Assessing the Head, Eyes, Ears, Nose, and Throat
Case study assigned
Adams, Baragar, Cacho, Cozad, Campbell, Freeman, Harrington, Hollowell, Jeffries, Lawhon-Ward, Navarro
Focused Nose Exam
Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for 5 days. As you check his ears and throat for redness and inflammation, you notice him touch his fingers to the bridge of his nose to press and rub there. He says he’s taken Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if the Mucinex has helped at all, he sneers slightly and gestures that the improvement is only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.
INstructions and template
Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
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.
RESOURCES
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 (9
Assessing the Head, Eyes, Ears, Nose, and Throat
Patient Information:
R, 50-years old Caucasian male.
S.
Chief Complaint (CC):
Nasal congestion and itching for 5 days.
HPI:
Richard is a 50-year-old white male complaining of nasal congestion, sneezing and rhinorrhea, itching nose, ears, and palate, and postal drainage for 5 days. The patient reports that has taken Mucinex for the last 2 days to allow him breathe well while sleeping. He accepts that the relief from the medication is minimal. The patient denies headache or pain.
Current Medications:
Mucinex OTC 1 tablet every night.
Allergies:
NKDA, seasonal allergies.
PMHx:
No significant medical history. Denies surgery or illnesses.
PSHx:
The patient had arthroscopic meniscus repair in 2018
Sexual Reproductive History:
He is married to one wife and is sexually active.
Personal/Social History:
Takes alcohol only during celebrations. He has no history of substance and drug abuse. He eats a balanced diet every day.
Immunization History:
Immunizations are up to date. He received a flu shot last season.
Significant Family History:
He is heterosexual and sexually active. He is married to one wife, 48, and together they have one daughter, 25. The daughter has no significant medical history. The grandparents passed on 4 years ago in a car accident. They both had hypertension.
Lifestyle:
The patient is a truck driver. He attends church once a week. He lives with his family and an aunt.
ROS:
GENERAL:
AAO*4, no weight loss or gain. The patient denies headache, fever, or pain. Appears tired due to lack of sleep.
HEENT:
Eyes: Itchy and red. No changes in vision.
Ears: No hearing problem, tympanic membrane is intact.
Nose: Itchy nose and congested.
Throat: Mildly erythematous and no enlarged tonsils.
Neck: No abnormalities.
Breasts: No malignant or asymmetrical tenderness.
Respiratory: Nasal congestion, clear lung sound, shortness of breath and sputum.
Cardiovascular/Peripheral Vascular: No chest pain or discomfort or edema.
Gastrointestinal: Normal bowel movement, no diarrhea, nausea, or vomiting.
Genitourinary: The patient denies dysuria and polyuria.
Musculoskeletal: No history of bone or joint pain or injuries.
Psychiatric: No anxiety, suicidal thoughts, or depression.
Neurological: No dizziness, seizures or headache. Normal bladder control.
Skin: No skin lashes or lesions.
Hematologic: No blood disorder or bruising.
Endocrine: No abnormal sweating or fever.
Allergic/Immunologic: NKDA
LYMPHATICS: Swollen lymph nodes. No splenectomy.
ALLERGIES: NKDA
Objective Data.
Physical exam:
The general information shows that the patient is unwell.
Vital Signs: ht 5’8, wt 190, BMI 24.2.
General: A&O * 4, appears unwell with a pale and dull appearance. Dressed for the event. No bad breath and conscious of the environment.
HEENT: Eyes: Itchy and red. No changes in vision. Ears: No hearing problem, tympanic membrane is intact. Nose: Itchy nose and congested. Throat: Mildly erythematous and no enlarged tonsils.
Neck: JVD or megaly or full ROM, carotid no bruit.
Chest/Lungs: CTA AP&L, no dyspnea.
Heart/Peripheral Vascular: RRR, no murmur, peripheral pulses +2 bilaterally, no edema.
Abdomen: Normal bowel sounds plus no masses.
Genital/Rectal: Deferred.
Musculoskeletal: Symmetrical movement, and development. The strength is 5/5.
Neurological: DTR intact, CN II – XII intact.
Skin: No rashes and bleeding, watery blisters, itchy and painful silver-colored plaques.
A.
Differential Diagnoses:
a) Allergic rhinitis:
Allergic rhinitis is a type of hay fever that occurs when the immune system overreacts. The symptoms include runny, stuffy nose, red, itchy, and watery eyes. Diagnosis involves examination of nasal passages and examination of medical history (Small et al., 2018). Allergic rhinitis occurs mostly after exposure to hay, pollen or dust. The patient is most likely suffering from allergic rhinitis due to the similarities in the symptoms.
b) Common cold:
It is a viral infection of both nose and throat. Symptoms include running nose, congestion, and sneezing (Van Driel et al., 2018). Most people recover within 2 weeks. Home remedies and over the counter drugs can relieve the symptoms.
c) Acute sinusitis
It involves inflammation of the nose and sinuses. It caused by cold and viral infection. Symptoms include headache, fever, and fatigue (DeMuri et al., 2019). Patients experience a green thick discharge from the nose.
Reflection
I have learned that patients can present with multiple symptoms, and their primary condition is not exact. It is essential to evaluate the medical history and a comprehensive assessment of the body’s various parts or organs. A comprehensive assessment shows possible conditions. An understanding of the symptoms related to head, eyes, ears, nose, and throat infections helps determine the appropriate diagnosis for the condition (Ball et al., 2019). Conditions such as allergic rhinitis can occur after patients are exposed to dust, hay, or pollen. Older adults should avoid such exposure since it can affect their respiratory system or trigger adverse effects.
Elderly patients are at risk of various infections. They should take care of their health using preventive measures and taking a balanced diet. Patient education can reduce cases of head, eyes, ears, nose, and throat infections. Patient education helps them take preventive measures that will hinder the deterioration of the conditions. The patient should avoid taking OTC drugs since some may trigger adverse effects, while others may have little or no help.
References
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.
DeMuri, G. P., Eickhoff, J. C., Gern, J. C., & Wald, E. R. (2019). Clinical and Virological Characteristics of Acute Sinusitis in Children. Clinical Infectious Diseases, 69(10), 1764-1770.
Small, P., Keith, P. K., & Kim, H. (2018). Allergic rhinitis. Allergy, Asthma & Clinical Immunology, 14(2), 51.
Van Driel, M. L., Scheire, S., Deckx, L., Gevaert, P., & De Sutter, A. (2018). What treatments are effective for common cold in adults and children?. BMJ, 363, 3786.
