Assessing the Head, Eyes, Ears, Nose, and Throat NURS 6512
Assessing the Head, Eyes, Ears, Nose, and Throat NURS 6512
Assessing the Head, Eyes, Ears, Nose, and Throat NURS 6512
Having Trouble Meeting Your Deadline?
Get your assignment on Assessing the Head, Eyes, Ears, Nose, and Throat NURS 6512 completed on time. avoid delay and – ORDER NOW
Assessment of patients to determine conditions on the head, the eyes, the ears, the nose, and the throat ought to be properly done, which would then inform the appropriate treatment. Different formats can be used to assess the patient, and this essay considers Lily’s case, which is assessed using the SOAP Note format.
Patient Information: the patient is Lily, aged 20 y/o Sex: Female
Struggling to Meet Your Deadline?
Get your assignment on Assessing the Head, Eyes, Ears, Nose, and Throat NURS 6512 done on time by medical experts. Don’t wait – ORDER NOW!
S
CC: Lily indicated that she had a sore throat for the previous three days, and a headache accompanies this, a lot of pain while swallowing, and a decrease in appetite. She indicates that she is worried that the symptoms could be related to the current flu outbreak in her school.
HPI: Lily, a 20 y/o Female Caucasian, presented with a sore throat that had lasted for three days. The presentation was not really concerning initially, but following the flu outbreak in her school, two weeks made her really get concerned as they could be related. The patient also reported having a headache, pain during swallowing, and appetite loss alongside the sore throat.
The current medication indicated that the patient was taking an oral daily dose of multivitamin for six months.
Allergies: the patient is allergic to bee stings and hives
PMH: the patient did not report any previous hospitalizations or any underlying medical condition. She noted that there was a report of immunization against the flu in October 2017.
Social History: Lily attends school in the local community college and lives with her parents and a younger brother. There is no report of using any drugs, and she also denies smoking and alcohol use history.
Family Hx: there was no report of any significant family history from Lily’s assessment.
Review of Systems
General: the patient was alert in all spheres and was totally cooperative throughout the assessment. There was no indication of distress and no report of loss or gain of weight, no fever, no fatigue, and no weakness.
HEENT: the patient indicated that she had a headache, there were no challenges with vision, no problems with hearing, but a running nose and pain while swallowing, and there was a sore throat.
Skin: there were rashes or itching on the skin. No observable bruises on the skin.
Cardiovascular: the patient did not report any chest pain, no report of palpitations, no pressure in the chest, and no edema reported.
Respiratory: the patient indicated that she had a running nose, but there was no shortness of breath, there was nasal congestion, and no cough was reported.
Gastrointestinal: no report of abdominal discomfort/ pain, no nausea, no vomiting but a decrease in appetite. There were observed abnormal bowel movements.
Genitourinary: there were no changes in the patterns of urination, no urinary urgency, no increase in urine frequency, no report of blood in the urine. There was no report of any sexually transmitted diseases.
Neurological: the patient reported a headache that had persisted for three days but no indication of dizziness or fainting.
Hematologic: no report of a history of blood transfusion, and the patient did not have any history of anemia.
Lymphatics: the patient did not have enlarged lymph nodes
Psychiatric: patient did not indicate any history of psychiatric condition.
Endocrinologic: no report of sweating, no heat or cold intolerance, and no reports of polydipsia.
Allergies: patient allergic to bee stings and hives.
O
Physical Exam: the patient had blood pressure, pulse, and temperature within the normal ranges with adequate oxygen saturation. Blood Pressure 112/72, the pulse 65 (very regular); temperature 96.8 F; respiratory rate 20; the SpO2: 98% under room air; weight: 125 lbs; height: 5’4
General: the patient was oriented in four spheres and very cooperative, and not under any duress.
Diagnostic results
Lab results: the CBC: WBC was 7.8; RBC 5.0; H/H 12.4/38.8.
Swab culture: there were no conclusive results, but the intermediate findings could indicate group A strep infections. There was also a need to conduct a throat swab to determine if viral infections were present.
A
Differential Diagnoses:
Influenza infection: this is a viral infection that attacks the throat, nose, and lungs, commonly known as flu. In most cases, it would resolve on its own, but when complications occur, they are deadly (Boggess, 2019). This condition is contagious and could easily spread with a lot of ease in Lily’s case due to the closeness with which students live with each other and the different social amenities that they share (Sellers, Hagan, Hayden, & Fischer, 2017). When it occurs, the condition is associated with a high fever, runny nose, and sore throat alongside headache, body aches, and even fatigue.
Acute Laryngitis: this is a condition that is self-limiting, and it is caused by viral infections, postnasal drainage, irritants from the environment, and complicated allergic rhinitis (She, et al., 2020). In most cases, the condition would be less than three weeks but could become chronic beyond three weeks. Voice hoarseness, weak voice, sore throat, and a dry cough are symptoms associated with the condition (Jaworek et al., 2018). This diagnosis would easily be ruled out because the patient did not have any cough evidence, although there was hoarseness of voice.
Postnasal drip: this is one of the common causes of a persistent cough, and there is often excessive production of mucus, which results in a scratchy throat. The voice’s hoarseness is associated with mucus getting plugged into the Eustachian tube, a connection between the throat and the middle ear, and this could potentially cause an ear infection (Wolf, n.d.). Other symptoms associated with the condition include a blocked or running nose, having a hoarse voice, tickling sensation in the throat, and wheezing while breathing. There were other presentations like headache, difficulties swallowing, and therefore, postnasal drip cannot be ascertained as the diagnosis.
Acute Epiglottitis: this is a condition that is progressive and leads to an inflammation of the epiglottis and the tissues which surround the epiglottis, a situation that leads to blockage of the upper airway and challenges in breathing (Tsai et al., 2018). This condition is, in most cases, caused by bacterial colonization. Some of the symptoms associated with this condition include a very severe sore throat, having difficulties while swallowing, high fever, drooling, and abnormal sounds while breathing (Lindquist, Zachariah, & Kulkarni, 2017). The patient did not present with a high fever, and this condition can hence be ruled out.
Infectious mononucleosis: The Epstein Barr virus causes this condition, and it is most commonly diagnosed among teenagers, although it could occur at any age. The virus is spread through saliva, and it is therefore referred to as the kissing virus. The condition symptoms include sore throat, fever, and enlargement of the lymph nodes (Zhang et al., 2018). The condition would also be associated with body aches, including headaches and a rash.
P
There is a need to complete the physical examination of the patient of the ear, nose throat to determine further presentations associated with the condition. Since there is a recent outbreak of influenza in the college, there would be a need for a nasopharyngeal swab to determine if she has the infection. A throat culture would also be needed to isolate the specific microorganisms responsible for the current clinical symptoms. If the hoarse voice persists, then there would be a need for a laryngoscopy to check the larynx’s shape and therefore rule out other potential complicated conditions.
Examining the laryngeal structure is also important to eliminate possible underlying conditions that would cause long term problems with the voice. Since the patient had some disturbing symptoms, it would be necessary for symptomatic management. For instance, she would be put on analgesics to manage the headache and possible body aches. NSAIDs would also be an ideal choice to manage the inflammation, which is currently the reason for swallowing difficulties. It would also be necessary to expedite the tests to prevent complications for the patient.
Conclusion
During the assessment of patients, it is possible that several conditions can be associated with the presentation. Therefore, as a result, careful examination of the differentials helps to narrow down to a diagnosis and therefore initiate the appropriate interventions. SOAP Note provides an ideal approach to the assessment of patients and therefore informs diagnosis and treatment.
References
Boggess, K. (2019). The Deadly Influenza Virus and Its Changing Forms. D.U.Quark, 3(2). Retrieved from https://dsc.duq.edu/duquark/vol3/iss2/3
Jaworek, A. J., Earasi, K., Lyons, K. M., Daggumati, S., Hu, A., & Sataloff, R. T. (2018). Acute infectious laryngitis: A case series. Ear, Nose and Throat Journal, 97(9), 306–313. https://doi.org/10.1177/014556131809700920
Lindquist, B., Zachariah, S., & Kulkarni, A. (2017). Adult Epiglottitis: A Case Series. The Permanente Journal, 21, 16–089. https://doi.org/10.7812/TPP/16-089
Sellers, S. A., Hagan, R. S., Hayden, F. G., & Fischer, W. A. (2017, September 1). The hidden burden of influenza: A review of the extra-pulmonary complications of influenza infection. Influenza and Other Respiratory Viruses, Vol. 11, pp. 372–393. https://doi.org/10.1111/irv.12470
She, C., Wang, L., Liu, Y., Liu, J., Ahmad, F., Hamulati, H., … & Jiao, F. (2020). Acute Laryngitis in Children: A Study of 121 Cases. Clinical Research in Pediatrics, 3(1), 1-4.
Tsai, Y.-T., Huang, E. I., Chang, G.-H., Tsai, M.-S., Hsu, C.-M., Yang, Y.-H., … Li, H.-Y. (2018). Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study. PLOS ONE, 13(6), e0199036. https://doi.org/10.1371/journal.pone.0199036
Wolf. (n.d.). THI NA NAMIN TURUT HADITATE US009801752B2 ( 12 ) United States Patent.
Zhang, L., Zhou, P., Meng, Z., Pang, C., Gong, L., Zhang, Q., … Song, K. (2018). Infectious mononucleosis and hepatic function. Experimental and Therapeutic Medicine, 15(3), 2901–2909. https://doi.org/10.3892/etm.2018.5736
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
Click here to ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Assessing the Head, Eyes, Ears, Nose, and Throat NURS 6512
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
| S. CC: “Chest pain” HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms. Medications: Lisinopril 10mg, Omeprazole 20mg, Norvasc 5mg PMH: Positive history of GERD and hypertension is controlled FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives. SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years Allergies: PCN-rash; food-none; environmental- none Immunizations: UTD on immunizations, covid vaccine #1 1/23/2021 Moderna; Covid vaccine #2 2/23/2021 Moderna ROS O. VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70” General–Pt appears diaphoretic and anxious Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal space which radiates to the neck. A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted. Gastrointestinal–The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas; a bruit is heard in the right para-umbilical area. No masses or splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation. Pulmonary— Lungs are clear to auscultation and percussion bilaterally Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines) A. Differential Diagnosis: 1) Myocardial Infarction (provide supportive documentation with evidence based guidelines). 2) Angina (provide supportive documentation with evidence based guidelines). 3) Costochondritis (provide supportive documentation with evidence based guidelines). Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction |
A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).
Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction
P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.