial pain, headache, and maxillary tenderness. However, patient is afebrile, without facial edema, is absent of tooth pain and presents with good dentition.
Thirds would be: Influenza:
Classic symptoms of influenza include fever greater than 100.4, body aches, chills, sweats, headache, persistent cough, malaise, nasal congestion and sore throat.
Is currently flu season, however, patient is afebrile, without chills or sweats, persistent cough, malaise, or sore throat
PROBE
Verbalize any knowledge gaps, points of confusion or dilemmas that you have regarding your understanding of the case by identifying questions that you would (or did) ask your preceptor.
During flu season do you always collect a rapid flu swab when a patient presents with these symptoms?
PLAN
At a novice level, propose an appropriate plan to confirm and/or manage the problem.
No diagnostic testing
Treatment of symptoms with:
• Oral decongestants
• Tylenol or ibuprofen for headache and body aches
• Saline nasal irrigation using distilled or boiled “cooled” water. Squeeze bottles are best
• Flonase for nasal congestion and ear fullness, following nasal saline irrigation
• Humidified air can improve mucus clearance
• Increase fluid intake of at least 6 to 8 20-ounce bottles of water, to thin secretions
• Sleep with head of bed elevated to promote drainage
• Get plenty of rest
• Call the office for acute follow up if symptoms persist greater than 3 to 5 days or if symptoms worsen
• Possibly consider antibiotic therapy if symptoms do not resolve
SELF-DIRECTED LEARNING
Identify one issue for self-directed learning.
How do you determine when to treat an acute sinusitis infection with antibiotics?
In the written portion of this assignment, you will present your findings. [Show Less]