Feb 23, 2024 NURS 6512 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
Patient Information:
CT, 32 years old
S.
CC (chief complaint) “I feel tired and my hair is falling off”
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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.
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.
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
NURS 6512 Assessing the Head, Eyes, Ears, Nose, and Throat
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.
Otoscopy.
Tympanocentesis.
Culture.
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.
SUBJECTIVE DATA:
Chief Complaint (CC): “I guess I’m kind of sick. . . I’ve been coughing a lot’
History of Present Illness (HPI): The affected person A young boy named Danny Riviera, who is only 8 years old, visits the medical center because he has been coughing for the past few days. According to what he says, the cough is very clear and has a watery quality to it. His cough is worse at night, which prevents him from getting adequate rest. As a consequence of this, he has trouble concentrating in class and often comes home exhausted. It’s painful in his right ear.
The decision his mother made to use over-the-counter cough medicine, which only provided temporary relief, was made. Danny claims that he has a cold and that he suffers from a runny nose on a regular basis. Additionally, he inhales his father’s secondhand smoke on a regular basis. Within the past year, he has also been diagnosed with pneumonia. However, he does not have a fever, difficulty breathing, abdominal pain, chest tightness, or chills. He also does not have chest tightness.
Medications: The patient acknowledges that they do take their medications at home. In addition to that, he takes a vitamin every day. In addition to that, he takes a medication for coughing that is purple.
Allergies: NKDA
Past Medical History (PMH): Denies asthma diagnosis. Identifies immunizations as being up to date. Previous symptoms include chronic coughing and pneumonia.
Past Surgical History (PSH): None reported.
Sexual/Reproductive History:
Personal/Social History: Identifies himself as a member of a household that also includes his parents and grandparents. avers having a sense of well-being while at home. Describes a park with a playground in the neighborhood. It is reported that the father smokes in the house.
Immunization History: Immunizations are current.
Significant Family History: He is supported by his biological parents as well as both sets of grandparents.
Review of Systems:
General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.
HEENT: The mucus membrane is wet, and the discharge from the nose is clear. However, the back of his throat is red and clogged with mucus. His eyes are lifeless, and the conjunctiva around them is a pinkish hue. It seems as though the right tympanic membrane is inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged, and they have a certain degree of tenderness.
Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.
Cardiovascular/Peripheral Vascular:
OBJECTIVE DATA:
Physical Exam:
Vital signs:
Blood Pressure
120/76
O2 Sat
96%
Pulse
100
Resp. Rate
28
Temperature
37.2 c
General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.
HEENT: The head is atraumatic and has a normocephalic shape. The mucus membrane is wet, and the discharge from the nose is clear. However, the back of his throat is red and clogged with mucus. His eyes are lifeless, and the conjunctiva around them is a pinkish hue. It seems as though the right tympanic membrane is inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged, and they have a certain degree of tenderness.
Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.
Cardiology: In S1 and S2, there were no murmurs, gallops, or rubs.
Lymphatics: When palpated, the lymph nodes in the right cervical region are tender.
Psychiatric: No mental issues noted.
Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.)
ASSESSMENT:
Based on the findings of the completed physical examination and the observations that were made, the following possible diagnoses can be made.
Common cold: The patient complains of having a stuffy nose and a sore throat, which are both symptoms of a common cold. This observation was also supported by the findings of a physical examination, which showed that the patient had swollen lymph nodes.
Streptococcus throat infection: The patient’s complaint of a sore throat suggests that they may have strep throat. On the other hand, symptoms like nausea, vomiting, headaches, and fever did not present themselves at any point.
iii. Rhinitis is another condition that could have been causing the patient’s symptoms, as they included stuffy nose, sore throat, and drainage from the nose. In addition to this, the patient has a history of recurrent ear infections throughout their lifetime.
Allergies and asthma: The patient does not have a history of allergic reactions. Nevertheless, it is possible that this condition will occur. This condition may have been the cause of the persistent cough. On the other hand, the patient does not exhibit any symptoms of wheezing, chest pain or tightness, or difficulty breathing.
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 InformationTo 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 Refe
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