NR 511 WEEK 2 SNAPPS ORAL PRESENTATION TEMPLATE

SNAPPS ORAL PRESENTATION TEMPLATE This template should only be used to organize your oral presentation, IT SHOULD NOT BE SUBMITTED. 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.