APA format for SOAP NOTE 3 peer review articles 1 and half pages long please follow below instructions

Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition and justify your reasoning

case Study #3   Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked

S

Cc: “Earache right ear”

HPI: Patient is an 11-year-old Caucasian boy who was brought in by his grandmother after complaining about having a mild earache for the past two days.  Patient states that the pain is worse when he falls asleep and that it has become harder for him to hear, grandmother believes that he feels warm but has not taken his temperature

Medications: Patient does not take any medications

PMH: No significant illnesses, shots are up to date

FH: No history of previous ear concerns no family history of ear disease. During the school year, patient lives at home with his mother, father and he does not have pets. Patient is staying with grandmother and grandfather most of summer

SH: Student in public school and is currently on summer break, has been spending a lot of time this summer in the pool per his grandmother that he is spending the summer with.

ROS: general: negative for chills fever currently

EENT: complains of mild right ear pain and mild hearing loss, denies tinnitus, denies pain in throat, or eye pain

O

VS: T 100.8, P 94, R 18, BP 98/64

General: Patient appears to be in mild pain, holding head to right side slightly

HEENT: right tympanic membrane obscured, ear canal is read and has a musty odor from ear canal with small amount of watery drainage, head is normocephalic without signs of trauma, no nasal drainage, PEARL, no complaints of sore throat, no redness in throat

SKIN: Warm and dry, good skin turgor, prominent tan

NECK: No lymph node edema or signs of pain on palpation

NEUROLOGICAL: No complaints of headache or dizziness

Diagnostic results. WBC slightly elevated, low grade temp

A

Differential Diagnoses:

1) Acute Otitis Externa

2) Acute Otitis Media

3) Pharyngitis

Primary diagnoses/presumptive diagnoses: Acute otitis media

P – not indicated per template

Assessing for a possible ear infection would require additional information from the patient in addition to a physical assessment of the ear and the patient.  Obtaining background information including recent travel, activities, family history, trauma, history of previous illnesses and treatments that have been used for treatment that were successful or not successful.

Diagnostic studies used to diagnose the specific pathogen would include obtaining a culture of purulent drainage, simple otoscopy was mostly used for diagnosing AOM (D’silva, 2013) or a more invasive way of evaluating white blood cell elevation is by completing a CBC which is not used as often as visual inspection of the ear canal. White blood cell count (WBC), a classical inflammation marker, is also used in many scoring systems during routine daily clinical practice (Kutlucan et al., n.d.). Using data from a CBC can also provide information about the patient’s overall health.

Otitis externa

Acute otitis externa is the most common infection of the external auditory canal (Demirel et al., 2018). Ball describes (2015) symptoms of otitis externa as having watery to purulent and thick drainage mixed with pus with a musty odor and usually occurs after swimming.

Acute otitis media

Acute otitis media is one of the most frequent bacterial infections in children, and one of the primary reasons for the prescription of antibiotics by pediatricians (Intakorn, n.d.). Otitis media can have an abrupt onset with fever, feeling of a blockage, and interferes with sleep.  The middle ear fills with pus causing conductive hearing loss (Ball).

Acute pharyngitis:

Acute respiratory infections are one of the most common diseases, accounting for one of the main causes of patient visits to community health centers and hospitals (Yuniar, 2017). Ball (2015) describes a patient with acute pharyngitis as having a sore throat with deferred pain in ears and dysphagia with fever, malaise, fetid breath, abdominal pain and headache.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S.,   Stewart, R. W. (2015). Seidel’s guide to

physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.

Demirel, H., Arlı, C., Özgür, T., İnci, M., & Dokuyucu, R. (2018). The Role of Topical

Thymoquinone in the Treatment of Acute Otitis Externa; an Experimental Study in

Rats. Journal of International Advanced Otology, 14(2), 285–289. https://doi-

org.ezp.waldenulibrary.org/10.5152/iao.2017.4213

D’silva, L., Parikh, R., Nanivadekar, A., & Joglekar, S. (2013). A Questionnaire-Based Survey

of Indian ENT Surgeons to Estimate Clinic Prevalence of Acute Otitis Media, Diagnostic

Practices, and Management Strategies. Indian Journal of Otolaryngology & Head & Neck

Surgery, 65, 575–581. https://doi-org.ezp.waldenulibrary.org/10.1007/s12070-012-0545-2

Intakorn, P., Sonsuwan, N., Noknu, S., Moungthong, G., Pircon, J.-Y., Liu, Y., … Hausdorff, W.

P. (n.d.). Haemophilus influenzae type b as an important cause of culture-positive acute

otitis media in young children in Thailand: a tympanocentesis-based, multi-center, cross-

sectional study. BMC PEDIATRICS, 14. https://doi-org.ezp.waldenulibrary.org

/10.1186/1471-2431-2431-14-157

Kutlucan, L., Kutlucan, A., Basaran, B., Dagli, M., Basturk, A., Kozanhan, B., … Kos, M. (n.d.).

The predictive effect of initial complete blood count of intensive care unit patients on

mortality, length of hospitalization, and nosocomial infections. EUROPEAN REVIEW

FOR MEDICAL AND PHARMACOLOGICAL SCIENCES, 20(8), 1467–1473.

Retrieved from

https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=t

rue&db=edswsc&AN=000380260000006&site=eds-live&scope=site

Yuniar, C. T., Anggadiredja, K., & Islamiyah, A. N. (2017). Evaluation of Rational Drug Use for

Acute Pharyngitis Associated with the Incidence and Prevalence of the Disease at Two

Community Health Centers in Indonesia. Scientia Pharmaceutica, 85(2), 1–10.

https://doi-org.ezp.waldenulibrary.org/10.3390/scipharm85020022

  View Rubric   Due Date:   Feb 22

Details:
Review the Topic Materials and the work completed in NRS-433V to   formulate a PICOT statement for your capstone project.

A PICOT starts with a designated patient population in a particular   clinical area and identifies clinical problems or issues that arise   from clinical care. The intervention should be an independent,   specified nursing change intervention. The intervention cannot require   a provider prescription. Include a comparison to a patient population   not currently receiving the intervention, and specify the timeframe   needed to implement the change process.

Formulate a PICOT statement using the PICOT format provided in the   assigned readings. The PICOT statement will provide a framework for   your capstone project.

In a paper of 500-750 words, clearly identify the clinical problem   and how it can result in a positive patient outcome.

Make sure to address the following on the PICOT statement:

1. Evidence-Based Solution
2. Nursing Intervention
3. Patient Care
4. Health Care Agency
5. Nursing   Practice

Prepare this assignment according to the guidelines found in the APA   Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to   beginning the assignment to become familiar with the expectations for   successful completion.

You are required to submit this assignment to Turnitin. Please refer   to the directions in the Student Success Center.

Apply Rubrics

PICOT Statement Paper
1
Unsatisfactory
0.00%                                                     2
Less than Satisfactory
75.00%                                                     3
Satisfactory
79.00%                                                     4
Good
89.00%                                                     5
Excellent
100.00%                            80.0 %Content     30.0 % Identification of Clinical Problem/Issue                                                   Clinical problem/issue is not identified, and resolution is not addressed.                                                  Clinical problem/issue is identified with little discussion of resolution or patient outcome.                                                  Clinical problem/issue is identified but not  supported with clinical observations or evidence. The identified  problem/issue can be resolved, or a patient outcome shows minimal  improvement.                                                  Clinical problem/issue is identified based  on clinical observation experience or evidence in literature. Articles  are cited to support the need for change in nursing practice. The  identified problem/issue can be resolved, or a patient outcome can be  improved using nursing interventions.                                                  Clinical problem/issue is identified based  on key concepts that define evidence-based practice or clinical  experience. Articles are cited to support the need for change in nursing  practice. The identified problem/issue can be resolved, or a patient  outcome can show a marked improvement through a nursing intervention.   30.0 % Clinical  Problem/Issue, Including Description, Evidence-Based Solution, Nursing  Intervention, Patient Care, Health Care Agency, and Nursing Practice                                                   Clinical problem/issue is not described with  clarity and the corresponding elements are not included.                                                  Clinical problem/issue description includes a  basic understanding of the problem/issue and setting, with few of the  following elements explained: evidence-based solution, nursing  intervention, patient care, health care agency, and nursing practice.                                                  Clinical problem/issue description includes a  basic understanding of the problem/issue, the setting, and the patient  population. The following elements are explained: evidence-based  solution, nursing intervention, patient care, health care agency, and  nursing practice. Minimal rationale is provided to support the  resolution of the clinical problem/issue.                                                  Clinical problem/issue description includes a  thorough understanding of the problem/issue, the setting, the patient  population, and why it is a problem/issue. The following elements are  explained in detail: evidence-based solution, nursing intervention, and  patient care consistent with specific health care agency and nursing  practice. Sound rationale is provided supporting the clinical  problem/issue resolution.                                                  Clinical problem/issue description includes a  developed and thorough explanation of the problem/issue, the setting,  the patient population, and the rationale for why it is a problem/issue.  The identified clinical problem/issue explains the following elements  with detail and clarity: evidence-based solution, nursing intervention,  and improved patient care consistent with specific health care agency  resulting in nursing practice change. Sound rationale is provided in the  discussion of the clinical problem/issue resolution.   10.0 % PICOT Statement Focused on Resolution, Improvement, Application, and Intervention                                                   PICOT statement does not focus on resolution  of a problem/issue, improvement of patient care or application of a  nursing intervention.                                                  PICOT statement discusses a clinical problem/issue without a focus on improvement or intervention.                                                  PICOT statement focuses on the resolution of  a clinical problem/issue that improves patient care through the  application of a nursing intervention.                                                  PICOT statement focuses on the resolution of  a clinical problem/issue, with discussion of improving patient care  through the application of an evidenced-based nursing intervention.                                                  PICOT statement clearly focuses on the  resolution of a clinical problem/issue and aims at improving patient  care through the application of an evidenced-based nursing intervention.   10.0 % PICOT Statement Including Population, Intervention, Comparison, Outcomes, and Time                                                   Population, Intervention, Comparison, Outcomes, and Time are not included.                                                  Population, Intervention, Comparison,  Outcomes, and Time are present, but lack detail or are incomplete.                                                  Population, Intervention, Comparison, Outcomes, and Time are present.                                                  Population, Intervention, Comparison, Outcomes, and Time are clearly provided and well developed.                                                  Population, Intervention, Comparison,  Outcomes, and Time are comprehensive and thoroughly developed with  supporting details.   15.0 %Organization and Effectiveness     5.0 % Presentation                                                   Paper lacks any discernible overall purpose or organizing claim.                                                  Thesis is insufficiently developed or vague. Purpose is not clear.                                                  Thesis is apparent and appropriate to purpose.                                                  Thesis is clear and forecasts the  development of the paper. Thesis is descriptive and reflective of the  arguments and appropriate to the purpose.                                                  Thesis is comprehensive and contains the  essence of the paper. Thesis statement makes the purpose of the paper  clear.   5.0 % Argument Logic and Construction                                                   Statement of purpose is not justified by the  conclusion. The conclusion does not support the claim made. Argument is  incoherent and uses noncredible sources.                                                  Sufficient justification of claims is  lacking. Argument lacks consistent unity. There are obvious flaws in the  logic. Some sources have questionable credibility.                                                  Argument is orderly, but may have a few  inconsistencies. The argument presents minimal justification of claims.  Argument logically, but not thoroughly, supports the purpose. Sources  used are credible. Introduction and conclusion bracket the thesis.                                                   Argument shows logical progressions.  Techniques of argumentation are evident. There is a smooth progression  of claims from introduction to conclusion. Most sources are  authoritative.                                                  Clear and convincing argument that presents a  persuasive claim in a distinctive and compelling manner. All sources  are authoritative.   5.0 % Mechanics of Writing  (includes spelling, punctuation, grammar, language use)                                                   Surface errors are pervasive enough that  they impede communication of meaning. Inappropriate word choice or  sentence construction is used.                                                  Frequent and repetitive mechanical errors  distract the reader. Inconsistencies in language choice (register),  sentence structure, or word choice are present.                                                  Some mechanical errors or typos are present,  but they are not overly distracting to the reader. Correct sentence  structure and audience-appropriate language are used.                                                   Prose is largely free of mechanical errors,  although a few may be present. A variety of sentence structures and  effective figures of speech are used.                                                   Writer is clearly in command of standard, written, academic English.   5.0 %Format      2.0 % Paper Format  (use of appropriate style for the major and assignment)                                                   Template is not used appropriately or documentation format is rarely followed correctly.                                                  Template is used, but some elements are  missing or mistaken; lack of control with formatting is apparent.                                                  Template is used, and formatting is correct, although some minor errors may be present.                                                   Template is fully used; There are virtually no errors in formatting style.                                                  All format elements are correct.    5.0 %Format      3.0 % Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)                                                   Sources are not documented.                                                  Documentation of sources is inconsistent or  incorrect, as appropriate to assignment and style, with numerous  formatting errors.                                                  Sources are documented, as appropriate to  assignment and style, although some formatting errors may be present.                                                  Sources are documented, as appropriate to assignment and style, and format is mostly correct.                                                   Sources are completely and correctly  documented, as appropriate to assignment and style, and format is free  of error.     100 % Total Weightage