Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat 

Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat 

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.

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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.

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RESOURCES

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

LEARNING RESOURCES

Required Readings

  • Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
    • Chapter 11, “Head and Neck”
      • This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck.
    • Chapter 12, “Eyes”
        • In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes.
      • Chapter 13, “Ears, Nose, and Throat”
        • The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat.
  • Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
    Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.

Shadow Health Support and Orientation Resources

Required Media

Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 (29m)

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)Links to an external site. – OSCE guide [Video]. YouTube. https://www.youtube.com/watch?v=SVuP5Td23AQ&feature=youtu.be
  • Health4TheWorld Academy Videos Channel. (2020, February 15).Paranasal sinus imagingLinks to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=8TQBtdbEY-I
  • University of Iowa Ophthalmology. (2016, December 19).Fluorescein staining of the corneaLinks to an external site.. 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.

Optional Resources

Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2020). DeGowin’s diagnostic examination (11th ed.). New York, NY: McGraw Hill Medical.

    • Chapter 7, “The Head and Neck”
      This chapter describes head and neck examinations that can be made with general clinical resources. Also, the authors detail syndromes of common head and neck 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 INFORMATION

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

  1. To submit your completed assignment, save your Assignment as WK5Assgn1+last name+first initial.
  2. Then, click on Start Assignment near the top of the page.
  3. Next, click on Upload File and select Submit Assignment for review.

 

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Rubric

NURS_6512_Week_5_Assignment_1_Rubric

NURS_6512_Week_5_Assignment_1_Rubric

Criteria Ratings Pts
This criterion is linked to a Learning OutcomeUsing the Episodic/Focused SOAP Template: · Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned. ·  Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.
50 to >44.0 ptsExcellent

The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

44 to >38.0 ptsGood

The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

38 to >32.0 ptsFair

The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.

32 to >0 ptsPoor

The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

50 pts
This criterion is linked to a Learning Outcome·   List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
35 to >29.0 ptsExcellent

The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected.

29 to >23.0 ptsGood

The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.

23 to >17.0 ptsFair

The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

17 to >0 ptsPoor

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

35 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 ptsExcellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 ptsGood

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 ptsFair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 ptsPoor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 ptsExcellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 ptsGood

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 ptsFair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 ptsPoor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 ptsExcellent

Uses correct APA format with no errors.

4 to >3.0 ptsGood

Contains a few (1 or 2) APA format errors.

3 to >2.0 ptsFair

Contains several (3 or 4) APA format errors.

2 to >0 ptsPoor

Contains many (≥ 5) APA format errors.

5 pts
Total Points: 100

Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat Sample

Patient Information: Initials: Lily   Age: 20 years  Sex: Female    Race- White

S.

CC (chief complaint): “Sore throat.”

HPI: Lily is a 20-year-old White female presenting with a chief complaint of a sore throat. She states that the sore throat started three days. She took the symptom seriously after she found out that there was a flu outbreak in their college two weeks ago. She is worried that her symptoms could be linked to the flu outbreak. Lily also states that she has a reduced appetite, headache, and pain when swallowing. Some of her classmates have been treated in the clinic after presenting with similar symptoms.

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Current Medications: None

Allergies: None

PMHx: No history of chronic medical illnesses or surgeries. The last TT was 4 years ago; my Last Flu shot was 15 months ago.

 

Soc Hx: Lily is a student at a local community college pursuing a Diploma in Culinary Arts. She lives with her parents and has one older and younger brother. Her hobbies include baking and trying new recipes. She admits to taking alcohol on weekends and using recreational marijuana but denies smoking.

Fam Hx: No history of chronic illnesses in the family.

ROS:

GENERAL: Reports appetite disturbance. Negative for fever, weight changes, or increased fatigue.

HEENT: Head: Reports headache. Negative for head injury. Eyes: Negative for vision changes, excessive lacrimation, or eye pain. Ears: Denies ear pain, discharge, tinnitus, or hearing loss. Note: Reports runny nose. Negative for nasal congestion or sneezing. Throat: Reports sore throat, slight hoarseness, and pain when swallowing.

SKIN: Denies itchiness, rashes, or lesions.

CARDIOVASCULAR: Denies chest pain, edema, dyspnea on exertion, or palpitations.

RESPIRATORY: Negative for SOB, cough, wheezing, or sputum.

GASTROINTESTINAL: Negative for nausea, vomiting, abdominal pain, diarrhea, or constipation.

GENITOURINARY: Negative for urinary or vaginal symptoms.

NEUROLOGICAL: Reports headache. Negative for dizziness, tingling sensations, or paralysis.

MUSCULOSKELETAL: Negative for muscle pain, joint pain, or stiffness.

HEMATOLOGIC: Negative for bruises or bleeding.

LYMPHATICS: Negative for lymph node swelling.

PSYCHIATRIC: Negative for anxiety, depression, or suicidal symptoms.

ENDOCRINOLOGIC: Negative for excessive perspiration, heat/cold intolerance, excessive hunger/thirst, or polyuria.

ALLERGIES: No history of eczema or hives.

Physical exam:

Vital Signs: BP- 122/76; HR- 84; Temp- 98.4; Resp- 16

GENERAL: Female patient in no acute distress. She is neat and appropriately dressed and maintains eye contact. The patient is alert and oriented.

HEENT: Head is symmetrical and normocpehalic. Eyes:  White sclera, Pink conjunctiva, PERRLA. Ears: TMs are shiny and patent bilaterally. Nose: Runny nose. The mucous membranes appear glistening and glassy. Throat: Slight voice hoarseness; Pharynx appears normal, without ulceration, signs of inflammation, or exudates.

RESPIRATORY: Smooth and effortless respirations. The lungs are clear on auscultation bilaterally.

CARDIOVASCULAR: Regular heart rate and rhythm. S1 and S2 are present. S gallop and systolic murmurs are absent.

Diagnostic results: No diagnostic tests were ordered.

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).

  1. Common Cold/ Upper Respiratory tract infection (URI):Pappas (2018) explains that URI is an acute, self-limited upper airway viral infection that often involves the lower respiratory tract. The characteristic symptoms include rhinorrhea, nasal congestion, and sore or scratchy throat. Other clinical features include headache, cough, facial and ear pressure, loss of sense of smell and taste, and voice hoarseness (Jaume et al., 2020). The patient has a runny nose, sore throat, pain when swallowing, headache, and hoarseness making this a presumptive diagnosis.
  2. Vasomotor rhinitis: Clinical features include headache, rhinorrhea, nasal congestion, sneezing, postnasal drip, facial pressure, coughing, and throat clearing (Crisci & Ardusso, 2020; Agnihotri & McGrath, 2019). The patient has positive symptoms like rhinorrhea and headache, making this a differential diagnosis.
  3. Influenza: This is a highly contagious acute viral respiratory infection. Clinical manifestations of influenza include severe headache, sore throat, fever, chills, cough, rhinorrhea, red-watery eyes, muscle aches, severe fatigue, and general body weakness (Phetcharakupt et al., 2021). GI symptoms include nausea, vomiting, loss of appetite, abdominal pain, and diarrhea (Chow et al., 2019). The patient has positive symptoms of influenza, like headaches, sore throat, rhinorrhea, and suppressed appetite.
  4. Acute Sinusitis: Acute sinusitis is characterized by facial pain, frontal headache, nasal discharge,nasal blockage, persistent cough, maxillary dental pain, and hypersomnia (Patel & Hwang, 2018). It is a differential based on positive findings of rhinorrhea and headache.
  5. Tonsillitis: The clinical features include sore throat, fever, difficult and painful swallowing, foul breath, tender cervical lymph nodes, and swollen tonsils with purulent exudates (Pérez et al., 2020). The patient has a sore throat and painful swallowing consistent with Tonsillitis. However, she has no fever or inflamed Tonsillar glands ruling out Tonsillitis as the primary diagnosis.

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

 

References

Agnihotri, N. T., & McGrath, K. G. (2019). Allergic and non-allergic rhinitis. Allergy and asthma proceedings40(6), 376–379. https://doi.org/10.2500/aap.2019.40.4251

Chow, E. J., Doyle, J. D., & Uyeki, T. M. (2019). Influenza virus-related critical illness: prevention, diagnosis, treatment. Critical care23(1), 1–11. https://doi.org/10.1186/s13054-019-2491-9

Crisci, C. D., &Ardusso, L. (2020). A Precision Medicine Approach to Rhinitis Evaluation and Management. Current treatment options in allergy7(1), 93–109. https://doi.org/10.1007/s40521-020-00243-1

Jaume, F., Valls-Mateus, M., &Mullol, J. (2020). Common Cold and Acute Rhinosinusitis: Up-to-Date Management in 2020. Current Allergy and asthma reports20(7), 28. https://doi.org/10.1007/s11882-020-00917-5

Pappas, D. E. (2018). The Common Cold. Principles and Practice of Pediatric Infectious Diseases, 199–202.e1. https://doi.org/10.1016/B978-0-323-40181-4.00026-8

Patel, Z. M., & Hwang, P. H. (2018). Acute Bacterial Rhinosinusitis. Infections of the Ears, Nose, Throat, and Sinuses, 133–143. https://doi.org/10.1007/978-3-319-74835-1_11

Pérez, R. P., González, F. Á., Baquero-Artigao, F., Cañete, M. C., i Bru, J. D. L. F., Landaluce, A. F., … & Fernández, J. S. (2020). Diagnosis and treatment of acute tonsillopharyngitis. Consensus document update. Anales de Pediatría (English Edition)93(3), 206-e1. https://doi.org/10.1016/j.anpedi.2020.05.004

Phetcharakupt, V., Pasomsub, E., & Kiertiburanakul, S. (2021). Clinical manifestations of influenza and performance of rapid influenza diagnostic test: A university hospital setting. Health science reports4(4), e408. https://doi.org/10.1002/hsr2.408

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