Assignment: Head-to-Toe Assessment

Week 4 Assignment 2 Grading Rubric

 

 

Assignment components	Unsatisfactory 1	Emerging 2	Proficient 3	Exemplary 4	Score
Incorporated topical headings to delineate systems.	Incorporated topical headings to delineate systems. Details are vague or nonexistent.	Incorporated topical headings to delineate systems. Some examples used, but there is a lack of detail.	Incorporated topical headings to delineate systems. Explanations were good but could be more detailed..	Incorporated topical headings to delineate systems. Specific, detailed evidence is used to support ideas.	_ of 20 points
Analyzed and described how portions of the assessment would be conducted without certain equipment.	Did not analyze and describe how portions of the assessment would be conducted without certain equipment, or the details are vague or nonexistent.	Analyzed and described how portions of the assessment would be conducted without certain equipment. Some examples used, but there is a lack of detail.	Analyzed and described how portions of the assessment would be conducted without certain equipment. Explanations were good but could be more detailed..	Analyzed and described how portions of the assessment would be conducted without certain equipment. Specific, detailed evidence is used to support ideas.	of 20 points
Provided a detailed review of each system with normal and abnormal findings and included normal laboratory findings for client age.	Did not provide a detailed review of each system with normal and abnormal findings and did not include normal laboratory findings for client age. Details are vague or nonexistent.	Provided a detailed review of each system with normal and abnormal findings and included normal laboratory findings for client age. Some examples used, but there is a lack of detail.	Provided a detailed review of each system with normal and abnormal findings and included normal laboratory findings for client age. Explanations were good but could include more detail and use of external resources to support findings.	Provided a detailed review of each system with normal and abnormal findings and included normal laboratory findings for client age. Specific, detailed evidence is used to support ideas.	of 16 points

 

 

 

Page 1 of 3

NSG3012 Principles of Assessment for Registered Nurses

© 2015 South University

 

 

Analyzed and explained age-specific risk reduction health screen and immunizations.	Did not analyze and explaine age-specific risk reduction health screen and immunizations. Details are vague or nonexistent.	Analyzed and explained age-specific risk reduction health screen and immunizations. Some examples used, but there is a lack of detail.	Analyzed and explained age-specific risk reduction health screen and immunizations. Explanations were good but could be more detailed..	Analyzed and explained age-specific risk reduction health screen and immunizations. Specific, detailed evidence is used to support ideas.	of 16 points
Provided expectations of normal findings and indicated abnormal findings in review of systems.	Did not provide expectations of normal findings and did not indicate abnormal findings in review of systems. Details are vague or nonexistent.	Provided expectations of normal findings and indicated abnormal findings in review of systems. Some examples used, but there is a lack of detail.	Provided expectations of normal findings and indicated abnormal findings in review of systems. Explanations were good but could be more detailed.	Provided expectations of normal findings and indicated abnormal findings in review of systems. Specific, detailed evidence is used to support ideas.	of 16 points
Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings.	Did not Analyze and describe the differential diagnosis (disease) associated with possible abnormal findings. Details are vague or nonexistent.	Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings. Some examples used, but there is a lack of detail.	Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings. Explanations were good but could be more detailed.	Analyzed and described the differential diagnosis (disease) associated with possible abnormal findings. Specific, detailed evidence is used to support ideas.	of 16 points
Designed a plan of care including nursing diagnosis, interventions, evaluation.	Designed a plan of care including nursing diagnosis, interventions, evaluation. Details are vague or nonexistent.	Designed a plan of care including nursing diagnosis, interventions, evaluation. Some examples used, but there is a lack of detail.	Designed a plan of care including nursing diagnosis, interventions, evaluation. Explanations were good but could be more detailed.	Designed a plan of care including nursing diagnosis, interventions, evaluation. Specific, detailed evidence is used to support ideas.	of 16 points
Discussed pharmacological treatments that can be used to address health issues for this client.	Did not discuss pharmacological treatments that can be used to address health issues for this client. Details are vague or nonexistent.	Discussed pharmacological treatments that can be used to address health issues for this client. Some examples used, but there is a lack of detail.	Discussed pharmacological treatments that can be used to address health issues for this client. Explanations were good but could be more detailed.	Discussed pharmacological treatments that can be used to address health issues for this client. Specific, detailed evidence is used to support ideas.	of 20 points
Included evidenced based practice strategies for health promotion.	Did not include evidenced based practice strategies for health promotion. Details are vague or nonexistent.	Included evidenced based practice strategies for health promotion. Some examples used, but there is a lack of detail.	Included evidenced based practice strategies for health promotion. Explanations were good but could be more detailed.	Included evidenced based practice strategies for health promotion. Specific, detailed evidence is used to support ideas.	of 20 points

 

 

 

Written components.	Introduction is limited or missing entirely.     Poorly organized document.   Transitions are infrequent, illogical, or missing entirely.   Conclusion is limited or missing entirely.   Writing contains numerous errors in spelling, grammar, or sentence structure that severely interferes with readability and comprehension.   No attempt at APA formatting.	Introduction is present but incomplete or underdeveloped.   Poorly organized document that interferes with readability and comprehension.   Transitions are sporadic. Conclusion is present, but incomplete or underdeveloped.   Writing contains numerous errors in spelling, grammar, or sentence structure that somewhat interfere with readability or comprehension.   APA format is attempted to paraphrase, quote, and cite, but errors are significant.	Introduction has a clear opening, provides background information, and states the topic.   Loosely organized document that may have to be inferred.   Transitions are appropriate and help the flow of ideas. Conclusion summarizes main argument and has a clear ending.   Writing follows conventions of spelling and grammar throughout. Errors are infrequent and do not interfere with readability or comprehension.   APA format is attempted to paraphrase, quote, and cite, but few errors are present.	Introduction catches the reader’s attention, provides compelling and appropriate background information, and clearly states the topic.   Well organized document with an appropriate introduction.   Transitions are thoughtful and clearly show how ideas relate. Conclusion leaves the reader with a sense of closure and provides concluding insights.   Writing follows conventions of spelling and grammar throughout that helps establish a clear idea and aid the reader in following the writer’s logic.   APA format is used throughout when appropriate or called for.	of 20 points
				Total Score	of 180 points

 HEAD TO TOE ASSESSMENT 1

HEAD TO TOE ASSESSMENT 13

Head to Toe Assessment

NAME

South University Online

 

Head to Toe Assessment

This is a complete head to toe assessment of a teenage boy covering; normal and abnormal findings (listed if they exist), a description of risk reduction, health screenings, immunizations, and a plan of care for health promotion with possible treatments for abnormal findings. Assignment: Head-to-Toe Assessment

Assessment

A complete head to toe assessment is essential in identifying the normal and abnormal findings in patients of all age groups. “Health assessment is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyze and synthesize the collected information in order to make judgement about the health status and life processes of individuals” (Guide to Good Nursing Practice Health Assessment, 2006). During the exam the cranial nerves will be assess and listed in parentheses and referenced to the web site; Test Your Cranial Nerves (n.d.).

Patient

Vital Signs: Height 6’ 1”, weight 162 pounds, B/P 132/ 61 (right arm) 134/67 (left arm), HR 72 (measured for a full minute), respirations 16 (measured for a full minute), temperature 98.0 F (oral). There is no pulse oximeter available, but the patient’s skin is clean, warm and dry with no signs of cyanosis. The patient states that he has no pain at this time.

The patient is in the 95th percentile for height and 78th percentile for weight (2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles, 2000). This patient’s body mass index (BMI) is 21.4 and this is considered a healthy BMI (BMI Percentile Calculator for Child and Teen, n.d.). The patient’s vitals are all within normal limits.

Appearance: The patient is well kept sixteen year old male with short brown hair and blue eyes, the patient walked into the room with a steady gait and no signs of distress noted. For the ease of the exam the patient is wearing bike shorts and no shirt.

Orientation: The patient is alert and oriented X 4 (name, date, location, and situation). The patient responds to questions in appropriate manner and follows directions. Speech is clear and well spoken (vagus- ten). Glasgow coma scale findings are: Eye opening – spontaneous (four points), verbal response- oriented (five points), and motor response- obeys commands (six points), for a total of 15; which is a normal response. “Glasgow Coma Scale, n.d.).

Head

The patient’s head is rounded and symmetrical with no signs of lesions, and upon palpation there are no signs of masses or depressions. The patient has short brown hair that is longer in the front than the back, and it is clean and soft with no signs of thinning or brittleness noted. Assignment: Head-to-Toe Assessment

Face

The patient’s face is symmetrical with no signs of discoloration or lesions. The skin is clean, intact, warm, dry, and consistent with race. Palpation of face including the sinuses (above and below the eyes) showed no masses, depression, or pain noted. The patient has some regrowth of hair noted on cheeks and upper lip, and the patient stated “I have not shaved for a couple days”. The patient has no complaints of pain when palpating the lymph nodes; in front and back of the ears, base of the skull, jaw, and under the chin (Screening Head to Toe Physical Examination 2011 – 2012, 2012). Using a cotton ball and a cotton tip applicator (the sharp and soft end); the patient’s face is touched on his forehead and checks, left and right sides, and the patient feels each side equally (trigeminal- five). To assess for hot and cold sensation on the face an ice cube and a warm washcloth are used, touching forehead and face (left and right sides); the patient feels each equally (trigeminal- five). The patient is able to smile, raise his eyebrows, and puff out his cheeks (facial- seven)

Eyes and Vision

The patient has blue eyes that are symmetrical and evenly spaced with no signs of redness. Examining the pupils with a pen light the pupils are; equal, round, reactive to light, with a brisk reaction. Accommodation is tested by having the patient focus on the examiners finger and bringing it towards the patient’s face, and the patient maintains focus in both eyes (oculomotor -third). The pupil size is a 3 millimeter. Using the pen light the patient is instructed to follow the pen light with his eyes only; the patient is able to follow the light up, down, side to side, and diagonal (trochlear- four and abducens- six). Using a Snellen eye chart, that was printed out, and a tape measure, measured twenty feet, the patient’s vision is 20/20 in both eyes(optic- two) (Snellen Eye Chart, n.d.).

Nose

The nose and nasal septum are midline and the patient is able to breath out of each nostril without difficulty. There is no discharge noted, the nasal mucosa is pink in color, and there is no pain or masses with palpation. To test the patient’s sense of smell the patient is asked to close his eyes and a cup of coffee is placed under the patient’s nostrils. When asked what the patient smells, he states “coffee” (olfactory-one).

Mouth and Throat

Mouth: The patient’s lips are intact with no breaks in the skin. The patient has braces on his teeth and is using rubber bands as part of his orthodontic treatment, his gums a slightly puffy and his teeth have food residue on them. Using the pen light for inspection the patient’s uvula is midline and moves up and down when the patient says ah, and the patient is able to swallow with no difficulties noted (glossopharyngeal- nine and vagus- ten). The patient has a strong gag reflex and this is assessed using the patient’s tooth brush, as there is no tongue depressor available (glossopharyngeal- nine). The patient is asked to stick his tongue out and move it from side to side, with no difficulty noted (hypoglossal- twelve). Assignment: Head-to-Toe Assessment

Abnormal Findings: The patient’s puffy gums and food residue in the teeth.

Throat: Palpation of the patient’s neck shows no signs of pain or masses. The skin is intact, clean, warm, dry, and consistent with race. When the patient looks up and swallows water there is no evidence of any masses on the front of the neck. Palpation on the back of the neck while the patient drinks water and turns his head reveals no masses.

Ears

The ears are symmetrical and the skin in intact, clean, warm, dry, and consistent with race; the patient has no pain upon palpation, and there are no masses or lesions. Using a pen light to look into the ear, there is some cerumen noted and this is a normal finding. An examination of the inner ear was not able to be performed as there was no otoscope available, but the patient stated that he has no pain. A hearing test using whispering and standing two feet from each ear, was performed and the patient heard without any difficulty (Vestibulochoclear- eight) (Screening Head to Toe Physical Examination 2011 – 2012, 2012).

Chest and Back

The skin on the chest and back has no signs of masses or lesions and is intact, clean, warm, dry, and is consistent with race. There is a small amount of hair noted on the patient’s chest (normal finding). The patient has no pain upon palpation of chest and back. He is able to shrug his shoulders with examiners hands pressing down on the shoulders without any difficulty (accessory- eleven). Percussion of the chest and back presents no abnormal findings. To assess for curvature of the spine, the patient is assessed standing straight and bending over at the waist; and there are no signs of curvature of the spine.

Breast: With the patient lying on his back on the bed, the patient’s breast and axillae are examined and no findings of; masses, lesions, or reports of drainage from the nipple. There is hair in the axillae, which is a normal finding for a male.

Lungs: With the patient sitting up, the lungs are assessed using a stethoscope and listening on the patient’s back in twelve different locations (six on each side of the spine); starting at the apex of the lung (upper back), and working down the patient’s back near bottom of the rib cage. To include, auscultation at the lateral rib area on the rib side to assess the right middle lobe of the lung. The lungs are clear, with equal rise and fall of chest, and no shortness of breath or dyspnea noted. The patient states that he does not have difficulty breathing or a cough. Assignment: Head-to-Toe Assessment

Heart: With the patient sitting upright the jugular vein is assessed for distention, none noted. With patient lying flat, auscultating the heart using the diaphragm of the stethoscope; starting at the aortic area (right second intercostal space), pulmonic area (left second intercostal space), Erb’s point (left third intercostal space), tricuspid area (left fourth intercostal space), mitral area (left fifth intercostal space- midclavicular). Then using the bell of the stethoscope and listening again, and working backwards on the patient’s chest through the areas again; S1 and S2 noted, but no abnormal cardiac sounds noted. The patient’s pulses (radial, femoral, popliteal, posterior tibial, and dorsalis pedis) are equal on all extremities and no edema is noted. The patient’s capillary refill is less than two seconds, and there are no signs of clubbing of the fingers. Assignment: Head-to-Toe Assessment

Abdomen

The patient’s abdomen is flat and symmetrical with a small amount of hair noted and no masses, lesions, or scars visible; skin is intact, clean, warm, dry, and consistent with race. Auscultation of bowel sounds with a stethoscope in all four quadrants reveals bowel sounds present and active. Percussion is within normal limits (although difficult to perform). Palpation reveals no masses or complaints of pain from the patient. The patient states he had normal bowel movements every day, and is not having any nausea or vomiting.

Genitourinary

The patient’s genitalia is within normal limits with no masses or lesions noted; skin is clean, warm, dry, and consistent with race. Dark hair is densely dispersed. The patient states that his urination is normal with no changes is frequency or amount urinating. The patient states that he is not sexually active.

Musculoskeletal

The patient’s skin on his legs and arms is intact, clean, warm, dry and consistent with race. The patient has densely dispersed brown hair on bilateral legs and sparsely dispersed hair on bilateral arms. On bilateral upper arms the patient has small bumps that are non-pruritic or painful. The skin on the patient’s hands and feet is intact, clean, warm, dry, and consistent with race. There is no edema noted. A safety pen is used to test sensation on his arms and legs in various locations, and the patient is able to state where the pen is being used and if it pen prick is sharp or dull (based on pressure applied to pen).

When the patient is asked to walk across the room his gait is fast and steady with no signs of distress noted. He is able to walk on tip toes and heels without any difficulty or pain. He is able to raise both arms and legs against the resistance of the examiner pressing against them. The patient is able to raise both arms over his head and out to his side without any difficulty or pain. Gripe strength in both hands are equal. Assignment: Head-to-Toe Assessment

Abnormal Findings: bilateral upper arms small bumps that are non-pruritic or painful

Risk Reduction

An important risk reduction for a patient of this age group is safe sex, abstinence of drugs and alcohol, vehicle safety, and depression/anxiety. The patient has already states that he is not sexually active; however, handouts on sexually transmitted disease (STDs in Adolescents and Young Adults, 2014) and birth control (Martinez, & Abma, 2015) are given and the topics are discussed.

Education on drugs and alcohol is discussed and the patient states he has tasted alcohol before and did not like it at all, the patient also lives in a household that does not have any alcohol or drugs (to include cigarette smoking), and so he has no plans on breaking his abstinence. A handout is given to the patient (Prevent Underage Alcohol Use, n.d.).

The patient has taken a drivers safety course and loves his new care that his parents bought him, so he drives safety and always wears his seat belt. The patient pointed out that he does not use his cell phone while driving; even though his car has a hands free Bluetooth device, he does not use it. A handout is given to the patient (Teen Drivers: Get the Facts, 2015).

The patient states that he does have anxiety and depression due to school and his grades, he is taking very difficult classes in his junior year of high school and wants to get into a good college. He talks with his friends and family, and they offer good advice which helps with the anxiety and depression. He states that he has no thoughts of suicide or self-harm. Handouts are given on depression (The Balanced Mind Parent Network, 2009) and anxiety (Lyness, 2014)

Abnormal Findings: Depression and anxiety, although at this age it can be normal.

Health Screenings and Immunizations

The patient states that he goes to his doctor every year for his physical, and this is consistent with research (Gavin, 2015). On his last visit he was told to increase his activity and to eat better. Is the last two months, the patient has started an exercise program with a friend and goes to the gym four-five times a week. He is also eating healthier by cutting out simple carbohydrates, and not drinking any soda products. The patient reports increased energy and he has lost ten pounds. He also noticed that working out helps his depression and anxiety. Assignment: Head-to-Toe Assessment

The patient is up to date on all of his immunization to include his human papilloma virus (HPV), he will need a booster of his meningococcal vaccination before he turns eighteen (Recommended Immunization Schedules for Persons Aged 0Through 18 Years, 2015).

Plan of Care

Nursing Diagnosis

Altered oral mucous membrane related to lack of hygiene as evidenced by the patient’s puffy gums and food residue in his teeth. Assignment: Head-to-Toe Assessment

Intervention

1. The patient will brush his teeth two times a day using the timer given to him by his orthodontist.

2. The patient will use his water pick every night.

3. The patient will floss his teeth every morning and use the special floss provided to him by his orthodontist.

Evaluation

The patient has noticed that his gums are not as puffy and are feeling better; he plans to continue with the interventions. Assignment: Head-to-Toe Assessment

Nursing Diagnosis

Impaired Skin Integrity related to dry skin as evidence by bilateral bumps on the upper arms that are non-pruritic or painful.

Intervention

1. The patient will apply a non-perfume lotion to his arms every day after his shower.

2. The patient will not pick at the bumps to possibly cause an infection.

3. The patient will not change any of his lotions, soaps, or detergents until the bumps have improved.

4. If there is no improvement, the patient will see a dermatologist for possible prescription medication.

Evaluation

The patient has just started using the lotion and reports improvement; he has not picked at his arm or changed any of his products.

Nursing Diagnosis

Anxiety and depression related to grades and school as evidenced by patient’s statements.

Intervention

1. The patient will continue to talk with pears and family about fears and listen to their input.

2. Patient will keep a journal to write down what feeling or actions are causing the depression and anxiety, in an attempt to decrease these feelings and learn warning signs for the future.

3. The patient will continue his workouts to help reduce his depression and anxiety.

Evaluation

The patient has already stated that working out has been helping with his anxiety and depression and he plans to continue the workouts. The patient states he will try harder to talk with his family and friends, even though he gets embarrassed to do so. He admits that writing in a journal will be the hardest of the interventions, but he is willing to try.

Conclusion

The assessment of this sixteen year old male proved that he is a healthy young man working towards bettering his health by diet, exercise, and being responsible in his health promotion and risk reduction. The abnormal findings have been discussed and the patient is working towards his goal of better hygiene and anxiety/depression reduction. A systematic thorough head to toe assessment is the best practice for patients, and the result is better interventions and plan of care for the patient to correct any abnormal findings. Assignment: Head-to-Toe Assessment

 

 

 

References

2 to 20 years: Boys Stature-for-age and Weight-for-age percentiles. (2000). Retrieved from http://www.cdc.gov/growthcharts/data/set1clinical/cj41c021.pdf

BMI Percentile Calculator for Child and Teen. (n.d.). Retrieved from http://nccd.cdc.gov/dnpabmi/Result.aspx?&dob=2/21/1999&dom=11/1/2015&age=201& ht=73&wt=162&gender=1&method=0&inchtext=0&wttext=0

Gavin, M. (2015). Medical care and your 13- to 18-year-old. Retrieved from http://kidshealth.org/parent/system/doctor/medical_care_13_18.html#

Glasgow Coma Scale. (n.d.). Retrieved from http://www.cdc.gov/masstrauma/resources/gcs.pdf

Guide to Good Nursing Practice Health Assessment. (2006). Retrieved from http://www.nchk.org.hk/filemanager/en/pdf/health_assessment_e.pdf

Lyness, A. (2014). Anxiety Disorders. Retrieved from http://kidshealth.org/teen/your_mind/mental_health/anxiety.html#

Martinez, G., & Abma, J. (2015). Sexual activity, contraceptive use, and childbearing of teenagers aged 15–19 in the United States. Retrieved from http://www.cdc.gov/nchs/data/databriefs/db209.htm

Prevent Underage Alcohol Use. (n.d.). Retrieved from http://www.toosmarttostart.samhsa.gov/media/LessonPlan.pdf

Recommended Immunization Schedules for Persons Aged 0Through 18 Years. (2015). Retrieved from http://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined- schedule.pdf

Screening Head to Toe Physical Examination 2011 – 2012. (2012). Retrieved from http://www.siumed.edu/oec/CCX_ASSESSMENTS/Y4_folder/HEAD toTOE Guidelines 2012.pdf

Snellen Eye Chart. (n.d.). Retrieved from http://www.i-see.org/snellen.gif

STDs in Adolescents and Young Adults. (2014). Retrieved from http://www.cdc.gov/std/stats13/adol.htm

Teen Drivers: Get the Facts. (2015). Retrieved from http://www.cdc.gov/MotorVehicleSafety/Teen_Drivers/teendrivers_factsheet.html

Test Your Cranial Nerves. (n.d.). Retrieved from https://faculty.washington.edu/chudler/cranial.html

The Balanced Mind Parent Network. (2009). Retrieved from http://www.thebalancedmind.org/learn/library/facts-about-teenage-depression

TYMPANIC MEMBRANE AND THE THYROID GLAND

TYMPANIC MEMBRANE AND THE THYROID GLAND 9

Tympanic Membrane and the Thyroid Gland

Tanyanika McMillian

South University

 

 

Tympanic Membrane and the Thyroid Gland

The thyroid gland has a butterfly shape and it is situated around the neck. It produces hormones that are responsible for metabolism control. These hormones are triiodothyronine (T3) and thyroxine (T4) and they are responsible for control of heart rate, breathing, body weight, peripheral and central nervous system, cholesterol level, menstrual cycle, body temperature, digestive function, brain development, and bone maintenance. Its correct functioning depends on having a good supply of iodine from food supply.

Dimensionally, it is around two inches in length and positioned in front of throat, typical known as Adam’s apple (Jarvis, 2016). It has two sides known as lobes and they are situated on each sides of the windpipe. The two are connected by thyroid tissue strip termed as isthmus. Interestingly, not all people possess isthmus, instead they have two separately located thyroid lobes (Mtsamples.com, n.d.). Assignment: Head-to-Toe Assessment

 

 

Thyroid gland Pictures

Source: http://www.endocrineweb.com/conditions/thyroid-nodules/thyroid-gland-controls-bodys-metabolism-how-it-works-symptoms-hyperthyroi

 

 

 

The tympanic membrane is a thin layered tissue that has a cone shape and it separates the middle ear from outer ear. It is also known as eardrum. Its main function is transmission of the vibrations of sound collected from the air to the middle ear.

Ear picture showing Tympanic membrane

Source: http://study.com/academy/lesson/tympanic-membrane-definition-function.html

Tympanic is derived from a Latin word known as Tympanum, which means drum. The analogy of its function has direct correlation from the way ancient types of drums produces sound (Mansour et al, 2015). The in depth analysis of the drum insinuates that it has sturdy substance, which is thin, for instance the hide of animal, plastics, or polyester that are tightly stretched athwart the hollow casing. When the drum is hit by the stick, vibrations begin at a given frequency. The vibrations generated push the molecules of the surrounding air resulting to compression waves. The same instance happens in the tympanic membrane.

 

 

 

Tympanic Membrane Patient

Patient ID: Mr. H, 25 yr. old

Physical and History done by: Clinician

Physical and History done on: June 20, 2016

Source: History given by patient and approved on its reliability

Main Complaint: Decreased hearing to right ear with pain and bloody discharge

Present Illness History

The 25 year old male patient sought help after he accidentally fell while he was waterskiing. He felt an acute pain immediately when he fell while waterskiing with the right side of his face hitting the water going at a fast speed, and his hearing decreased immediately. Assignment: Head-to-Toe Assessment

Past Medical History

No medical history to show

SOAP Note

Subjective

The 25 year old male present for physical examination, complaints of pain 8/10 to his right ear with decreased hearing. The pain is throbbing above his ear and right side of face. The patient states that the pain becomes worst when he puts pressure on his right ear. He states that the pain to his right ear was immediate when he fell on the right side of his face. Patient states that he has never had any pain to his right ear or face prior to the fall. Patient states he has been losing his balance when he gets up quickly from a sitting position.

Objective

Vital signs BP 130/80, HR 98, Resp 20, T 100.5, weight 160 lbs. Ht 5’9. Both of patients ears was assessed with an otoscope, right ear was noted with a small amount of bloody discharge in the ear canal and a perforated tympanic membrane. The patients hearing was tested using a pure tone audiometer. A pure tone audiometer gives a precise quantitative measure of hearing by assessing the person’s ability to hear sounds of varying frequency (Jarvis, 2016). The patient was noted to have minimal hearing loss in his right ear and no hearing loss in his left ear. The patient was asked to walk across the room putting one foot in front of the other and lost his balance.

Assessment

Perforated right tympanic membrane with complaints of pain, bloody discharge, and decrease in hearing of right ear; possible middle ear infection (otitis media).

Plan

The ear must be kept dry, antibiotics is advised in case of contaminants that may have entered the ear from the water. Tympanic membrane perforations usually heal spontaneously. Follow up with ENT for further workup, make need further hearing test with an audiologist if a decrease in hearing continues.

Discussions and Findings

There is no doubt that the traumatic perforations in Mr. H resulted from the impact of the right side of his face hitting the water at a very high speed. Possible cause of the perforation could be the impact of his ear/head or it may result from an object penetrating into the canal of the ear (Unmc.edu, 2016). Apart from waterskiing, other common causes of a perforated tympanic membrane are fireworks and Q-tips pushed too far in the ear canal. An audiogram is utilized to check on any disruptions on the ossicles. In case of ossicles disruption, surgical intervention is always recommended to realign the ossicles’ discontinuity. Drainage and infections are additional problems, in most cases traumatic perforations do heal spontaneously, normally within a month. Apart from perforations, research findings reveal several other defects related to eardrum that include entail cholesteatoma, chronic otitis media, and tympanosclerosis (Mansour et al, 2015). Trauma caused to the eardrum, can significantly lead to the defects discussed above. Therefore, quick response is required to treat the perforation. Assignment: Head-to-Toe Assessment

Thyroid Gland Patient

Patient ID: Mrs. L, 40 year old Woman

Physical and History done by: Clinician

Physical and History done on: Feb, 2008

Source: History given by patient and approved on its reliability

Main Complaint: Hypothyroidism/increased fatigue

Present Illness History

This treatment plan represents a return visit to the clinic for the patients named above. Nursing notes states that she is 45 years of age and her last visit was six months ago. She states that her health status has not changed much. She also states feeling fatigue throughout the day.

SOAP Note

Subjective

45 year old woman presents for physical examination complaints of feeling fatigue throughout the day. The patient reported that she does have temperature intolerance and is cold most of the time, she does have weaknesses of the muscles, no nausea, no palpitations, no tremors, occasional constipation, and no diarrhea. The patient’s weight has been stable the last 6 months, but does complaint of insomnia but states that when she sleeps with her CPAP machine she gets a good night rest.

 

Objective

Vital Signs: BP 135/65, HR 85, Temp 96.9, Weight 85.7 kg. Thorax had clear lungs with no defects, regular rhythm and rate in cardiovascular. The patient’s thyroid was assessed anteriorly by facing the patient tilting her head back to stretch the skin against the thyroid, giving her a glass of water inspecting her neck as she swallows the water looking for diffuse enlargement or a nodular lump (Jarvis, 2016). The patient’s thyroid was then assessed posteriorly with her sitting up straight bending her head slightly forward and to the right relaxing the neck muscles on the right side with the healthcare provider using their left hand to push the trachea slightly to the right and curving the right fingers between the trachea and the stern mastoid muscle, retracting it slightly, while the patient takes a sip of water. The thyroid moves up under the palpating fingers with the trachea and larynx as the patient swallows (Jarvis, 2016). Reversing the procedure to palpate the left side posterior. Lab results for the following: Free T4 1.35, and TSH at 6.121, and the patient is currently taking Lithium for Bipolar disorder. Assignment: Head-to-Toe Assessment

Assessment

No diffused enlargement or nodular lump noted.

Plan

Increase current dose of levothyroxine, currently taking 112mcg by mouth daily, due to TSH level at 6.121 normal range is 0.3-5. TSH levels are consistent with someone that has an underactive thyroid that will cause hypothyroidism, a high TSH level means hypothyroidism. Consult with psychologist that ordered the patient Lithium, this medication can trigger hypothyroidism, but normally in patients that are going to have thyroid problems anyway (Mtsamples.com, n.d.). Have patient come back in 4 weeks for repeat Free T4 and TSH.

Discussions and Findings

It is true that thyroid gland is responsible for various metabolic processes in the body.

Testing for hypothyroidism is simple, use of blood test is recommended, however certain patients presents complex treatment scenario like this patient where the cause of hypothyroidism is from a medication needed for a mental disorder.

Conclusion

Human hearing is very important part of human organs. Tympanic membrane being the converter of sounds from the air and that it is at the threshold of the inner ear, it plays a very important role in hearing. Every effort is vital that is aimed at keeping it effective for use. It therefore does transmissions of all the collected sounds from the air to the middle and inner ear. The patient in question had water causing disturbance in his ear during waterskiing, a condition that can be corrected with proper medical attention.

The thyroid gland is also a very vital organ in the body. It is the central organ that secures various hormones that are used in metabolism. The patient under question experiences low release of thyroid hormone, a condition that started due to the use of lithium that the patient was taking for her Bipolar disorder. Assignment: Head-to-Toe Assessment

 

 

 

 

 

References

Jarvis, Carolyn. (2016). Physical Examination and Health Assessment, 7th Edition. [VitalSource Bookshelf Online]. Retrieved from https://digitalbookshelf.southuniversity.edu/#/books/9781455728107/

Joanne, A. (n.d.). Tympanic Membrane: Definition & Function. Retrieved from study.com’s website http://study.com/academy/lesson/tympanic-membrane-definition-function.html

Mansour, S., Magnan, J., Haidar, H., & Nicolas, K. (2015). Tympanic membrane retraction pocket: Overview and advances in diagnosis and management.

Michael, K., W., Jonathan, M., K., Debra, J., A., & Rose L., A. (2000). External and Middle Ear Trauma Resulting From Ear Impression. Retrieved from website http://www.audiology.org/sites/default/files/journal/JAAA_11_07_01.pdf

Mtsamples.com (n.d.). Sample Type / Medical Specialty: SOAP / Chart / Progress. Retrieved from website http://www.mtsamples.com/site/pages/sample.asp?Type=91-soap&Sample=2287-Acquired%20Hypothyroidism%20Followup

Unmc.edu (2016). Unit Five: Tympanic Membrane Perforations. Retrieved from website http://app1.unmc.edu/medicine/heywood/otology/unit5-tympanic-membrane-perforations.cfm