NURS 6512 Week 5 Assignment – Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat
NURS 6512 Week 5 Assignment – Case Study Assignment: Assessing The Head, Eyes, Ears, Nose, And Throat
Patient Information:
28-year
Female
African American
S (subjective)
CC The patient presents to the clinic with a chief complaint of runny nose, itchy eyes, and ears that have felt full in the last nine days.
HPI; The patient is a 28-year-old African American female who complains of a runny nose, itchy eyes, and ears feeling full, lasting nine days. She reports she experiences these symptoms every spring season, which lasts approximately six to eight weeks. She says the runny nose has clear mucus with on-and-off sneezing throughout the day. She also states that she has itchy eyes and sometimes wants to scratch them. She also reports feeling a tickle at the back of her throat and her ears feeling full with pop sometimes. She says to have taken Claritin when she experienced the same symptoms last year, effectively relieving her symptoms.
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Current Medications: Denies using any medication currently
Allergies:
- Seasonal allergies of an unknown type
- Denies any food, latex, or medication allergies
PMHx:
- Pneumonia during his childhood
- Denies history of asthma
- Received all childhood immunizations
- Is current with flu and influenza vaccine
Soc and Substance Hx: The is single and lives alone in her apartment. She is currently employed and works as a supervisor in a pharmaceutical company. She is also a part-time student pursuing her Master’s. She reports having friends in church and at her workplace. She denies any use of alcohol, tobacco, or any illicit drug.
Fam Hx: Denies any family history of asthma, allergies, or pneumonia.
Surgical Hx: No surgical history
Mental Hx: Denies any history of psychiatric illnesses. Denies any suicidal thoughts or attempts.
Violence Hx: Reports living in a safe environment. Denies any form of physical abuse or sexual violence
Reproductive Hx: The patient is a heterosexual female. Denies any history of STDs and reproductive issues.
ROS
GENERAL: The patient denies weight loss, fever, chills, weakness, or fatigue.
HEENT: The patient denies headaches or dizziness. She reports having itchy but no visual problems. She also states that her nose is runny with clear mucosal discharge. She also says of sneezing on and off during the day. Her ears feel full and sometimes with a pop sound—she reports feeling a tickle in her throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough, or sputum.
GASTROINTESTINAL; Denies stomach pains, nausea, or vomiting. Reports normal bowel movements
GENITOURINARY: Denies any burning on urination—reports having a regular menstrual cycle that lasts up to four days.
NEUROLOGICAL: Denies any headache, dizziness, or tingling in the extremities.
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain, swelling, or stiffness.
HEMATOLOGIC: Denies nose bleeding or bruising.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: Denies sweating, cold or heat intolerance.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
Reports of seasonal allergies of an unknown type
O (objective)
Physical exam:
HEENT; the patient is sitting upright with no acute distress. She appears pale and tired. The head is normocephalic with a symmetrical face. Eyes appear red and watery. Has boggy nasal mucosa with clear thin secretions. She also has enlarged nasal turbinates. Enlarged tonsils with a mildly erythematous throat.
Cardiovascular: S1, S2 audible. Denies any murmurs, gallops or palpitations
Respiratory; Lungs are clear. Breath sounds clear to auscultations. Chest walls resonate to percussion.
Diagnostic results:
- Skin prick test to determine a specific allergen related to the symptoms
- Strep test-to rules out strep throat
An (assessment)
Allergic rhinitis; may be a highly appropriate diagnosis based on the abnormal findings. This condition occurs due to the production of immunoglobin E in response to an allergen. The primary symptoms include sneezing, nasal blockage, and itchy eyes and nose upon exposure to allergens (Nur Husna et al., 2022). The patient has these symptoms and reports having them around this time every year.
Common cold; This is also a likely diagnosis as the patient experiences symptoms such as a runny nose and itchy eyes. According to Pappas (2018), this condition is associated with an upper respiratory tract infection, whose clinical manifestation will include rhinorrhea, nasal congestion, and sore throat.
Strep throat; This is also a likely diagnosis as the patient experiences a tickle in his throat. A sore throat is the primary symptom of strep throat, which the patient is experiencing (Luo et al., 2019).
References
Luo, R., Sickler, J., Vahidnia, F., Lee, Y.-C., Frogner, B., & Thompson, M. (2019). Diagnosis and management of Group A streptococcal pharyngitis in the United States, 2011–2015. BMC Infectious Diseases, 19(1). https://doi.org/10.1186/s12879-019-3835-4
Nur Husna, S. M., Tan, H.-T. T., Md Shukri, N., Mohd Ashari, N. S., & Wong, K. K. (2022). Allergic rhinitis: A clinical and pathophysiological overview. Frontiers in Medicine, 9. https://doi.org/10.3389/fmed.2022.874114
Pappas, D. E. (2018). The common cold. Principles and Practice of Pediatric Infectious Diseases. https://doi.org/10.1016/b978-0-323-40181-4.00026-8
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Week 5 Announcement
This week, you will explore how to assess the head, neck, eyes, ears, nose, and throat. Whether dealing with a detached retina, sinusitis, meningitis, or even cough, advanced practice nurses need to know the proper assessment techniques to form accurate diagnoses.
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.
Provide a detailed assessment of affected system. Always include General, CV and Respiratory assessment in each Focus note.
Mayo and Cleveland Clinic are not Scholarly Resources, use more than one scholarly resource.
Focused Exam: Cough Assignment:
Complete the following in Shadow Health:
Respiratory Concept Lab (Required)
Episodic/Focused Note for Focused Exam: Cough
HEENT (Recommended but not required)
Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline
Focused Nose Exam
Case Study week 5
A 28-year-old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”.
Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop.
Last year i took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinate’s, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.
Document in SOAP note format, you must make up information to complete SOAP note.
Note: Mayo and Cleveland Clinic are not Scholarly resources.
Episodic/Focused SOAP Note Template
Patient Information:
Initials, Age, Sex, Race
Subjective.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
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Example of Complete Review Of Systems:
GENERAL: Denies weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: Denies shortness of breath, cough or sputum.
GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies anemia, bleeding or bruising.
LYMPHATICS: Denies enlarged nodes. No history of splenectomy.
PSYCHIATRIC: Denies history of depression or anxiety.
ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.
Objective.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
Assessment.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
Plan.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
