Assessing The Head, Eyes, Ears, Nose And Throat

Assessing The Head, Eyes, Ears, Nose And Throat

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. Assessing The Head, Eyes, Ears, Nose And Throat

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.

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? Assessing The Head, Eyes, Ears, Nose And Throat

· 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. Assessing The Head, Eyes, Ears, Nose And Throat

Case Study 1:   This assignment you will be doing in SOAP format.

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 Assessing The Head, Eyes, Ears, Nose And Throat

Medications:

Mucinex OTC QHS PRN

Lisinopril 20mg PO QD

Allergies:

NKDA

Past Medical History (PMH):

HTN

Past Surgical History (PSH):

Plate placed in left ankle and at 25 from MVA

Sexual/Reproductive History:

Heterosexual

Married, 2 children who are living outside the home

Personal/Social History:

Denies alcohol use, smoking, or drug abuse Assessing The Head, Eyes, Ears, Nose And Throat

Immunization History:

Unknown last Tdap, flu 2014

Significant Family History:

One brother, alive and no health history. Mother died from lung CA 2 years ago (age 73). Father is 76, alive and has a hx of HTN, DM and Alzheimer’s. Children are both healthy.

Review of Systems:

HEENT: nasal congestion, sneezing, runny/itchy nose, itchy eyes and ears x 5 days

Respiratory: Denies SOB, coughing, sputum production and lungs clear

Gastrointestinal: No change in bowel habits. No nausea, vomiting, diarrhea, or constipation.

GU: No dysuria, incontinence or other abnormalities Assessing The Head, Eyes, Ears, Nose And Throat

Skin: No rashes, itching, bruising. No open wounds or lacerations.

OBJECTIVE DATA

Physical Exam

Vital signs:

BP 136/74 R arm, sitting

P 79, regular

T 98.3 oral

RR 18, non-labored

Wt 223; Ht 6’1”

General: A&OX3, clean, appears ill Assessing The Head, Eyes, Ears, Nose And Throat

Neuro: AAO x4, appropriate behavior

HEENT: Denies vision or hearing alterations. Wears prescription readers. Reports allergy season being a problem this year, which is new. Lack of small/taste. Tonsils normal. Denies oral abnormalities, last saw dentist one month ago.

Neck: no abnormalities noted.

Heart: normal rate, regular, no murmur noted

Lungs: Lung sounds clear bilaterally.

Abdomen: Bowel sounds X 4 quadrants, no abnormalities noted

Genital/Rectal: not assessed

Skin: dry, warm

Musculoskeletal: no abnormalities noted

ASSESSMENT

Lab Tests/Exams and Results:

CBC-WNL

Flu Swab-Neg

Rapid Strep-Neg

Differential Diagnosis (DDx):

1. Rhinovirus- More than any other illness, rhinoviruses are associated with the common cold. Rhinoviruses may also cause some sore throats, ear infections, sinus infections (Kennedy, Heymann, & Platts-Mills, 2012).Symptoms include sore throat, runny nose, nasal congestion, sneezing and cough; sometimes accompanied by muscle aches, fatigue, malaise, headache, muscle weakness, or loss of appetite (Kennedy, Heymann, & Platts-Mills, 2012). Assessing The Head, Eyes, Ears, Nose And Throat

2. Acute sinusitis- Inflammation of one or all of the paranasal sinuses is often referred to as sinusitis –can be it infectious or non-infectious in etiology (Hawthorne & Ahmad, 2010). The vast majority of infectious causes are acute, self-limited viral infections (Hawthorne & Ahmad, 2010). Symptoms include: nasal obstruction/congestion; anterior discharge/postnasal drip; facial pain/pressure and/or reduction/loss of smell (Hawthorne & Ahmad, 2010).

3. Allergic rhinitis- Allergic rhinitis, also called hay fever, is the group of uncomfortable symptoms that occur when your body is exposed to a specific allergen (de Corso et al., 2014). An allergen is a typically harmless substance, such as grass or dust, which causes an allergic reaction (de Corso et al., 2014). Pollen is the most common allergen for most people (de Corso et al., 2014). Since Richard has been working in the hay field the week prior, this concludes the diagnosis. Uncomfortable symptoms of allergic rhinitis include runny nose, sneezing, and itchy eyes (de Corso et al., 2014).

4. Sinus obstruction- The sinuses are small, hollow chambers inside the nose and head that reduce the weight of the facial bones, give the bones shape and support, assist in mucus drainage from the nose, and help the voice resonate (Kennedy & Borish, 2013).Healthy sinuses are filled with air. When their mucous membranes swell from allergies, the common cold, infection or other causes, the narrow sinus openings become blocked, the pressure inside them drops, and they can fill with fluid, which easily leads to bacterial infection (Kennedy & Borish, 2013). Assessing The Head, Eyes, Ears, Nose And Throat

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5. Chronic Sinusitis- Chronic sinusitis is a common condition in which the cavities around nasal passages become inflamed and swollen — for at least eight weeks, despite treatment attempts (Kennedy & Borish, 2013). This condition interferes with drainage and causes mucus to build up. It can make it difficult to breathe through your nose. The area around your eyes and face may feel swollen, and you may have throbbing facial pain or a headache (Kennedy & Borish, 2013). Symptoms of chronic sinusitis are less obvious and may include nasal blockage or congestion, post-nasal drip, reduced sense of smell, and malaise (Kennedy & Borish, 2013). Assessing The Head, Eyes, Ears, Nose And Throat

References

de Corso, E., Battista, M., Pandolfini, M., Liberati, L., Baroni, S., Romanello, M., & … Paludetti, G. (2014). Role of inflammation in non-allergic rhinitis. Rhinology, 52(2), 142-149. doi:10.4193/Rhin

Hauk, L. (2014). AAP releases guideline on diagnosis and management of acute bacterial sinusitis in children one to 18 years of age. American Family Physician, 89(8), 676-681. Retrieved from: http://web.b.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfviewer/pdfviewer?vid=8&sid=642c28f0-7af4-4bb2-b3b0-bafbb5861d8a%40sessionmgr110&hid=106

Hawthorne, M. R., & Ahmad, N. (2010). Acute sinusitis: pitfalls in diagnosis and management. Clinical Risk, 16(6), 209-212. doi:10.1258/cr.2010.010052 Assessing The Head, Eyes, Ears, Nose And Throat

Kennedy, J. L., & Borish, L. (2013). Chronic sinusitis pathophysiology: the role of allergy. American Journal Of Rhinology & Allergy, 27(5), 367-371. doi:10.2500/ajra.2013.27.3906

Kennedy, J. L., Heymann, P. W., & Platts-Mills, T. E. (2012). The role of allergy in severe asthma. Clinical And Experimental Allergy: Journal Of The British Society For Allergy And Clinical Immunology, 42(5), 659-669. doi:10.1111/j.1365-2222.2011.03944.x Assessing The Head, Eyes, Ears, Nose And Throat

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