Feb 23, 2024 Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat
Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat
Case Study Assignment 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.
Episodic/Focused SOAP Note
Patient Information:
D.R. 8 years old male, Hispanic Initials, Age, Sex, Race
S.
CC (chief complaint) “I have been coughing for five days, feeling sick and fatigued due to lack of sleep.”
HPI: The eight-year-old presents with a cough that started some five days ago, and the cough becomes worse at night. The nighttime cough causes the patient to have fatigue due to a lack of sleep. Even though the sputum is clear, the cough is watery and gurgly. Even though the cough does not aggravate with activity, the patient coughs every few minutes. The patient reports pain in the throat and right year with scales of 3/10 and 2/10, respectively. The mother administered some over-the-counter yellow cough syrup for treatment which gave temporary relief.
Current Medications: unknown over-the-counter cough syrup to suppress the cough and daily intake of vitamins.
Allergies: Denies any seasonal, food, or medication allergies
PMHx: The patient has no history of hospitalizations or past surgical history. He was treated for pneumonia in the past year and had had recurrent ear infections.
Fam Hx: The father had a history of asthma as a child, and the father currently smokes cigarettes; hence the patient is exposed to secondhand smoke
ROS:
General: The patient denies night sweats, chills, or fevers. No changes in normal activities or appetite. However, the patient admits to enhanced fatigue.
Skin: Denies any skin changes or rashes.
HEENT: No headaches, denies blurred vision or vision changes. Reports pain in the right ear as a 3/10. Denies any hearing changes, vertigo, or tinnitus. Has throat pain as a 2/10.
Respiratory: Admits to coughing that commenced five days ago and worsening at night. Denies wheezing or shortness of breath. No history of asthma.
Cardiovascular: Denies palpitations, chest tightness, or pain.
Gastrointestinal: normal appetite, denies abdominal pain, constipation, diarrhea, or vomiting.
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O.
Physical exam:
General: The boy appears fatigued but stable, good eye contact during the exam, appropriately dressed
Skin: The skin is intact with no visible rashes, lesions, or wounds
Head: Normocephalic and atraumatic
Eyes: No conjunctival discharge, the conjunctiva is pink and moist. The sclera is white. The eyes are dull in appearance.
Ears: The right tympanic membrane is inflamed and red. No noticeable visible findings like perforations, bulging, or fluid. The left auditory canal looks pink, and the tympanic membrane is pearly gray.
Nose: The mucus membrane has a clear discharge and is moist.
Throat: cobblestoning and redness observed in the throat back
Lymph nodes: The right cervical lymph node appears bigger, and tenderness also observed upon palpation
Respiratory: There is an increased respiratory rate, but no acute distress was observed. No
Case Study Assignment Assessing The Head, Eyes, Ears, Nose, And Throat
bronchophony and adventitious breath sounds were observed. The breath sounds are clear. The chest wall is resonant to percussion. Productive cough even though the sputum is clear, expected fremitus.
Spirometry: FEV1: 3.15 L, FVC 3.91L (FEV1/FVC: 80.5%)
A.
Differential Diagnoses
From the observation and the physical assessment accomplished, the following differential diagnoses apply.
Common cold: This diagnosis is highly likely as indicated from the symptoms described by the patient including running nose cough and sore throat. From the physical examination, the patient’s lymph nodes were also observed to be swollen
Strep throat- The condition is also likely due to the sore throat and the condition is also common among children. However the patient had no fever, headache, rash, vomiting or nausea.
Rhinitis: Rhinitis is another condition that is likely for this patient. Various symptoms could point to it. Some of the symptoms include stuffy nose, itchy throat, and clear nose drainage. Ear infections that keep on coming back
Asthma and allergies: Asthma and allergies are also a possibility, even though the patient denies any history of allergic reactions. The patients has had coughs which is a major symptom of cough. However, there was no shortness of breath, chest tightness or pain or wheezing.
Primary Diagnosis/Presumptive Diagnosis: Common cold
Additional tests and referrals should be made to help confirm or rule out certain suggested conditions. The patient should do an allergy test to help rule out the possibilities of allergies. A rapid strep test should also be conducted to help eliminate strep throat through a Strep culture (Bickley et al., 2020). Another assessment is necessary to identify a possible bacterial infection. The patient should be offered medication as guided by the outcomes of the rapid strep test. An RX antitussive therapy at bedtime or OTC should be introduced for ten days. Education is key for the management of this patient.
The patient and the family members should be educated on how to avoid possible allergens which can aggravate the situation or trigger a new attack (Sexton et al., 2019). The family members are also to be advised to maintain cleanliness by washing the child’s bedsheets weekly. The father smokes, and this could be an aggravating factor. Therefore, the parents should be advised to smoke away from the house, away from the patient. Some of the indicated referrals and consultations include allergy tests to rule out allergies and lung function tests to help rule out asthma.
In terms of follow-ups, the patient needs to visit the facility in a fortnight for review and assessments. However, they should seek medical attention immediately in case other symptoms such as fainting, chest pain, dizziness, shortness of breath, and high fever appear.
References
Brooker, C. (2021). Cough and cold: The perils of the season. AJP: The Australian Journal of Pharmacy, 102(1206). Doi: 10.3316/informit.789777137910856
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2020). Bates’ pocket guide to physical examination and history taking. Lippincott Williams & Wilkins.
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.
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.
Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
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.
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.
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.
Resources
Be sure to review the Learning Resources before completing this activity.Click the weekly resources link to access the resources.
WEEKLY RESOURCES
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 st
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