Feb 23, 2024 Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Patient Information:
CT, 32 years old
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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.
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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.
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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.
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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.
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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.
S.
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.
Assignment 1 Case Study Assignment Assessing the Head, Eyes, Ears, Nose, and Throat
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.
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
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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.
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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.
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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.
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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.
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References
Boggess, K. (2019). The Deadly Influenza Virus and Its Changing Forms
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