NURS 6512 Week 5 Discussion | Review of Case study # 3 | Solution Guide. | Walden University

NURS 6512 Week 5 Discussion | Review of Case study # 3 | Solution Guide. | Walden University
NURS 6512 Review of Case study # 3
Case 3: Focused Ear Exam
Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He
has complained to her about a mild earache for the past two days. His grandmother believes that
he feels warm but did not verify this with a thermometer. James states that the pain was worse
while he was falling asleep and that it was harder for him to hear. When you begin basic
assessments, you notice that James has a prominent tan. When you ask him how he's been
spending his summer, James responds that he's been spending a lot of time in the pool.
Patient Information:
JM, age 11, Male, caucasion
S.
CC: “My ear has been kind of hurting for two days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section
is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the
patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with
age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each
principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the
HPI might look like the following example:
Location: Right ear
Onset: 2 days ago
Character: Achy

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