I need assistance with writing a case study scenario using SOAP format and APA style format. NO PLAGIARISM allowed. Will need attachment documentation for turnitin. PLEASE read the instructions. Will

I need assistance with writing a case study scenario using SOAP format and APA style format. NO PLAGIARISM allowed. Will need attachment documentation for turnitin. PLEASE read the instructions. Will
Case Study#2 Assignment Instructions:  1. Write a case study about the given case scenario using the SOAP format.  2. Review and follow the case study writing outline and rubric in building your case and as basis of grading.  3. Paperwork must be submitted via assignment link provided in the Blackboard on or before 7/29/2020 11:59 pm.   Case Scenario: A 21-year old college student and self-described as a “ladies’ man” presents to the clinic because of a concerning spot that developed on his penis. He complains of pain at the spot but denies itching. He reports no fever. When asked further about his sexual practices, he reports no condom use because his partners are all “on the pill.” He had chlamydia in high school but is otherwise healthy.   The rest of the pertinent medical histories are unremarkable.  His review of systems is negative.   VS: BP 120/80; HR  70; RR 16; T 98.0 F; Pain level 3/10  On examination of the penis, you find a 1-cm tender, erythematous papule with a deep central ulceration at the glans penis. There is some mild, tender lymphadenopathy in the inguinal area. The rest of the examination is unremarkable. 
I need assistance with writing a case study scenario using SOAP format and APA style format. NO PLAGIARISM allowed. Will need attachment documentation for turnitin. PLEASE read the instructions. Will
Running head: CASE STUDY 1: ADULT ONSET ASTHMA CASE STUDY 1: Adult Onset Asthma Irene Pocasangre, RN, BSN, PHN, FNP-S Mervyn M. Dymally School of Nursing Charles R. Drew University of Medicine and Science June 30th 2020 This paper was written for NUR 620 Physical Assessment taught by Nancy Diago Abstract This case study takes place in an Urgent Care (UC). The patient that self presented to the UC consist of the following given scenario: A 25-year-old previously well woman presents to your office with complaints of episodic shortness of breath and chest tightness. She has had the symptoms on and off for about 2 years but states that they have worsened lately, occurring two or three times a month.She notes that the symptoms are worse during the spring months. She has no exercise-induced or nocturnal symptoms. The family history is notable for a father with asthma. She is single and works as an administrative assistant in a high-tech firm. She lives with a roommate, who moved in approximately 2 months ago. The roommate has a cat. The patient smokes occasionally when out with friends and drinks socially but has no history of illicit drug use. Pertinent PE findings include the following:VS 115/80 HR 84 RR 22 T 98.6 O2 sat 95% room air. Pertinent physical examination is notable for mild end-expiratory wheezing. The rest of the PE findings are unremarkable. Case Study 1: Adult Onset Asthma PATIENT INFORMATION: W.E. is a 25-year-old woman who self-presented to Urgent Care (UC) for medical services. CHIEF COMPLAINT: Patient states “I have been having more episodes of shortness of breath and chest tightness”. HISTORY OF PRESENT ILLNESS: W.E. self presented to UC stating that she has been experiencing shortness of breath and chest tightness on and off for about 2 years now. However, symptoms have been increasing in frequency. She reports experiencing these symptoms two to three times a month. Symptoms appear to be worst during the spring months. Currently, W.E. denies worsening symptoms when exercising or at nighttime. Denies identification of triggers at this time. Patient reports that it is difficult to catch her breath, symptoms have resolved with no interventions. However, the increase in number of episodes a month is worrisome enough to have her come in today. ALLERGIES: No known food or drug allergies. PAST MEDICAL HISTORY: Denies any medical history, accidents, or any past hospitalizations. Reports that Immunization status is up to date, Influenza vaccine last received on 12/15/2019. PAST SURGICAL HISTORY: Patients denies any previous surgeries. FAMILY HISTORY: Mother is reported to be well and alive with no medical history. Father has a history of asthma. Denies family history of Hypertension, Diabetes, Heart Disease or Cancers. SOCIAL HISTORY: Works as an administrative assistant in a high-tech firm. Usually works long hours, but the pay is adequate for the job. Patient reports being single. Lives with roommate and roommates’ cat, as of two months ago. Father, mother and younger brother live 20 minutes away, parents are very supportive. Smokes occasionally when out with friends, drinks socially, denies drug use. SEXUAL HISTORY: Currently practicing celibacy. Last Pap smear almost 4 years ago. MEDICATIONS: Denies taking any medications. REVIEW OF SYSTEMS: Constitutional: Denies chills, fever, fatigue, weakness, weight changes, headaches, malaise, or night sweats. Skin: No rash, discoloration, itching, pruritus, lumps/bumps, nail, or hair changes. Head: No headache, dizziness, lightheadedness, or vertigo. Eyes: No changes in vision, eye pain, tearing, eye discharge. Ears: No ear pain, discharge, ear fullness, tinnitus, or hearing loss. Nose/Sinuses: No congestion, nasal discharge, epistaxis, sinus pain, sneezing, Oral: No sores, dental cavities, gum lesions or gingivitis, gum bleeding. Throat/Neck: No sore throat, hoarseness, dysphagia, neck pain, or neck swelling. Cardiovascular: (+)Occasional chest pain and shortness of breath. Denies palpitations, orthopnea, or worsening symptoms at nighttime. Respiratory: (+) Occasional shortness of breath, trouble breathing, and wheeze. No cough, congestion or hemoptysis. Gastrointestinal: no abdominal pain, nausea, vomit heartburn, changes in bowel habits or blood in stools. Genitourinary: No dysuria, hematuria, urinary frequency, incontinence, genital discharge. Musculoskeletal: No leg pain, cramps, joint pain, joint stiffness, swelling, redness or weakness. Neurological: No headaches, seizures, tremors, numbness, or tingling. Endocrine: No polyphagia, polydipsia, polyuria, denies intolerance to heat or cold. Hematological: No easy bruising Psychiatric: No anxiety, feeling of sadness, mood swings, insomnia. PHYSICAL EXAMINATION: General Survey: Patient is awake, alert, oriented, not in acute respiratory distress. VS: BP: 115/80 mmHg HR: 84/min RR: 22/min Temp: 98.6F (oral) O2 sat 95% room air Hgt: 5’5” Wgt:120­ lbs BMI: 21.6 Skin: Intact, pink, warm, moist, free of rashes, no atypical pigmentation. Head: Normocephalic/atraumatic, even hair distribution, no scalp lesions or bald spots, no scalp tenderness or palpable mass. Eyes: no ptosis, pink palpebral conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation (PERRLA), (+) intact extraocular muscles (EOM’), (+) red orange reflex bilaterally, fundoscopic findings shows no papilledema, no retinal hemorrhages, blood vessels appear normal with sharply demarcated optic disc. Ears: normal pinna, no lesions, no tragal tenderness, otoscopy showed non erythematous ear canal, minimal cerumen, no aural discharge, tympanic membrane pearly gray, good cone of light, no bulging or retraction, bilaterally. Nose/Sinus: nasal septum midline, nostrils patent bilaterally, no nasal discharge, no inflammation, pink nasal mucosa, no bogginess noted, no tenderness over frontal and maxillary sinuses. Oral/Throat: pink moist oral mucosa, no oral lesion, good dentition, no dental caries, no halitosis, no gum lesions, swelling or bleeding. Pink pharyngeal wall, no airway obstruction Neck: supple, no tenderness, no stiffness, carotid pulse with normal upstroke, no bruit appreciated. Trachea midline, thyroid normal size and consistency, no palpable mass, no JVD. Cardiac: normal rate regular rhythm, no heaves, no thrills, S1 and S2 sounds normal, no gallops, clicks or rubs. PMI best appreciated on the 5th ICS-MCL, no murmur. No edema to extremities. Lungs: respiratory effort even with noted tachypnea. No intercostal or supraclavicular retractions, symmetrical chest expansion, equal tactile fremitus bilaterally, resonant on percussion with noted hyperresonance or dullness. End expiratory wheezing with prolongation of expiratory phase noted. No ronchi, no rales. Abdomen: flat, nontender and nondistended. No skin discoloration, no visible lesion, flat umbilicus, normoactive bowel sounds, liver span 6.5 cm, spleen non palpable, no mass Genitalia: Deferred per patient request. Extremities: no rashes, no abnormal pigmentation, no edema, no swelling, no deformity, pulse full and equal on all extremities, good range of motion, muscle strength 5/5 on all extremities. Neurologic: alert, oriented to time, and place, responds appropriately to questions and follows simple commands, CN I – XII intact, good coordination and balance, no gross or fine motor deficits. ASSESSMENT: PRIMARY DIAGNOSIS: Adult Onset Asthma The patient in this case study presented with adult onset asthma. Adult onset asthma is noted during physical examination with symptoms of end-expiratory wheezing and slightly tachypneic with respiration of 22. Although SaO2 is 95%, it is noted to be low normal for a fairly healthy 25-year-old. Subjective information includes chest tightness and shortness of breath. These symptoms demonstrate bronchial hyperresponsiveness and strongly suggest a diagnosis of adult onset asthma. The roommate’s cat may be a trigger or allergen for this specific patient. Exposure to allergens can initiate a cascade of cellular activation events in the airway leading to acute and chronic inflammatory response resulting in the release of cytokines and other mediators (Asthma and Allergy Foundation of America. 2020). Mediators cause increase airway inflammation, air way hyperresponsiveness and asthma symptoms. The cascading events can result in permanent changes in both structure and function of the airway. PATHOPHYSIOLOGY Asthma is a common pulmonary condition defined by airway inflammation that causes inflammation to the respiratory tubes, tightening of respiratory smooth muscles, and episodes of brochoconstriction (Brashers, V., & Rote, N. 2018). The airways narrow resulting in an increase in resistance that manifest as episodes of coughing, shortness of breath, and wheezing (Brashers, V., & Rote, N. 2018). Airway capillaries may dilate and leak, increasing secretions, which in turn causes edema and impairs mucus clearance (Brashers, V., & Rote, N. 2018). The increase in mucus can cause plugs that block the airway. It can affect the trachea, bronchi, and bronchioles. In many healthy individuals the airway does not contribute to significant changes to airflow resistance. Loss of the epithelia’s barrier function allows allergens to penetrate, causing the airways to become hyperresponsiveness (Brashers, V., & Rote, N. 2018). The extent of inflammation along with the individual’s immunologic response will account for the level of hyperresponsiveness. DIFFERENTIAL DIAGNOSES: Acute Coronary Syndrome Acute Coronary Syndrome (ACS) is a term that encompasses many cardiac diagnoses, which include STEMI, NONSTEMI, unstable angina, cardiac arrhythmia, and cardiac tamponade (Uptodate, 2020). These cardiac diseases can reduce blood flow to the heart causing changes in how the heart works. These changes can predispose individuals to heart attacks or even sudden death. These symptoms include chest pain, shortness of breath, nausea, vomit, dizziness, lightheadedness, fatigues, and sudden sweating (Uptodate, 2020). Many times, dyspnea might be the only presentation, especially in females, older adult, and diabetics. In this case, ruling out ACS is imperative. Heart failure can also mimic symptoms of asthma, however, this patient is too young and healthy to suspect heart failure at this time. Pulmonary Embolism Pulmonary Embolism (PE) occurs when there is a blockage in the pulmonary arteries by a blood clot that usually forms in other parts of the body, dislodges and travels upwards (Wedo, B., 2019). It usually forms in the deep veins of the upper and lower extremities. Symptoms can be very similar to that of asthma; symptoms include dyspnea at rest, tachypnea, anxiety, and pleuritic chest pain (Wedo, B., 2019). Symptoms can present acute or chronic. Diagnosis can be suspected if patient reports prolonged immobilization such as in prolonged bedrest due to surgery or illness or prolonged sitting during traveling, trauma to one of the extremities, bleeding abnormalities, pregnancy, use of birth control, or certain cancers. PE is not the proper diagnosis for this patient as patient denies recent immobilization as she continues to work as schedule, recent travel as she denies taking any vacations, denies being sexually active at this time with no need to take contraception, and denies any medical history. Physical examination did not observe edema, redness, tenderness to any of the 4 extremities. Chronic obstruction pulmonary disease can mimic symptoms of asthma; however, this patient does not seem to suffer from progressively worsening lung disease, cough and trouble breathing. The patient reports episode of shortness of breath and chest pain, increasing in frequency. Patient denies being a heavy smoker and physical assessment did not find signs of barrel chest. PLAN:  DIAGNOSTIC TESTS: Electrocardiogram An electrocardiogram (EKG) is a noninvasive, painless diagnostic procedure that measures electrical signals in the heart. It can detect irregular heart rhythms and identify causes of chest pain, shortness of breath, dizziness and fainting. The test consists of having small electrodes attached to specific areas in the chest and extremities while a technician records the signal. The procedure can take a few minutes, typically less than 10. This test can rule out emergent situations such as a ST-Elevation Myocardial Infarction (Papadakis, M & McPhee, S. 2020). Individuals presenting with chest pain or epigastric pain should have an EKG completed to rule out STEMI. This test can also help identify abnormal rhythms such as Atrial fibrillation. Chest Radiography Chest radiography (CXR) is another noninvasive diagnostic tool that is used to identify conditions of the lungs such as pneumonia, pulmonary edema, pulmonary effusion, lung mases or nodules (Papadakis, M & McPhee, S. 2020). It uses small amount of radiation to create an image of the structures within the chest as a beam of radiation passes through the body. As a result, a black and white image is created. Asthma is not diagnosed using a radiographic image, however, it can be very useful in ruling out other lung diseases. Ancillary Laboratory Tests A. Cardiac Panel- A cardiac panel identifies abnormal cardiac enzymes and cardiac markers. It is useful in identify cardiac emergencies such as STEMI’s. It can be use in conjunction with an EKG to assess the heart condition. A negative cardiac panel rules out a cardiac event. B. Complete Blood Count – A CBC is important when providing care for a patient reporting shortness of breath. Although a CBC can identify eosinophilic asthma, it can also identify other conditions such as anemia which can cause shortness of breath and fatigue (Papadakis, M & McPhee, S. 2020). C. Basic Metabolic Panel (BMP) – A BMP can provide information about the body’s fluid and electrolyte balance. Electrolytes, like potassium, play a role in cardiac health. Hyperkalemia and hypokalemia can affect the heartbeats and cause arrythmias. Ruling electrolyte imbalance is necessary. 4. Peak Expiratory Flow- A peak flow is a handheld device that measures how well air flows out the lungs. Peak expiratory flow (PEF) can be an important aspect of asthma management. It can help identify early signs of an asthma attack or when medication is no longer producing optimal results and might require changes. PEF monitoring can establish peak flow variability and quantify asthma severity, can be very useful in new adult onset asthma as baseline condition is crucial (Papadakis, M & McPhee, S. 2020). MEDICAL MANAGEMENT:   Medical management of Adult Onset Asthma generally consists of pharmacological interventions. Medications can generally be divided into two different categories, the reliever and the controller (Papadakis, M & McPhee, S. 2020). Relieving medication act primarily by promoting direct relaxation on bronchial smooth muscles while controlling medication helps to attenuate airway inflammation and are taken daily independent of symptoms. (Papadakis, M & McPhee, S. 2020). For this case scenario, pharmacological management consists of prescribing Albuterol, a Beta-adrenergic agonist (SABA). SABAs are considered the rescue therapy of asthma patients making them extremely important and accessible to all asthma patients. According to Papadakis, M & McPhee, S. (2020) “SABAs are the most effective bronchodilators during exacerbations and provide immediate relief of symptoms”. For those with mild to moderate symptoms, one-two inhalations of a SABA would suffice, however, “severe exacerbations frequently require higher doses: 6–12 puffs every 30–60 minutes of albuterol by MDI with an inhalation chamber or 2.5 mg by nebulizer provide equivalent bronchodilation” (Papadakis, M & McPhee, S. 2020). Albuterol comes in tablet form, immediate and extended release, oral solution and inhaled solution. Immediate release tablet comes in 2 mg and 4 mg with usual prescription of 2-4 mg PO tid-qid; Max of 32 mg/day (Papadakis, M & McPhee, S. 2020). Extended release tablets come in 4 mg and 8 mg, with usual prescription of 4-8 mg ER PO q 12h; Max of 32 mg/day. Do not cut, crush, or chew ER tablets (Papadakis, M & McPhee, S. 2020). Oral solution comes in 2mg/5ml and would follow the immediate release order (Papadakis, M & McPhee, S. 2020). Inhaled albuterol MDI comes in 90 mcg per actuation. For bronchospasm the order usually is for 2 puffs inhaled q 4-6h prn (Papadakis, M & McPhee, S. 2020). Prescription for this patient would be as follow: Abuterol 90 mcg 2 puffs inhaled q 4-6h prn shortness of breath wheezing Using the table above, from CURRENT Medical Diagnosis & Treatment 2020, patient falls under Step 1 where SABA PRN is the only recommended pharmacological intervention.  PROGNOSIS: The prognosis of asthma is not well described, however, when well-managed, life expectancy can be as long as someone without asthma. Different factors such as smoking, persistent presence of irritants and lifestyle choices can play a role. Education will be necessary to inform patients of the DO’s and Don’ts after an asthma diagnosis has been given. In recent months, there has been increase awareness associated with asthma patients being more susceptible to other illness such as COVID-19. HEALTH PROMOTION/REFFERAL Patient will be instructed to stay current with vaccinations such as influenza and pneumonia, when of age, in order to prevent triggering asthma flare-ups. Avoiding known allergens is important. This patient is appropriate for a Nurse Practitioner (NP) as a provider in an Urgent Care setting. The NP is able to provide enhance care and education for asthma control, prescribe medication for acute phase or management of the diagnosis. Patients with moderate to severe asthma may require referral to a specialist, the NP must be able to discern which patients require referrals. In this case, the patient will need to see their PCP for follow up visits at periodic intervals in order to assess their asthma control and to modify treatment plan if needed (Papadakis, M & McPhee, S. 2020). In the UC setting, the patient will receive information of what is asthma, medications and devices, and an asthma action plan, however, the PCP will be able to provide the patient with additional resources available, such as Asthma Education in Home Visits and a home exposure assessment (Center of Disease Control and Prevention. 2020). The patient’s PCP can refer them to a Pulmonologist if asthma worsens. A pulmonologist referral is appropriate since they specialize in diseases that affect the lungs, upper airway, thoracic cavity and chest wall (Allergy & Autoimmune Disease, 2020). A pulmonologist can better treat moderate to severe asthma. Depending on the severity of the asthma, a pulmonologist can then refer the patient to an allergist-immunologist to better treat the patient. An allergist-immunologist can help identify allergy and asthma triggers (Allergy & Autoimmune Disease, 2020). FOLLOW UP CARE/REFERRAL: Follow up care will include visit with PCP in seven days. Patient with also need planned follow up visits with PCP at periodic intervals in order to assess asthma control and to modify treatment plan if needed. Patient will be instructed to return if symptoms do not improve or if experiencing nausea, vomit, headache or severe pain. Call 911 or seek emergency services if experiencing worsening trouble breathing or shortness of breath unresolved with prescribed medication, swelling of the face/tongue, or feeling of closing of the airway. This patient is also overdue for a pap-smear and would benefit from a woman health referral. According to Womenshealth.Gov. 2020, pap-smears should be done every 3 years between the ages of 21-29, unless there is a history of sexual transmitted diseases/infections. PATIENT EDUCATION: Patient education will consist on aftercare instructions following an asthma diagnosis. Education will include a comprehensive explanation of what adult onset asthma is, signs symptoms to monitor, medication regimen, side effects of the medication, and when to seek medical help. Patient will be instructed to carry rescue medication with them at all times. If asthma symptoms are not resolved with the use of prescribed medication, seek medical help. References Asthma and Allergy Foundation of America. 2020. Adult Onset Asthma. Retrieved from https://asthmaandallergies.org/asthma-allergies/adult-onset-asthma/ Allergy & Autoimmune Disease. 2020. Allergies and Asthma. Retrieved from https://www.thermofisher.com/diagnostic-education/hcp/us/en/allergic-asthma-diagnosis-treatment.html?gclid=CjwKCAjwxev3BRBBEiwAiB_PWOhfkXM_jkHEuunydfoTfE33PoorxhiWQownL7wnSumtbLhOHbweDxoCbEcQAvD_BwE&cid=idd_standard_adwords_0120&ef_id=CjwKCAjwxev3BRBBEiwAiB_PWOhfkXM_jkHEuunydfoTfE33PoorxhiWQownL7wnSumtbLhOHbweDxoCbEcQAvD_BwE:G:s&s_kwcid=AL!8552!3!389636482731!b!!g!!%2Bdiagnose%20%2Basthma!6890339487!83463654207 Baldwin, Gran., Nastoff, Teresa., & Wade Pharagood. 2008. Environmental Triggers of Asthma. Retrieved from https://www.atsdr.cdc.gov/hec/csem/asthma/docs/asthma.pdf Brashers, Valentina & Rote, Neal. 2018. Pathophysiology 8th ed. Elsevier. Cleveland, Ohio. Center of Disease Control and Prevention. 2020. Strategies for addressing Asthma in Homes. Retrieved from https://www.cdc.gov/asthma/pdfs/Asthma_In_Homes_508.pdf Papadakis, M & McPhee, S. 2020. Current 2020 Medical Diagnosis and Treatment 59th ed. Mc Graw Hill. E-book conversion Pawankar R, Holgate S, Canonica G, at el. World Allergy Organization. White Book on Allergy (WAO). 2011. Retrieved from http://www.worldallergy.org/UserFiles/file/WAO-White-Book-on-Allergy_web.pdf Uptodate. 2020. Acute Coronary Syndrome. Retrieved from https://www.uptodate.com/contents/acute-coronary-syndrome-terminology-and-classification Wedo, Benjamin. 2019. Pulmonary Embolism (Blood Clot in the Lung). Retrieved from https://www.medicinenet.com/pulmonary_embolism/article.htm Womenshealth.Gov. 2020. Pap Smear. Retrieved from https://www.womenshealth.gov/a-z-topics/pap-hpv-testsy
I need assistance with writing a case study scenario using SOAP format and APA style format. NO PLAGIARISM allowed. Will need attachment documentation for turnitin. PLEASE read the instructions. Will
GUIDELINES FOR INDIVIDUAL CASE STUDY Required elements of the case study: All papers are to be type written, double spaced, with pages numbered. Please write course name and number, your name, and date clearly on materials submitted. Use American Psychological Association (APA) style 6th edition including paper format and references. Points may be deducted for multiple spelling, grammar, format and typing errors. 1.    Subjective (0.5 point) State the patient’s chief complaint, reason for visit and/or the problem for which the patient sought consultation. All symptoms related to the problem are described using the following cue descriptive categories: Precipitating/alleviating factors (including prescribed and/or self-remedies and their effect on the problem). Associated symptoms Quality of all reported symptoms including the effect on the patient’s lifestyle Temporal factors (date of onset, frequency, duration, sequence of events) Location (localized or generalized? does it radiate?) Sequelae (complications, impact on patient and/or significant other) Severity of the symptoms Past Medical History including immunizations, allergies, accidents, illnesses, operations, hospitalizations. Family History includes family members’ health history. Social history to include habits, residence, financial situation, outside assistance, family inter-relationships. Review of Systems relevant to the chief complaint/presenting problem is included. Include pertinent positives and negatives. 2.  Objective (0.5 point) Using inspection, palpation, percussion, and auscultation, the examiner evaluates all systems associated with the subjective complaint including all systems which may be causing the problem or which will manifest or may potentially manifest complications and records positive and pertinent negative findings Performs appropriate diagnostic studies if equipment is available Records results of pertinent, previously obtained diagnostic studies. Use Handout Guidelines to Physical Examination. 3.  Assessment (1.5 points) Diagnosis/es is (are) derived from the subjective and objective data highlighting the pathophysiology of the case/s. Differential diagnoses are prioritized (minimum of 3) Diagnosis/es come(s) from the medical and/or nursing domain Assessment includes health risks/needs assessment 4.  Plan (1.5 points) Appropriate diagnostic studies with rationale Therapeutic treatment plan with rationale Was this patient appropriate for a nurse practitioner as a provider? Is consultation or collaboration with another health care provider required? Health promotion/disease prevention carried out or planned: education, discussion, handouts given, evidence of patient’s understanding. What community resources are available in the provision of care for this client? Referrals initiated (including to whom the patient is referred to and the purpose) Target dates for re-evaluating the results of the plan and follow up 5.  Other (1 point) Information is typed, double-spaced, 12pt font, and concise (using short paragraphs and phrases) Information is written so that the objective reader can follow the progression of events and information Only standard, accepted medical terminology and abbreviations are used. At least three (3) references from recent professional journal publications are required for each (APA format).  These can include but not limited to medical, research, pharmacological or advanced practice nursing journals.  More than 3 references should be used. Rationales need to include a clear demonstration of the use of evidence-based practice in decision-making.  Risks and benefits as well as how an intervention was determined to be evidence-based will be clear to the reader. Rationales need to include a clear demonstration of the use of evidence-based practice in decision-making.  Risks and benefits as well as how an intervention was determined to be evidence-based will be clear to the reader.
I need assistance with writing a case study scenario using SOAP format and APA style format. NO PLAGIARISM allowed. Will need attachment documentation for turnitin. PLEASE read the instructions. Will
CASE STUDY: ACUTE EXUDATIVE TONSILLITIS 1 CASE STUDY: ACUTE EXUDATIVE TONSILLITIS Maria Makiling, RN, FNP-S NUR 620 Advanced Physical Assessment Mervyn M. Dymally School of Nursing Charles R. Drew University of Medicine and Science February 29, 1999 ABSTRACT This is a case of a 17-year old male who presented with an acute onset of sore throat, painful swallowing, hoarseness, bilateral ear pain, headache, body malaise, and fever. The physical findings of enlarged hyperemic tonsils with yellowish exudate along with presenting symptoms is suggestive of bacterial etiology. An initial diagnosis of Acute Exudative Tonsillitis was made with differential diagnoses of Acute Mononucleosis, Peritonsillar Abscess and Gonococcal Pharyngitis. Diagnotic tests to confirm initial diagnosis and to rule out the differential diagnoses include Rapid Antigen Detection Test, throat culture for Group A Beta Hemolytic Streptococcus and Neisseria Gonorrhea, Monospot test. Once diagnosis is confirmed and GABHS is established as the causative agent, empiric antibiotic treatment should be started immediately. Penicillin V is the first line of antibiotic but Amoxicillin is most often prescribed. Antibiotic treatment should be completed for 10 days. This ensures relative protection from complications such as rheumatic fever. In patients with Penicillin or Amoxicillin allergy, Macrolide is an alternative choice with the advantage of shorter antibiotic treatment, typically 3 – 5 days, which translates to better patient compliance and a greater chance of completion of the full course of antibiotic therapy. Supportive measures include bed rest, oral hydration, analgesics and steroids. Patient should be educated about personal hygiene with emphasis on hand washing, avoid touching mouth, nose, or eyes, keeping distance from infected individuals and safe sex practice. CASE STUDY: ACUTE EXUDATIVE TONSILLITIS PATIENT INFORMATION: S.J. is a 17-year old Caucasian male. CHIEF COMPLAINT: Sore throat for 2 days HISTORY OF PRESENT ILLNESS: S.J. was brought in by his mother because of sore throat which occurred two days prior to consult. Mother shared that her son was exposed to a classmate with similar symptoms one day prior to the appearance of his symptoms. S.J. describes his sore throat as constant, burning in nature, 9/10 on the pain scale and worsens with eating and swallowing especially non liquid food. This was also associated with hoarseness, headache, body weakness and high fever (maximum reading of 101.9 F) which breaks off with intake of Tylenol 500 mg every 4 hours as needed. Patient also states that he would experience some relief of sore throat when drinking warm lemon juice. Due to his symptoms progressively getting worse, mother decided to bring him for medical consultation. ALLERGIES: No known food or drug allergies. PAST MEDICAL HISTORY: Patient denies any previous hospitalizations and presence of other co morbid medical conditions. Immunization status up to date. PAST SURGICAL HISTORY: Patients denies any previous surgeries. FAMILY HISTORY: (-) Heart Disease, Kidney pathology, Rheumatic Fever SOCIAL HISTORY: High school student attending public education, resides with parents and 2 other younger siblings. Denies smoking, alcohol intake, and tobacco or illicit drug use. SEXUAL HISTORY: Sexually active, in a monogamous relationship with current partner. REVIEW OF SYSTEMS: Constitutional: No chills, weight changes, fatigue, weakness, night sweats. Skin: No rash, discoloration, itching, pruritus, lumps/bumps, nail, or hair changes. Head: (+) headache, no dizziness, lightheadedness, or vertigo. Eyes: No changes in vision, eye pain, tearing, eye discharge. Ears: (+) ear pain bilaterally worse with swallowing, no aural discharge, ear fullness, tinnitus, or hearing loss. Nose/Sinuses: No congestion, nasal discharge, epistaxis, sinus pain, sneezing, Oral: No sores, dental cavities, gum lesions or gingivitis, gum bleeding. Throat/Neck: (+) sore throat, hoarseness, dysphagia, no neck pain, no neck swelling. Cardiovascular: No chest discomfort, palpitations, orthopnea, shortness of breath. Respiratory: No dyspnea, cough, hemoptysis, shortness of breath, wheeze. Gastrointestinal: Unable to eat well due to painful swallowing, no abdominal pain, heartburn, nausea, vomiting, changes in bowel habits or blood in stools. Genitourinary: No dysuria, hematuria, urinary frequency, incontinence, genital discharge. Musculoskeletal: No leg pain, cramps, joint pain, joint stiffness, swelling, weakness. Neurological: No headaches, seizures, tremors, numbness, tingling. Endocrine: No polyphagia, polydipsia, polyuria, denies intolerance to heat or cold. Hematological: No easy bruising, anemia. Psychiatric: No anxiety, feeling of sadness, mood swings, insomnia. PHYSICAL EXAMINATION: General Survey: Patient is awake, alert, oriented, not in acute respiratory distress. VS: BP:110/78 mmHg PR: 100/min RR: 18/min Temp:101F (oral) O2 sat: 98% Hgt: 5’7” Wgt:150 lbs BMI: 23.49 Skin: pink, warm, moist, intact, no rashes, no atypical pigmentation. Head: normocephalic, even hair distribution, no scalp lesions or bald spots, no scalp tenderness or palpable mass. Eyes: no ptosis, pink palpebral conjunctivae, anicteric sclerae, pupils equally reactive to light and accommodation, (+) red orange reflex bilaterally, fundoscopic findings shows no papilledema, no retinal hemorrhages, blood vessels appear normal with sharply demarcated optic disc. Ears: normal pinna, no lesions, no tragal tenderness, otoscopy showed non erythematous ear canal, minimal cerumen, no aural discharge, tympanic membrane pearly gray, good cone of light, no bulging or retraction, bilaterally. Nose/Sinus: nasal septum midline, nostrils patent bilaterally, no nasal discharge, pink nasal mucosa, no bogginess noted, no tenderness over frontal and maxillary sinuses. Oral/Throat: pink moist oral mucosa, no oral lesion, good dentition, no dental caries, no halitosis, no gum lesions, swelling or bleeding. Pink pharyngeal wall, cherry red swollen tonsils (+3) with yellowish exudates bilaterally. Neck: supple, no tenderness, no stiffness, carotid pulse with normal upstroke, no bruit appreciated. Palpable mobile, enlarged tender superficial cervical lymph nodes bilaterally, trachea midline, thyroid normal size and consistency, no palpable mass. Cardiac: normal rate regular rhythm, no heaves, no thrills, S1 and S2 sounds normal, PMI best appreciated on the 5th ICS-MCL, no murmur. Lungs: respiratory effort even and unlabored, no intercostal or supraclavicular retractions, symmetrical chest expansion, equal tactile fremitus bilaterally, resonant on percussion, clear breath sounds on all lung fields, no wheeze, no ronchi, no rales. Abdomen: flat, no skin discoloration, no visible lesion, flat umbilicus, normoactive bowel sounds, soft, no tenderness on palpation, liver span 7 cm, spleen non palpable, no mass Genitalia: Tanner stage V, normal looking circumcised penis, no penile discharge, testes bilaterally descended, non tender, no swelling, no palpable scrotal or testicular mass. Extremities: no rashes, no abnormal pigmentation, no edema, no swelling, no deformity, pulse full and equal on all extremities, good range of motion, muscle strength 5/5 on all extremities. DTRs (+2) bilaterally. Neurologic: alert, oriented to time, and place, responds appropriately to questions, CN I – XII intact, good coordination and balance, no gross or fine motor deficits. ASSESSMENT: PRIMARY DIAGNOSIS: Acute Exudative Tonsillitis The patient is this case study presented with an acute onset of sore throat, fever, odynophagia (painful swallowing), hoarseness, and otalgia (ear pain) coupled with the physical findings of erythematous and edematous enlargement of the tonsils bilaterally and presence of anterior cervical lymphadenitis which strongly suggest a diagnosis of Acute Tonsillitis. The presence of yellowish exudates is highly suggestive of bacteria as the etiologic agent of the disease thus descriptive of an exudative type of tonsillitis. The patient’s course of illness patterns that of the classic presentation of Acute Tonsillitis. This is further strengthened by a positive history of exposure to an individual who presented with the same symptoms. PATHOPHYSIOLOGY: Tonsillitis is defined as inflammation of the tonsils. Tonsils are part of the lymphoid system of the body and has a significant role in fighting infections. They appear as pink fleshy structures on each side of the pharynx and are equal in size. Tonsils typically have pits called crypts running through its mucosa which are colonized by different types of microorganisms. Microscopically, tonsils also have lymph nodules which are made up of immune cells particularly B cells, T cells, and macrophages. Tonsils are part of the Waldeyer’s ring which consists of the palatine, lingual, and tubal tonsils together with the adenoids. Until the age of 6, tonsils are expected to be hyperplastic after that they start to regress in size and shrink by 12 years of age. When a patient has tonsillitis, the palatine tonsils are mainly involved. Palatine tonsils are highly vascularized which is why bleeding is one of the most common post operative complication following tonsillectomy. Tonsillar invasion by either viral or bacteria result to infection. Insults caused by microorganism leads inflammatory responses. The mode of transmission is droplet infection by either close or direct contact (coughing, sneezing, kissing, touching contaminated object). Common viruses causing tonsillitis include Ebstein Barr virus, Adenovirus, Rhinovirus, Coronavirus, Influenza and Parainfluenza viruses while the main bacterial etiologic agent involved is Group A Beta-hemolytic Streptococcus (GABHS), however Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenza have also been identified as possible causes. Viral etiology is more common than bacterial. It is therefore crucial for the health care provider to identify the difference in order to provide appropriate medical management. The signs and symptoms of Acute Exudative Tonsillitis such as sorethroat, fever, pain, tonsillar erythema and edema, lymphadenitis are due to the release of inflammatory cytokines by the pathogen invasion. Inflammatory cytokines cause increased vascular permeability and leakage of protein and fluid into the surrounding tissues resulting to tonsillar edema. In addition, cellular injury and hemolysis causing erythema, release of pyrogens resulting to fever, and increase in lymph drainage into regional lymph nodes leading to cervical lymphadenitis, simultaneously occur. The findings of yellowish exudates can be explained by the cytokine mediated leucocyte activation, infiltration, and opsonization of the pathogen at the tonsillar site resulting to accumulation of cellular debris and byproducts of the inflammatory response (Marchak, 2008). The presence of otalgia (ear pain) in a patient with Acute Tonsillitis but with no evidence of ear infection is often considered a referred pain due to the involvement of the Jacobson’s nerve, a derivative of the glossopharyngeal nerve (CN IX). Cranial nerve IX provides sensory innervation to the oropharynx, middle ear, eustachian tube, posterior third of the tongue, the carotid body and sinus. According to a study conducted by Z. Abd-Alkader Taboo and M. Buraa on the etiology of otalgia, referred otalgia may be experienced when there is presence of inflammatory lesions of the palatine tonsils, nasopharynx, soft palate or the posterior third of the tongue due to the involvement of the sensory arm of the glossopharyngeal nerve (Taboo and Buraa, 2013). In the initial stage of tonsillitis, it is extremely difficult to distinguish viral from bacterial cause. As a health care provider, it is crucial to correctly identify the cause of Acute Tonsillitis to prevent potential life threatening complications which include Rheumatic Fever, Scarlet Fever, and Post Streptococcal glomerulonephritis, and peritonsillar abscess to name a few. For this reason, it highly recommended that clinicians utilize the Modified Centor Scoring system which is a set of criteria that provides an estimate risk of GABHS in a patient presenting with tonsillopharyngitis. The criteria include absence of cough, presence of anterior cervical lymph nodes, temperature of 100.4 F or 38 C, presence of tonsillar exudates or swelling, and age groups divided into 3-14 years old, 15 – 44 years old, and 45 years old and older. A score of 1 is assigned for each criterion except for the older age group. Age group 15 – 44 is assigned 0 while the oldest age group receive a -1 score. Risk scores and corresponding management are as shown (Choby, 2009). Clinical Decision Rule for Management of Sore Throat DIFFERENTIAL DIAGNOSES: Infectious Mononucleosis This disease was considered because patient in this case study belongs to the age group (15 – 30 years old) where infectious mononucleosis is most common as well being sexually active with his partner. This disease is also known as kissing disease because it is spread through infected saliva. It is caused by Ebstein Barr virus which belongs to the Herpes viruses. Patients with infectious mononucleosis also present with sorethroat, fever, generalized lymphadenitis, and tonsillar enlargement and injection. The distinctive features of patient with infectious mononucleosis is its insidious onset, the character of the exudates which appear as white and gray deposits, and presence of hepatosplenomegaly in some cases. This disease entity was ruled out in this case study on the basis of the acute onset of sorethroat, the character of the exudates which is yellowish rather than white or gray, and the absence of hepatosplenomegaly. Peritonsillar Abscess Peritonsillar abscess is a complication of a tonsillar infection. Symptoms are not usually apparent until about 5 days from the time abscess formation starts. Peritonsillar abscess also presents with sore throat, painful swallowing, fever, chills, and ear pain usually on the same side of the abscess. However, the characteristic features that distinguish this diagnosis from a simple Acute Tonsillitis are the presence of trismus (spasm of the jaw muscles), torticollis (spasm of the neck muscles) as well as a muffled voice described as “hot potato” voice (talking as if you have a mouthful of hot potato). Clinical findings include an enlarged and displaced tonsil and uvula as well as swelling of the peritonsillar area. There could also be unilateral neck swelling. Absence of these symptoms and physical findings in this patient strongly rules out this diagnosis. Gonococcal Pharyngitis This is common in the adolescent age group with history of oral-genital sex. Although there is no established history of oral-genital sex in this case study, the patient admits to being sexually active with his partner. The main symptom of gonococcal pharyngitis is sore throat however majority of infected patients have little or no symptoms. Throat findings are similar to that of Streptococcal infection such white yellowish tonsillar exudates. PLAN: DIAGNOSTIC TESTS: Confirmatory Microbiological Tests: Rapid Antigen Detection Test – performed by doing a throat swab to determine Group A Beta Hemolytic Streptococcus infection. The test detects the group specific carbohydrate antigen on the GABHS cell wall and identifying the antigen by way immunologic reaction (Leung et.al, 2006). The advantage of this test is that the result is readily available to the provider in about 10 – 15 minutes thus an appropriate treatment can be provided immediately. Other positive aspects of this tests include less incidence of complications, shortens illness days, reduces the chance of spreading infection, decrease in antibiotic abuse and misuse, and lesser down time for patients allowing them to go back to work or school quicker. Much as it is a highly specific test (>95% specificity), there is a also a downside to the test, that is, the possibility of getting false negative results. For this reason, a throat culture is always recommended. Throat Culture – provides the most definitive result in so far as identifying the etiologic agent of Tonsillitis. This test is most helpful especially in patients whose rapid antigen test is negative but is clinically showing signs of bacterial tonsillitis. This test is performed likewise by doing a throat swab. As with any tests, good results depend on good samples. Ask patient if antiseptic mouthwash was used prior to swab as this may alter results. This test can also be used for detection for Neiserria Gonorrhoea, the bacteria that causes Gonococcal pharyngitis. The technique is the same, they just differ in the medium used for culture. The medium used to test for gonorrhea is Thayer Martin whereas the medium used to detect Streptococcal infection is blood agar. The downside of this test is that it takes several days for the result to be ready. Monospot Test – a test for mononucleosis which involve a fingerstick or blood sample collection. The results are readily available within 5 – 10 minutes. The test is based on blood agglutination. A positive monospot test means presence of heterophile antibodies. The disadvantage of this test is its high rate of false negative results in patients who are younger than 4 years old and if the test was conducted early in the course of illness. Studies show that if monospot test is obtained 1 – 2 weeks from the onset of symptoms, the rate of false negative results are higher. This is due to the fact that heterophile antibodies has not yet reached its threshold (Stuempfig & Seroy, 2019). Ancillary Laboratory Tests Complete Blood Count – there is an increase of white blood cells particularly neutrophils which supports bacterial infection. In viral infection, typically the CBC picture will be that of lymphocytic predominance, although this is not always the case. In severe infection such as peritonsillar abscess, there will be overwhelming neutrophilia. Erythrocyte Sedimentation Rate – blood sample is taken to determine how quickly red blood cells settle at the bottom of the test tube when the test is run. A normal result will show slow settling of RBC. A faster than normal rate indicates inflammation. C-Reactive Protein – a protein is produced by the liver. CRP is detected in the blood levels when there is inflammation occurring in the body . Note that CRP levels are elevated in acute or chronic inflammation. Diagnostic Imaging – typically this is not as part of the initial approach for a patient presenting with Acute Tonsillitis or Peritonsillar abscess since both are clinical diagnoses. However if there is a strong suspicion that the infection has spread in the deep neck structures then it is imperative to order Xray or CT scan of the lateral neck be as this might compromise airway and also lead to systemic infection. MEDICAL MANAGEMENT: Medical management of Acute Tonsillitis is generally done on an outpatient basis. On rare occurrence, hospital admission may be necessary in severe cases. After conducting a Centor score screening and obtaining a Rapid Antigen Detection Test, patients with Centor score of 3 or 4 and a positive RADT will receive empirical treatment of antibiotics. Traditionally the first line of antibiotic is broad spectrum Penicillin. However, oral Amoxicillin is often substituted for its better taste. Beta lactam antibiotics are effective not only in eradicating the streptococcal infection but also providing relative protection from complications such as rheumatic fever. According to American Academy of Family Physician, antibiotic treatment for a patient with acute bacterial tonsillitis is as follows: Penicillin V – children: 250 mg two to three times per day, adolescents and adults: 250 mg three to four times per day or 500 mg two times per day. Amoxicillin – children (mild to moderate GABHS pharyngitis) 12.25 mg per kg two times per day or 10 mg per kg three times per day, children (severe GABHS pharyngitis) 22.5 mg per kg two times per day or 13.3 mg per kg three times per day, adults (mild to moderate GABHS pharyngitis) 250 mg three times per day Or 500 mg two times per day, adults (severe GABHS pharyngitis) 875 mg two times per day (Choby MD, 2009). The length of antibiotic treatment is 10 days. Macrolides (Clarithrymocin, Erythromycin, Azithromycin) are effective alternative antibiotic for patients allergic to Penicillin/Amoxicilin. The advantage of prescribing macrolides is that it is taken for a shorter period of time, typically 3 – 5 days as compared to 10 days with Penicillin or Amoxicillin treatment. This results to better patient compliance and completion of the full course of antibiotic treatment. Part of the complete management is providing supportive measures such as oral hydration, analgesics, and/or steroids for pain relief. Avoid the use of Aspirin in patients younger than 20 years of age as it is linked to a serious disease called Reye Syndrome. Traditional warm salt water gargle (1 tsp of salt in 8 oz of warm water) and plenty of rest is advised. Use of humidifier or vaporizer may also provide soothing relief. Tonsillectomy is not yet recommended at this time. This procedure is reserved for chronic and recurrent tonsillitis, extremely hypertrophic tonsils described as kissing tonsils, history of peritonsillar absence, and history of poor response to antibiotic treatment. Meeting the Paradise criteria is an another indication for tonsillectomy in the pediatric population. The criteria looks at the frequency of sore throat episodes (> 7 in the past year or > 5 in the past 2 years or > 3 in the past 3 years), clinical features which includes fever (T > 100.9 F), cervical lymphadenopathy (>2 cm), tonsillar exudate, positive GAHBS culture, antibiotic treatment for each episode of infections, and clinical documentation of each episode of infection is in patient’s clinical records (Stelter 2014). PROGNOSIS: Acute Tonsillitis is a self-limiting disease and resolves without sequelae with adherence to the full course of antibiotic treatment. Patient may return to usual activity after 24 hours of antibiotic therapy. FOLLOW UP CARE/REFERRAL: Follow up care with primary health care provider after 72 hours is recommended if sore throat does not improve or became progressively worse and if fever does not break off. A referral to ENT specialist may be necessary. During routine follow up, check for heart murmur and joint pains which suggest complication related to Rheumatic Fever. PATIENT EDUCATION: Explain to the patient the importance of completing the full course of antibiotic to prevent complications. Instruct patient to seek immediate medical consult if experiencing difficulty breathing, if painful swallowing becomes progressively worse, and if there is occurrence of one -sided neck or throat swelling. In the same manner, patient should be instructed to contact the provider if sore throat persist for more than 3 days or if fever does not break after treatment. Educating the patient on practical preventive measures such as frequent proper hand washing and cough etiquette is essential to the complete care of tonsillitis. Because the patient is a young adult, providing education on safe sex practice is also helpful. REFERRENCES Marchak,A. (2018). Tonsillitis: pathogenesis and clinical findings. The Calgary Guide to Understanding Disease, https://calgaryguide.ucalgary.ca Abd-Alkader Taboo, Z., Buraa, M. (2013). Etiology of referred otalgia. The Iraqi Postgraduate Medical Journal, 12(3), 436-442. Choby MD, B. (2009). Diagnosis and treatment streptococcal pharyngitis. American Family Physician, 79(5), 383-390. https://www.aafp.org/afp/2009/0301/p383.html. Stetler, K. (2014). Tonsillitis and sore throat in children. German Medical Science Current Top Otorhinolaryngol Head Neck Surgery, 13(7), doi: 10.3205/cto000110. Stuempfig N., Seroy J.(2019). Monospot test. StatPearls [Internet], StatPearls Publishing, https://www.ncbi.nlm.nih.gov/books/NBK539739. Vincent MD, et al. (2004). Pharyngitis. American Family Physician, 15, 69(6), 1465-1470, https://www.aafp.org/afp/2004/0315/p1465.html Leung, et al.(2006). Rapid antigen detection testing in diagnosing group A beta-hemolytic streptococcal pharyngitis. Expert Review of Molecular Diagnostics. 6(5), 761-6, https://www.ncbi.nlm.nih.gov/pubmed/17009909.