Sample Answer for NURS 6512 Case Study Assessing the Head, Eyes, Ears, Nose, and Throat Included After Question
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 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.
- To submit your completed assignment, save your Assignment as WK5Assgn1+last name+first initial.
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
A Sample Answer For the Assignment: NURS 6512 Case Study Assessing the Head, Eyes, Ears, Nose, and Throat
Title: NURS 6512 Case Study Assessing the Head, Eyes, Ears, Nose, and Throat
Patient Information:
CC: ” sore throat”
HPI: The patient is a 20-year-old female who presented to the facility for evaluation. She complained of a sore throat of insidious onset that began 3 days before the admission. The patient had previously been treated for a tonsillar infection a month ago. It is associated with a clear nasal discharge, occasional nasal congestion, voice alteration into hoarseness, fatigue, chills, unilateral ear pain located on the right, fever, rigors, and occasional headaches. The patient grades the pain as 5/10. The patient also reports poor appetite, nausea, and feeling generally unwell. Moreover, she developed painful swallowing a day ago and difficulty in swallowing. The discomfort was briefly relieved by over-the-counter analgesics but is now persistent. The pain is worsened on swallowing and taking cold drinks or food.
Current Medications: currently the patient isn’t on any medication but had tried over-the-counter Tylenol with no significant improvement.
Allergies: None
PMHx: The patient reports her immunization status is updated. However, she doesn’t recall her last tetanus immunization. The patient has been previously admitted for an ectopic pregnancy where she underwent an emergency explorative laparotomy. There was no history of other surgeries. She received a blood transfusion of one pint after the procedure.
Soc Hx: The patient works part-time at the mall and works the afternoon and weekend shifts when she’s not at school. She is majoring in marketing and finance at the local college. The patient participates in awareness programs at her school. She is also a member of the rehab club at school and they mentor and help other students with drug abuse issues in partnership with a local clinic. She enjoys visiting museums and art shows. She also enjoys watching football games. The patient denied taking any drugs.
Fam Hx: the patient denied any history of inheritable diseases in her family including cancers and allergic illnesses.
ROS:
GENERAL: chills, fatigue, no history of weight loss
HEENT: Eyes: no pain, no disturbances of color vision, no conjunctival pallor, no visual disturbances, no jaundice. Ears: No hearing loss. Nose: No pain, no congestion. Throat: pain, no coughing blood,
SKIN: no jaundice, no wounds, no itching, no bruises, no xanthoma
CARDIOVASCULAR: no palpitations, no dyspnea, no paroxysmal dyspnea, no cough, RESPIRATORY: No chest pain,
GASTROINTESTINAL: no abdominal pain, no diarrhea,
Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6512 Case Study Assessing the Head, Eyes, Ears, Nose, and Throat
GENITOURINARY: No hematuria, no urgency, no frequency. The patient is 4 weeks pregnant.
NEUROLOGICAL: no focal neurological deficits, no syncope, no sensation loss, no gait disturbances, GCS 15/15,
MUSCULOSKELETAL: no joint stiffness, no joint sweating, no joint
HEMATOLOGIC: No palmar or conjunctival pallor, no prolonged bleeding, LYMPHATICS: No lymphadenopathy.
PSYCHIATRIC: No history of anxiety, irritability, or elated mood. The patient denies any psychiatric management.
ENDOCRINOLOGIC: no weight loss, no polyphagia, no tremors, no neck swellings, no darkening of the skin, no nipple discharge,
ALLERGIES: No history of asthma or eczema.
Physical exam:
GENERAL: a 20-year-old female patient, seated comfortable, not in pain, no palmar pallor or redness, no Osler’s nodes, no jaundice, maintains eye contact, is appropriately groomed and well kempt, cooperative,
Temperature 101.5 F, BP 121/79, Pulse 75 beats per minute, Respiratory rate 17 breaths per minute, oxygen saturation 99%, height 5”4”, Weight 119 lbs.
HEENT: Head: normocephalic. Eyes: normal visual acuity, normal color vision, no watery eyes, no tearing, no ptosis, no pain, no
conjunctival pallor, no jaundice. Ears: No discharge, no conductive or sensorineural hearing loss, normal appearance of the tympanic membranes. Nose: Normal nasolabial folds, no crusting, clear discharge, no pain, Throat: there is an obvious swelling around the pillars with a deviation of the uvula to the left, fetid breath, edema and redness of the pillars, soft palate hyperemia, purulent discharge around the tonsils, enlarged tonsils
CARDIOVASCULAR: normoactive precordium, peripheral pulse present, radial pulse present, no delays, capillary refill 2 seconds, no murmurs, S1 and S2 heard
RESPIRATORY: trachea centrally placed, no obvious masses, resonant percussion note, vesicular breath sounds heard bilaterally, no added sounds.
GASTROINTESTINAL: flat abdomen, no obvious masses, no cars or therapeutic marks, tympanic percussion note, bowel sounds present.
NEUROLOGICAL: GCS 15/15, normal reflexes, normal muscle bulk, normal muscle tone, lower 5/5 in all muscle groups
Diagnostic results:
Complete blood count revealed elevated white blood cells, other differentials normal, normal electrolyte, complete metabolic profile with normal parameters, awaiting culture results
Differential Diagnoses
Quincy (Peritonsillar abscess)
Peritonsillar abscess is the collection of purulent material within the confines of the peritonsillar space. It can arise as an isolated infection of the space but occasionally may be preceded by acute or chronic infection of the tonsils. The signs of presentation may include but are not limited to the deviation of the uvula, usually to the contralateral side, edema of the soft palate, tonsils, and pillars. Pus may also be revealed on the tonsils (Jameson, 2018). Hypertrophy of the tonsils may be revealed. Redness of the palate and pillars may be evident. Additionally, some patients may present with torticollis. The patient presented with a deviation of the uvula, congestion, and edema of the soft palate, pillars, and tonsils. Moreover, there was hyperemia of the soft palate and pharyngeal wall. However, the patient did not present with torticollis. Some of the symptoms may include throat discomfort, fever, constipation, headache, body pains, rigors, chills, earache on the same side, trismus, foul breath, and thick speech. Odynophagia and cervical lymphadenopathy may also be a presentation. The patient in question presented with hoarseness, ipsilateral earache, foul breath, painful swallowing, fever, chills, headaches, rigors, and fatigue. She however did not present with trismus or cervical lymphadenopathy. Her signs and symptoms point to a likely diagnosis of peritonsillar abscess.
Acute Tonsillitis
This is an infection of the tonsils and may be classified as acute or chronic. Some of the signs and symptoms include fever, general body malaise, chills, dysphagia, edema of the pharynx, redness of the palate, pillars, and tonsillar hypertrophy (Ralston et al., 2018). The causes may be classified as infectious and non-infectious. The infectious causes include bacteria and viruses. Non-infectious causes include fungi and parasites. The patient presented with constitutional symptoms such as fever, general body weakness, chills, rigors, congestion of the pharyngeal wall, and hyperemia of the pillars and palate. These presentations could mimic acute tonsillitis thus making this a likely diagnosis.
Covid 19
This is a highly infectious respiratory illness that may be spread through inhalation of infected aerosols which may be produced by infected individuals through laughing, speaking, sneezing, and even coughing. It has a myriad of presentations with mild symptoms and in some cases severe life-threatening symptoms. Some of the symptoms may mimic flu-like illnesses and include but are not limited to fever, cough, rigors, chills, loss of sense of smell and taste, sore throat, nasal discharge general body malaise, and headaches (Esakandari et al., 2020). Life-threatening symptoms include shortness of breath, confusion, and respiratory failure. These may need aggressive management strategies such as implementing ventilator use. The patient in question presented with similar flu-like symptoms such as fever, headaches, rigors, chills, and fatigue. However, she did not present with anosmia or loss of sensation of taste, or any of the life-threatening conditions. This is still a likely diagnosis due to the symptomatology presented.
References
Esakandari, H., Nabi-Afjadi, M., Fakkari-Afjadi, J., Farahmandian, N., Miresmaeili, S.-M., & Bahreini, E. (2020). A Comprehensive Review of COVID-19 Characteristics. Biological Procedures Online, 22(1). https://doi.org/10.1186/s12575-020-00128-2
Jameson, J. L. (2018). Harrison’s principles of internal medicine (20th ed.). New York Mcgraw-Hill Education.
Ralston, S. H., Penman, I. D., Strachan, M. W. J., & Hobson, R. P. (2018). Davidson’s principles and practice of medicine (23rd ed.). Churchill Livingstone/Elsevier.