NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5

NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5

NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5

Patient Information:

CT, 32 years old

S.

CC (chief complaint) “I feel tired and my hair is falling off”

HPI: Chantal is a 32-year-old female who visited the facility with complaints of feeling tired and her hair falling out. She reports that she has gained 30 pounds of weight in the past year. Chantal also reports that her appetite has significantly decreased. She denied accompanying symptoms such as nausea, vomiting, and pain. She reports that engaging in active physical activities worsens the fatigue that she is experiencing.

Current Medications: Chantal denies any current use of medications

Allergies: Chantal reports seasonal allergies. She denies food or drug allergies.

PMHx: Chantal’s immunization record is up-to-date. Her last tetanus vaccination was 10/10/23. She has no history of hospitalization or chronic illnesses. She also denied any history of surgeries.

Soc Hx: Chantal is married with no children. She works as a teacher. She lives with her husband in a rented apartment. She does not smoke or abuse any drugs. She loves spending her leisure time with her husband and family. She wears a seat belt while driving. Their home has smoke detectors. She engages in regular exercises at least four times weekly.

Fam Hx: Chantal’s mother was diagnosed with cervical cancer a year ago and has been on treatment. Her father is an alcoholic and has hypertension and asthma. Her paternal grandfather died of heart disease. Her paternal grandmother died of major depression. Her maternal grandmother died of diabetes mellitus type 2.

ROS:

GENERAL:  Chantal was dressed appropriately for the occasion. She was alert and oriented to herself, time, and events. She reported fatigue and weight gain. She denied fever, pain, or chills.

HEENT:  Eyes: Chantal denies blurred vision, eye drainage, pain, or double vision. Ears, Nose, Throat:  Chantal denies ear pain, decreased hearing, ringing, or ear fullness. She denies sneezing, nasal drainage, or septum deviation. She denies a sore throat, difficulty swallowing, or postnasal drainage.

SKIN:  Chantal reports her hair falling out. She denies abnormal changes in her skin color, itching, or skin rashes. CARDIOVASCULAR: Chantal denies palpitation, peripheral edema, palpitations, or chest pain and discomfort.

RESPIRATORY:  Chantal denies wheezing, cough, dyspnea, cyanosis, or sputum. GASTROINTESTINAL:  Chantal reports decreased appetite. She denies nausea, vomiting, diarrhea, heartburn, abdominal pain, or bleeding.

GENITOURINARY:  Chantal reports that her last menstrual period was 24/12/2023. She denies urgency, frequency, or dysuria.

NEUROLOGICAL:  Chantal denies loss of balance, difficulty with movement, tingling sensations, syncope, dizziness, or paralysis. Her bowel and bladder movements are normal.

MUSCULOSKELETAL: Chantal denies fractures, joint pains, muscle pain, stiffness, and back pains.

HEMATOLOGIC:  Chantal denies easy bruising and a history of excessive bleeding and bleeding disorders

LYMPHATICS:  Chantal denies any enlarged notes or a history of splenectomy. PSYCHIATRIC:  Chantal has no history of any mental health disorders

ENDOCRINOLOGIC:  Chantal reports weight gain, feeling cold, fatigue, and disturbance in her sleeping pattern. She denies polydipsia or polydipsia.

ALLERGIES:  Chantal reports a history of her hair falling out.

O.

Physical exam:

Vital signs: T 37.3, RR 20, BP 102/62, P 70, and SPO2 96%, Weight 276 lbs Height 5’5

Skin: Scarce hair distribution, dry and cold skin to touch

 

Diagnostic results: A complete blood count and thyroid function tests were ordered. This was to rule out infections and abnormal thyroid hormones as the cause of Chantal’s problems.

A.

Differential Diagnoses

Hypothyroidism: Hypothyroidism is Chantal’s primary diagnosis. Hypothyroidism is a thyroid disorder that develops from low thyroid hormone levels. Hypothyroidism develops due to central or secondary causes. Central hypothyroidism arises from inadequate stimulation of the thyroid gland by the central nervous system while secondary hypothyroidism develops due to other causes such as thyroid surgery. Patients suffering from hypothyroidism experience symptoms such as cold intolerance, skin changes, puffiness, decreased sweating, gastrointestinal disturbances, hair loss, voice changes, fatigue, sleep disturbances, and weight gain. They also experience galactorrhea and menstrual cycle abnormalities (Patil et al., 2023; Wilson et al., 2021). Chantal has symptoms seen in hypothyroidism, hence, her primary diagnosis.

Major depression: Major depression is the secondary diagnosis that should be considered for Chantal. Major depression is a mental health disorder characterized by a severely depressed mood on most days, throughout the day. Patients also report additional symptoms such as fatigue, feelings of worthlessness and guilt, and changes in appetite, sleep patterns, and weight. Patients are also easily distracted, and experience difficulties concentrating and making decisions, suicidal thoughts, plans, and attempts (Bode et al., 2021). Chantal has some symptoms of major depression such as weight and appetite changes and sleep disturbances. However, she does not have a depressed mood, hence; major depression is the secondary diagnosis.

Sleep apnea: Sleep apnea is the other differential diagnosis that should be considered for Chantal. Sleep apnea is a sleep disorder characterized by problems with sleeping patterns. The affected patients experience repeated episodes of interrupted sleep due to the stopping of the breathing process. Patients experience symptoms such as snoring loudly, feeling tired after a night’s sleep, gasping for air during sleep, morning headaches, and irritability (Gottlieb & Punjabi, 2020; Malhotra et al., 2021). Chantal has sleep disturbance problems, which do not qualify her for sleep apnea, hence, it being a secondary diagnosis.

Chronic fatigue syndrome: Chronic fatigue syndrome is the other differential that should be considered for Chantal. Chronic fatigue syndrome is a condition associated with symptoms such as profound tiredness despite bed rest. The symptoms worsen when patients engage in any activity that requires intensive mental or physical activity. Additional symptoms associated with the syndrome include light sensitivity, headaches; tender lymph nodes, insomnia, and difficulties with concentration (Deumer et al., 2021; Sandler & Lloyd, 2020). Despite Chantal reporting fatigue, she does not suffer from chronic fatigue syndrome because of the presence of other symptoms such as weight gain and cold intolerance.  

Addison’s disease: Addison’s disease is the other differential diagnosis that should be considered for Chantal. Addison’s disease develops from insufficient production of steroid hormones by the adrenal gland. Patients experience symptoms that include skin hyperpigmentation, low blood pressure, nausea, vomiting, diarrhea, constipation, and abdominal pain, weight loss. Patients might also experience fever, convulsions, severe gastrointestinal disturbances, and hypoglycemia during adrenal crises (Husebye et al., 2021; Saverino & Falorni, 2020). Addison’s disease is Chantal’s least likely diagnosis because of weight gain, cold intolerance, and lack of skin hyperpigmentation.

1.  

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

 

References

Bode, H., Ivens, B., Bschor, T., Schwarzer, G., Henssler, J., & Baethge, C. (2021). Association of Hypothyroidism and Clinical Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry, 78(12), 1375–1383. https://doi.org/10.1001/jamapsychiatry.2021.2506

Deumer, U.-S., Varesi, A., Floris, V., Savioli, G., Mantovani, E., López-Carrasco, P., Rosati, G. M., Prasad, S., & Ricevuti, G. (2021). Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): An Overview. Journal of Clinical Medicine, 10(20), Article 20. https://doi.org/10.3390/jcm10204786

Gottlieb, D. J., & Punjabi, N. M. (2020). Diagnosis and Management of Obstructive Sleep Apnea: A Review. JAMA, 323(14), 1389–1400. https://doi.org/10.1001/jama.2020.3514

Husebye, E. S., Pearce, S. H., Krone, N. P., & Kämpe, O. (2021). Adrenal insufficiency. The Lancet, 397(10274), 613–629. https://doi.org/10.1016/S0140-6736(21)00136-7

Malhotra, A., Ayappa, I., Ayas, N., Collop, N., Kirsch, D., Mcardle, N., Mehra, R., Pack, A. I., Punjabi, N., White, D. P., Gottlieb, D. J., & for SRS Task Force. (2021). Metrics of sleep apnea severity: Beyond the apnea-hypopnea index. Sleep, 44(7), zsab030. https://doi.org/10.1093/sleep/zsab030

Patil, N., Rehman, A., & Jialal, I. (2023). Hypothyroidism. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK519536/

Sandler, C. X., & Lloyd, A. R. (2020). Chronic fatigue syndrome: Progress and possibilities. Medical Journal of Australia, 212(9), 428–433. https://doi.org/10.5694/mja2.50553

Saverino, S., & Falorni, A. (2020). Autoimmune Addison’s disease. Best Practice & Research Clinical Endocrinology & Metabolism, 34(1), 101379. https://doi.org/10.1016/j.beem.2020.101379

Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: Diagnosis and Treatment. American Family Physician, 103(10), 605–613.

1.  

CC:     “Fever and ear pain”

HPI:    The patient is a 3 year old girl who developed fever and ear pain that started 3 days ago.   She has no significant medical history.  The pain seems to be severe. The patient is not           pleased to be at the practioner’s office since she has been crying constantly. Her mother           states that shed developed a cold 3 days ago with sniffles. As she continues to cough she           produces a yellowish nasal discharge.

Medications: paracetamol 500mls syrup, amoxicillin 5mls syrup, ibuprofen 5mls twice daily

PMH: Has received all immunizations expected for children such as the BCG, oral polio,            and pentavalent vaccines and measles vaccine.

            Has not been previously hospitalized are undergone any surgical procedures

            Has achieved all childhood milestones expected at that age.

            Has not been transfused or transfused any blood

FH:     Mother has been diagnosed with diabetes; Father is a hypertensive patient.  No history of tuberculosis and mental illness in the family. The patient is the only child in that family.

SH:   The patient has not been exposed to second hand smoking and the parents have never             experimented with illicit drugs

Allergies: The patient has no known food or drug allergies

Immunizations: The patient is fully immunized according to EPI guidelines. Has received all             immunizations expected for children such as the BCG, oral polio,   and pentavalent           vaccines and measles vaccine.

ROS- body systems that would help with the diagnosis include the constitutional, HEENT and    respiratory.

General-Positive for fevers and no chills.

HEENT- presence of ear pain, no abnormalities on the head, positive for cough, yellowish                       discharge noted in the nose. The eyes are clear and vision is normal.

Respiratory- positive for cough, no wheezing or stridor, lung sounds are clear

Cardiovascular- Heart beat regular, no presence of murmurs and no cyanosis reported.

Gastrointestinal- No distention noted; bowel sounds normal in all areas. No splenomegaly nor   masses. No tenderness.

Pulmonary-Lungs are clear.

 

O.

            VS: BP 124/80; P -98; R 20; T 37.2 degrees Celsius;

The physical exam should be conducted should prioritize the constitution, HEENT and respiratory systems. These is due to the condition probably being an ear infection hence these areas should be considered to provide the more likely diagnosis. Ear infections could come from upper respiratory infections hence the respiratory system is considered. The clinical manifestations the patient also present are majorly occurring on the forenamed systems.

Constitutional- positive for fever and irritability.

HEENT- positive for ear pain, yellowish nasal discharge noted, positive for ear pain.

Respiratory- positive for cough.

Diagnostics

The likely condition of the child is an ear infection hence diagnostics done should aim to prove which one or rule out. Therefore an otoscopy should be done to examine the tympanic membrane. Tympanocentesis should also be done to determine middle ear fluid. Culture should also be done for the nasal discharge and also if there’s fluid in the middle ear. The height and weight of the child should also be obtained for medication prescription purposes.

1. Otoscopy.
2. Tympanocentesis.
3. Culture.
4. Height and weight (Hinkle & Cheever, 2014).

A.

Differential Diagnosis:

1) Acute otitis media -the clinical manifestations associated with this condition include ear pain,

fever and a cough. It is known to also present with symptoms of respiratory infections hence the nasal discharge.  Patients are also known to be irritable (McCance & Huether, 2019).

2) COVID- 19- due to the recent viral infection characteristics it could be a likely diagnosis. The symptoms associated with this condition vary and have included fever, cold, irritability and presence of nasal discharge. The virus affects upper respiratory systems hence causing a wide range of symptoms (McCance & Huether, 2019).

3) Acute mastoiditis- this is due to inflammation of the air cells that could bring about clinical manifestations such as fever and ear pain. As the patient is presenting symptoms associated with ear infection this could be a likely diagnosis (McCance & Huether, 2019)

4) Herpes zoster infection is another likely diagnosis as due to the viral infection a patient presents with clinical manifestations such as irritability, fever and pain in various areas. Since the patient is a child it is a condition that is common in children hence it could be what is affecting her (McCance & Huether, 2019).

5) Acute otitis externa is another possible differential as due to inflammation of the external ear canal a patient could present with the symptoms such as ear pain irritability and a fever. Hence it is possible the patient could be suffering from this (McCance & Huether, 2019).

Primary Diagnosis/Presumptive Diagnosis: Acute Otitis Media

References

McCance, K. L., Huether, S. E., BRASHERS, V. L., & ROTE, N. S. (2019). Pathophysiology:    The biologic basic for diseases in adults and children (No. ed. 8). Elsevier.

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth’s textbook of medical-surgical          nursing (Edition 13.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

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/.

Geeky Medics. (2020, June 5). Fundoscopy (Ophthalmoscopy) – OSCE guide [Video]. YouTube. https://www.youtube.com/watch?v=SVuP5Td23AQ&feature=youtu.be

Health4TheWorld Academy Videos Channel. (2020, February 15). Paranasal sinus imaging [Video]. YouTube. https://www.youtube.com/watch?v=8TQBtdbEY-I

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.

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.

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5

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

Allergic rhinitis is an inflammation of the nasal membranes characterized by sneezing, nasal itching, nasal congestion, and rhinorrhea. It is triggered by reactions to airborne allergens such as dust, plant pollens, molds, animal dander, wool, and air pollutants (Bjermer et al., 2019). Clinical features of Allergic rhinitis include itching nose, eyes, ears, and palate, sneezing, rhinorrhea, postnasal drip, nasal congestion, loss of smell, headache, earache, excessive tearing, red eyes, eye swelling, fatigue, drowsiness, and malaise (Bjermer et al., 2019).

Physical exam findings in allergic rhinitis include nasal crease, thin, watery nasal secretions, deviation or perforation of the nasal septum (Crisci & Ardusso, 2020). Besides, the patient may have mouth breathing, frequent sniffling or throat clearing, and dark circles under the eyes referred to as allergic shiners. Anterior rhinoscopy typically reveals swelling of the nasal mucosa and thin, clear secretions (Bjermer et al., 2019). The mucosa of the nasal turbinates may be swollen or boggy and have a pale, bluish-gray appearance.

Allergic rhinitis is the presumptive diagnosis based on pertinent positive subjective findings of itchy nose, eyes, palate, and ears, nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Objective findings in line with Allergic rhinitis include dark circles around the eyes, excessive lacrimation, pale boggy nasal mucosa, clear thin secretions, and enlarged nasal turbinates obstructing airway flow.  Furthermore, the patient is allergic to pollen and dust mites which are documented triggers of Allergic rhinitis.

Vasomotor Rhinitis:

Vasomotor rhinitis refers to non-inflammatory rhinitis triggered by a change in temperature, odors, or humidity. It is thought to result from disturbed regulation of the parasympathetic and sympathetic systems whereby the parasympathetic system dominates, causing vasodilation and edema of the nasal vasculature (Crisci & Ardusso, 2020). The resulting symptoms include rhinorrhea, sneezing, congestion, headache, facial pressure, postnasal drip, coughing, and throat clearing. Physical exam findings in vasomotor rhinitis include boggy edematous mucosa with clear mucoid secretions (Crisci & Ardusso, 2020). In addition, mucosal injection and lymphoid hyperplasia involving the adenoids, tonsils, and lingual tonsils may be present.

Pertinent positive findings consistent with vasomotor rhinitis include nasal congestion, sneezing, rhinorrhea, postnasal drainage, boggy nasal mucosa, clear thin nasal secretions, and throat clearing.

Common Cold:

Common cold is caused by Rhinoviruses, which mainly cause upper respiratory tract infections. Clinical features of Rhinovirus infection include nasal dryness or irritation and sore throat or throat irritation, which are often the initial symptoms (Jaume, Valls-Mateus & Mullol, 2020). Nasal discharge, nasal congestion, and sneezing then occur and intensify over 2-3 days. Other signs and symptoms include headache, facial and ear pressure, loss of sense of smell and taste, cough, hoarseness, post-tussive vomiting, irritability, and in some cases, low-grade fever.

Physical exam findings in th