Assignment 1: Case Study Assignment: Assessing the Head Eyes Ears Nose and Throat NURS 6512N-32

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Assignment 1: Case Study Assignment: Assessing the Head Eyes Ears Nose and Throat NURS 6512N-32

Assignment 1: Case Study Assignment: Assessing the Head Eyes Ears Nose and Throat NURS 6512N-32

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and

Throat

Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.

In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

To Prepare

  • By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
  • Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

With regard to the case study you were assigned:

  • Review this week’s Learning Resources and consider the insights they provide.
  • Consider what history would be necessary to collect from the patient.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
  • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

The Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

By Day 6 of Week 5

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

  • Please save your Assignment using the naming convention “WK5Assgn1+last name+first initial.(extension)” as the name.
  • Click the Week 5 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
  • Click the Week 5 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
  • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK5Assgn1+last name+first initial.(extension)” and click Open.
  • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
  • Click on the Submit button to complete your submission.

Photo Credit: Getty Images/Blend Images
Most ear, nose, and throat conditions that arise in non-critical care settings are minor in
nature. However, subtle symptoms can sometimes escalate into life-threatening
conditions that require prompt assessment and treatment.
Nurses conducting assessments of the ears, nose, and throat must be able to identify
the small differences between life-threatening conditions and benign ones. For instance,
if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the
inflammation is probably due to the pathogen causing the sore throat rather than a case
of throat cancer. With this knowledge and a sufficient patient health history, a nurse
would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes
but would probably perform a simple strep test.
In this Case Study Assignment, you consider case studies of abnormal findings from
patients in a clinical setting. You determine what history should be collected from the
patients, what physical exams and diagnostic tests should be conducted, and formulate
a differential diagnosis with several possible conditions.
To Prepare

 By Day 1 of this week, you will be assigned to a specific case study for this Case Study
Assignment. Please see the “Course Announcements” section of the classroom for your
assignment from your Instructor.
 Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note
format rather than the traditional narrative style format. Refer to Chapter 2 of the
Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning
Resources for guidance. Remember that all Episodic/Focused SOAP Notes have
specific data included in every patient case.
With regard to the case study you were assigned:
 Review this week's Learning Resources and consider the insights they provide.
 Consider what history would be necessary to collect from the patient.

 Consider what physical exams and diagnostic tests would be appropriate to gather
more information about the patient's condition. How would the results be used to make
a diagnosis?
 Identify at least five possible conditions that may be considered in a differential
diagnosis for the patient.
The Assignment
Use the Episodic/Focused SOAP Template and create an episodic/focused note about
the patient in the case study to which you were assigned using the episodic/focused
note template provided in the Week 5 resources. Provide evidence from the literature to
support diagnostic tests that would be appropriate for each case. List five different
possible conditions for the patient's differential diagnosis and justify why you selected
each.
By Day 6 of Week 5
Submit your Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
 Please save your Assignment using the naming convention “WK5Assgn1+last
name+first initial.(extension)” as the name.
 Click the Week 5 Assignment 1 Rubric to review the Grading Criteria for the
Assignment.
 Click the Week 5 Assignment 1 link. You will also be able to “View Rubric” for grading
criteria from this area.
 Next, from the Attach File area, click on the Browse My Computer button. Find the
document you saved as “WK5Assgn1+last name+first initial.(extension)” and
click Open.
 If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit
my paper(s) to the Global Reference Database.
 Click on the Submit button to complete your submission.
Grading Criteria
To access your rubric:
Week 5 Assignment 1 Rubric
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 5 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 6 of Week 5
To participate in this Assignment:
Week 5 Assignment 1

 

Learning Resources

Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Seidel's guide to physical examination: An interprofessional
approach (9th ed.). St. Louis, MO: Elsevier Mosby.

 Chapter 11, “Head and Neck”
This chapter reviews the anatomy and physiology of the head and neck.
The authors also describe the procedures for conducting a physical
examination of the head and neck.

 Chapter 12, “Eyes”
In this chapter, the authors describe the anatomy and function of the eyes.
In addition, the authors explain the steps involved in conducting a physical
examination of the eyes.

 Chapter 13, “Ears, Nose, and Throat”
The authors of this chapter detail the proper procedures for conducting a
physical exam of the ears, nose, and throat. The chapter also provides

pictures and descriptions of common abnormalities in the ears, nose, and
throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health
assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., &
Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Chapter 15, “Earache”
This chapter covers the main questions that need to be asked about the
patient’s condition prior to the physical examination as well as how these
questions lead to a focused physical examination.
Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It
provides strategies for evaluating the patient, both through questions and
through physical exams.
Chapter 25, “Nasal Symptoms and Sinus Congestion”

In this chapter, the authors highlight the key questions to ask about the
patients symptoms, the key parts of the physical examination, and
potential laboratory work that might be needed to provide an accurate
diagnosis of nasal and sinus conditions.
Chapter 30, “Red Eye”

The focus of this chapter is on how to determine the cause of red eyes in
a patient, including key symptoms to consider and possible diagnoses.
Chapter 32, “Sore Throat”

A sore throat is one most common concerns patients describe. This
chapter includes questions to ask when taking the patient’s history, things
to look for while conducting the physical exam, and possible causes for
the sore throat.
Chapter 38, “Vision Loss”
This chapter highlights the causes of vision loss and how the causes of
the condition can be diagnosed.

Note: Download the six documents (Student Checklists and Key Points)
below, and use them as you practice conducting assessments of the
head, neck, eyes, ears, nose, and throat.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Head and neck: Student checklist. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W.
(2019). Head and neck: Key points. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Eyes: Student checklist. In Seidel's guide to physical examination:
An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Eyes: Key points. In Seidel's guide to physical examination: An
interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Ears, nose, and throat: Student checklist. In Seidel's guide to
physical examination: An interprofessional approach (9th ed.). St. Louis,
MO: Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W.
(2019). Ears, nose, and throat: Key points. In Seidel's guide to physical
examination: An interprofessional approach (9th ed.). St. Louis, MO:
Elsevier Mosby.
Credit Line: Seidel's Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., &
Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the
Copyright Clearance Center.

Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia,
PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis
Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.

 Chapter 71, “Visual Function Evaluation: Snellen, Illiterate E, Pictorial

This section explains the procedural knowledge needed to perform eyes,
ears, nose, and mouth procedures.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.).
Philadelphia, PA: F. A. Davis.

 Chapter 2, "The Comprehensive History and Physical Exam" (Previously
read in Weeks 1, 3, 4, and 5)
Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in clinical
examination. Vision Research 90, 32–37.
doi:10.1016/j.visres.2013.02.001. Retrieved from
https://www.sciencedirect.com/science/article/pii/S0042698913000217
Rubin, G. S. (2013). Measuring reading performance. Vision Research,
90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from
http://www.sciencedirect.com/science/article/pii/S0042698913000436

Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison,
R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment.
American Family Physicians, 88(7), 435–440.

Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT,
and MRI). Retrieved from
http://www.ghorayeb.com/ImagingMaxillarySinusitis.html

This website provides medical images of sinusitis, including X-rays, CT
scans, and MRIs (magnetic resonance imaging).
Document: Episodic/Focused SOAP Note Exemplar (Word document)

Document: Episodic/Focused SOAP Note Template (Word document)

Document: Midterm Exam Review (Word document)
Shadow Health Support and Orientation Resources
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file].
Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved
from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2)
(PDF)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE
Assignment in Shadow Health to acknowledge your commitment to
Walden University’s Code of Conduct.
Document: DCE (Shadow Health) Documentation Template for Focused
Exam: Cough (Word document)
Use this template to complete your Assignment 2 for this week.

Optional Resource
Use the following resources to guide you through your Shadow Health orientation
as well as other support resources:
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s
diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.

 Chapter 7, “The Head and Neck” (pp. 178–301)

This chapter describes head and neck examinations that can be made
with general clinical resources. Also, the authors detail syndromes of
common head and neck conditions.
Required Media (click to expand/reduce)
Online media for Seidel's Guide to Physical Examination
It is highly recommended that you access and view the resources included with
the course text, Seidel's Guide to Physical Examination. Focus on the videos and
animations in Chapters 10, 11, and 12 that relate to the assessment of the head,

neck, eyes, ears, nose, and throat. Refer to the Week 4 Learning Resources
area for access instructions on https://evolve.elsevier.com/.
University of Iowa Ophthalmology. (2016, December 19). Fluorescein
staining of the cornea. Retrieved from https://vimeo.com/198695974
Credit Line: University of Iowa Ophthalmology. (n.d.). Fluorescein staining of the cornea [Video file]. Retrieved from
​https://vimeo.com/198695974. The author(s) and publishers acknowledge the University of Iowa and EyeRounds.org
for permission to reproduce this copyrighted material.

Note: Approximate length of this media program is 25 seconds.

NURS_6512_Week_5_Assignment_1_Rubric

Excellent Good Fair Poor
Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.·  Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.
Points Range: 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Points Range: 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
Points Range: 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.
Points Range: 0 (0%) – 32 (32%)
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
Points Range: 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected.
Points Range: 24 (24%) – 29 (29%)
The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.
Points Range: 18 (18%) – 23 (23%)
The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.
Points Range: 0 (0%) – 17 (17%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
Points Range: 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
Points Range: 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
Points Range: 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
Points Range: 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
Points Range: 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) grammar, spelling, and punctuation errors.
Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
Points Range: 5 (5%) – 5 (5%)
Uses correct APA format with no errors.
Points Range: 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors.
Points Range: 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors.
Points Range: 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.
Total Points: 100
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