(Solution) NURS 6512 Week 5 Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

CASE STUDY 1: Focused Nose Exam

Richard is a 50-year-old male with nasal congestion, sneezing, rhinorrhea, and

postnasal drainage. Richard has struggled with an itchy nose, eyes, palate, and ears for

5 days. As you check his ears and throat for redness and inflammation, you notice him

touch his fingers to the bridge of his nose to press and rub there. He says he’s taken

Mucinex OTC the past 2 nights to help him breathe while he sleeps. When you ask if

the Mucinex has helped at all, he sneers slightly and gestures that the improvement is

only minimal. Richard is alert and oriented. He has pale, boggy nasal mucosa with clear

thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs

are clear. His tonsils are not enlarged but his throat is mildly erythematous.

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.

Solution:

Nose Focused Exam

Focused SOAP Note

Patient Information: Mr. R.B, a 50-year-old Caucasian Origin

Subjective Assessment

Chief Complain: “Nasal Congestion and itching for five days.”

H.P.I.: Mr. R.B., a 50-year Caucasian white male who complain of nasal congestion, itchy nose,eyes,palate, ears, rhinorrhea, sneezing, and post drainage for five consecutive days.The patient is taking Mucinex OTC to enhance his breathing during the night. However, the problem does not seem to go. No headache or other pains reported.

Medications: Mucinex OTC 1 tab orally per night

Allergies: The patient reports seasonal allergies, NKDA

PMHx:There is no significant medical history reported. The patient denies any recent diagnosis or surgeries. However, he had a back injury in 2002 after an accident and was hospitalized for treatment. He has recently received a flu shot as much as immunizations are concerned.

Soc Hx: The patient is married with two children aged 12 and 14 consecutively. He used to smoke but quit in 2006. He takes alcohol on an occasional basis at least twice per month. He earned himself a bachelor’s in BCOM and ran a consultation firm.  He likes snowboarding and surfing alongside his family. He denies using cell phones while driving and emphasize the use of a seat belt. The patient eats a heart healthy diet performs physical exercises regularly. He always hasa quality sleep except for the last five days after the onset of the symptoms.

Fam Hx: The patient’s parents are alive. Father has a well-managed H.T.N. Mother has developed breast cancer, done S/P mastectomy 1994, in remission.  He has two healthy siblings aged 42 and 46. The two children are healthy as well.The grandparents are deceased, andthe patient does not know their medical history or age.

R.O.S.:

General: The patient appears well-groomed, denies fatigue, fever, or chills. He seems tired and wasted due to the lack of sleep.

HEENT: Patient has itchy and red eyes, PERRLA, no vision variation. The patient denies headache.Normal hearing, tympanic membranes are intact,no noticeable from the ears. The nasal mucosa appears pale and boggy with tiny open secretions, congested nose, and elongated nasal turbinates.The throat is slightly erythematous, with no inflamed tonsils.

Neck: No deviation in the trachea. No inflamed lymph nodes

Skin: The color and the pigmentation are clear. No itching and remarkable skin turgor……Please click the icon below to purchase full answer at only $10