Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Sample Answer for Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat Included After Question
Emily, age 15, is brought to your clinic complaining of chills, aches, and a sore throat. Without any testing, consider all of the possible diagnoses. It could be a cold, the flu, bronchitis, or even something more serious, such as meningitis or mononucleosis. Assessing the actual cause will involve much more than simple visual inspection. Some conditions are so subtle that they require the use of special instruments and tests in addition to a trained eye and ear.
This week, you will explore how to assess the head, neck, eyes, ears, nose, and throat. Whether dealing with a detached retina, sinusitis, or meningitis, advanced practice nurses need to know the proper assessment techniques in order to form accurate diagnoses.
Learning Objectives
Students will:
- Apply assessment skills to diagnose eye, ears, and throat conditions
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat
Photo Credit: Patrick Heagney/E+/Getty Images
Learning Resources
Required Readings
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 10, “Head and Neck” (pp. 184-203)
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 11, “Eyes” (pp. 204-230)
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 12, “Ears, Nose, and Throat” (pp. 231-259)
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. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 15, “Earache” (pp. 174–183)
This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination, as well as how these questions lead to a focused physical examination.
- Chapter 21, “Hoarseness” (pp. 248-255)
This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient both through questions and through physical exams.
- Chapter 25, “Nasal Symptoms and Sinus Congestion” (pp.301-309)
In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions.
- Chapter 30, “Red Eye” (pp. 357-368)
The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses.
- Chapter 32, “Sore Throat” (pp. 381-389)
- A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat.
- Chapter 38, “Vision Loss” (pp. 446-457)
This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
- Chapter 3, “SOAP Notes” (pp. 45-57)
Note: Download the seven documents (Adult Examination Checklists and Physical Exam Summaries) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat.
Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment. American Family Physicians, 88(7), 435–440. Retrieved from http://www.aafp.org/journals/afp.html
Retrieved from the Walden Library Databases.
Document: Episodic/Focused SOAP Note Exemplar (Word document)
Document: Episodic/Focused SOAP Note Template (Word document)
Required Media
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 Week 4 Learning Resources area for access instructions on https://evolve.elsevier.com/.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 7, “The Head and Neck” (pp. 178–301)
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.
A Sample Answer For the Assignment: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Title: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
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 Discussion, 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.
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following specific case studies for this Discussion. Also, your Discussion post should be in the Episodic/Focused SOAP Note format, rather than the traditional narrative style Discussion posting 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.
Case 1: Nose Focused 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 two 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.
Case 2: Focused Throat Exam
Lily is a 20-year-old student at the local community college. When some of her friends and classmates told her about an outbreak of flu-like symptoms sweeping her campus over the past two weeks, Lily figured she shouldn’t take her three-day sore throat lightly. Your clinic has treated a few cases similar to Lily’s. All the patients reported decreased appetite, headaches, and pain with swallowing. As Lily recounts these symptoms to you, you notice that she has a runny nose and a slight hoarseness in her voice but doesn’t sound congested.
Case 3: Focused Ear Exam
Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past two days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he’s been spending his summer, James responds that he’s been spending a lot of time in the pool.
To prepare:
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 5 possible conditions that may be considered in a differential diagnosis for the patient.
Note: Before you submit your initial post, replace the subject line (“Week 5 Discussion”) with “Review of Case Study ___,” identifying the number of the case study you were assigned.
By Day 3
Post an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in 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.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days who were assigned different case studies than you. Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition and justify your reasoning.
Submission and Grading Information
Grading Criteria
Post by Day 3 and Respond by Day 6
To participate in this Discussion:
A Sample Answer 2 For the Assignment: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Title: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Episodic/Focused SOAP Note Template
Patient Information:
J.M., 11yrs, M, W
CC (chief complaint): bought in by grandmother with a complaint of right ear pain. Pain is described as mild but gets worse at night. The patient states that pain interrupts his sleep and it is harder for him to hear. Pt states that the pain started two days ago. Pt also stated that he spent a lot of time in the pool over the summer. Questionable fever. The grandmother stated that the patient felt warm but did not check temperature with a thermometer.
HPI:11-year-old-W male accompanied with the grandmother. Complain of right ear pain that started two days ago. Pain is mild but worse at night with interruption with sleep. Pt had spent a lot of time in the pool over the summer. Pt does have a prominent tan. Pt has only taken Tylenol 650mgx1 with no relief from pain. Pain is a 7/10 on a pain scale. Pt is having a problem with hearing in right ear.
Current Medication: Tylenol 650mg for pain as needed. Multivitamin one gummy daily for wellbeing.
Allergies: No Known Allergies
PMHx: all immunizations are up-to-date. No past illness or surgeries. Has not been sick besides having a common cold that lasts less than a week.
Soc Hx: pt goes to public school five days a week. Participates in sports activities in school, which includes wrestling and swimming. Enjoys swimming, playing video games, and playing with friends. Denies smoking tobacco and marijuana. Denies during any illicit drugs. Lives with both parents and one older sister (16yrs of age). Wears a seat belt while in a motor vehicle. Feels safe at home. Visits grandparents every summer.
Fam Hx: Both parents are in good health. Mom a Nurse Practitioner. Dad is a lawyer. Sister a full-time student at a local high school also on the swim team. Sister is in good health. Grandmother a retired nurse in good health. Grandfather retired Navy. Previous smoker of 1 pack of cigarettes daily. Quit 5 years ago. Occasional drinker. Drinks one shot glass of vodka once a month. Dad has hypertension that is controlled with diet and exercise.
ROS:
GENERAL: No weight loss, chills, and fatigue.pt have a fever of 101.0 F Has pain in the right ear. Right ear is red and tender to touch.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears: right outer ear red, tender to touch, the right inner ear is red with some clear drainage. Some hearing loss noted in the right ear. Left ear is non-tender, no drainage, no redness is noted. The left hearing is intact. Nose: clear with no secretions. No sneezing or congestion Throat: no hoarseness, redness, or soreness.
SKIN: No rash, or bruising. Tan is noted without any peeling at this time.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or tenderness.
GENITOURINARY: no pain on urination. Urine is clear and yellow. Not cloudy
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: Some enlarged nodes noted on the right side of the neck. No history of splenectomy
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis. No known allergies.
Physical exam: right ear is noted to be red and tender to touch with some clear drainage and swelling noted in the right ear canal. Right neck tender with swollen lymph nodes. No nasal congestion or a runny nose is noted. Lung sounds are clear on auscultation. Vital signs are temp 101.0 F, blood pressure 110/65 respiration 20 pulse 75. Skin is warm and dry to touch. Prominent tan is noted without any peeling at this time.
Diagnostic results: WBC: 15,000/mm3. Normal white blood cell count for a child 11 years of age is5,000 to 10,000/mm3. A high WBC may indicate an infection (University of Rochester Medical Center, n.d.). Ear culture of the drainage. Abnormal fluid in the ear canal may have bacteria or fungi presence and may pose a risk for recurrent infections (American Academy of Otolaryngology-Head, and Neck Surgery Foundation., 2018). Examination of the ear canal with an otoscope. The ear canal is red and swollen on examination.
- A.
Differential Diagnoses: Swimmers ear (otitis externa). Acute otitis externa is a common disease of children and adolescents that is defined by diffuse inflammation of the external ear canal (Hui, 2013). It is the primary cause of ear infection associated with swimming (Hui, 2013). Signs and symptoms are a pain, a sensation that the ear is blocked or full, drainage, a decrease in hearing, and fever.
Acute otitis media. Is the most common occurring inflammatory diseases of infancy and childhood that involve the middle ear and some involvement of the tympanic cavity (Thomas, Berner, Zahnert, & Dazert, 2014). Signs and symptoms include ear pain and impairment in hearing.
Acute bacterial rhinosinusitis. An infection of both your nasal cavity and sinuses that is caused by bacteria that causes the sinuses and nasal cavity to become inflamed (Cedars- Sinai, 2018). It causes facial pain, ear pressure and/or fullness, and fever (Cedars- Sinai, 2018).
Ear drops that are mixed with an antibiotic and hydrocortisone to fight infection and reduce inflammation for pain and fever over the counter pain relievers can be given.
References
American Academy of Otolaryngology–Head and Neck Surgery Foundation. (2018). Swimmer’s Ear (Otitis Externa). Retrieved from ENT Health: https://www.enthealth.org/conditions/swimmers-ear-otitis-externa/.
Cedars- Sinai. (2018). Acute Bacterial Rhinosinusitis. Retrieved from Cedars-Sinai: https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/acute-bacterial-rhinosinusitis-1.html.
Hui, C. P. (2013, February). Acute otitis externa. Paediatr Child Health, 18(2), 96-98. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3567906/.
Thomas, J. P., Berner, R., Zahnert, T., & Dazert, S. (2014, February 28). Acute Otitis Media—a Structured Approach. Deutsches Arzteblatt International, 111(9), 151-160. doi: 10.3238/arztebl.2014.0151.
University of Rochester Medical Center. (n.d.). White Cell Count. Retrieved from Health Encyclopedia: https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=167&contentid=white_cell_count.
A Sample Answer 3 For the Assignment: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Title: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Patient Information:
RM, 50 year old Caucasian male
CC: RM presents with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Complains of itchy nose, eyes, palate, and ears for five days.
HPI: 50 year old Caucasian male is pale, has nasal congestion, sneezing, rhinorrhea, and post nasal drainage. Itchy nose, eyes, palate and ears for 5 days. Boggy nasal mucosa with clear thin secretions. Mucinex OTC provided minimal improvement in nasal congestion during sleep. Mildy erythematous throat. Sensitivity to light.
Current Medications: Mucinex OTC at night for nasal congestion – recommended dosage
Simvastatin 40mg PO qHS
Allergies: Penicillin – causes rash.
PMHX: Flu and pneumonia vaccines current. Unknown date of last tetanus. History of right knee replacement in May 2016 with no complications. Hypercholesteremia – taking Simvastatin for three months. Reports no side effects.
Soc Hx: RM is a retired firefighter who enjoys fishing, hunting, and video games. Denies current tobacco and alcohol use. Reports smoking cigarettes and drinking vodka twenty years ago and quit in 1988. Grandmother died one year after having stroke at the age of 78. Two biologic children are alive and healthy.
ROS:
General: Denies unintended weight gain or loss, reports fatigue mid day to late afternoon for the last five days.
HEENT: Eyes: wears glasses, denies blurred vision w/ glasses, denies double vision, sclera are red. No drainage from ears, denies ringing in ears or hearing loss. Itchy nose, palate, face, and at time ears. Reports sore throat for last five days.
Skin: Denies itching, no rashes
Cardiovascular: Denies chest pain, pressure or discomfort. Reports “my heart skips a beat sometimes”. No edema
Respiratory: Reports nasal congestion, denies shortness of breath, cough, sputum. Lung sounds clears all lobes.
Gastrointestinal: Reports daily bowel movements, denies nausea, vomiting, diahrea. Denies abdominal pain. Denies blood in stool.
Genitourinary: Reports steady stream, no dribbling, urgency, or getting up at night
Neurological: Reports headaches “a few times” this past week – “feels like pressure in my forehead”, otherwise no regular headaches. Denies dizziness on standing, numbing or tingling in the extremities. No change in bowel or bladder control.
Musculoskeletal: Right knee replacement two years ago. Denies back pain, joint pain, report stiffness in fingers “I can’t grip things like I used to”.
Hematologic: No anemia, bleeding, or bruising.
Lymphatics: Enlarged parietal nodes. No history of spleenectomy.
Psychiatric: Reports having periods of feeling “blue”, but “I usually snap out of it within a few days. Happens sometimes in the winter”.
Endocrinologic: Denies unusual sweating, cold or heat intolerance. Denies excess thirst and excessive urination.
Allergies: Denies history of asthma, hives, eczema.
Physical Exam: 50 year old Caucasian male presents as generally not feeling well. His face is pale, red nose with clear drainage. Red, puffy eyes with frequent tearing. RM rubbing itchy nose and face. RM reports “It feels like I have a bad cold”. Lungs clear all lobes, grossly intact review of systems.
Diagnostic results: Diagnostic tests have no cost/benefit effect in diagnosing the common cold (Arcangelo & Peterson, 2013). The rapid influenza diagnostic test is negative.
Differential diagnosis:
1. The common cold – According to Arcangelo & Peterson, Symptoms of the common cold are rhinorrhea, nasal obstruction, otitis media, headache, sore throat, malaise, myalgia, fever, chest congestion, sneezing and watery eyes (2013).
2. Seasonal allergies – According to Burchum & Rosenthal, symptoms of seasonal allergies are head congestion/runny nose, sneezing, itchy, watery eyes, and cough (2016).
3. Sinusitis – According to Seidels Guide to Physical Examination, symptoms are frontal headache, facial pain or pressure, nasal congestion, persistent cough (2016).
4. Respiratory infection – According to Arcangelo & Peterson, symptoms of a respiratory infection are pain in the sinuses, nasal congestion, post nasal drip, stuffy nose, cough, irritation of the tonsils, sore throat, cough, headache, inflammation of the ear, phlegm, swollen lymph nodes (2013).
5. Flu – According to Burchum & Rosenthal, flu symptoms include sore throat, runny nose, congestion, cough, fever, headache, and muscle soreness (2016).
References
Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for advanced practice:
A practical approach. St Louis, MO: Mosby
Burchum, J. R., & Rosenthal, L. D. (2016). Lehne’s pharmacology for nursing care (9th ed.).
ELSEVIER: Mosby
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., and Stewart, R. W. (2015). Seidel’s
Guide to physical examination (8th ed.). ELSEVIER; Mosby
A Sample Answer 4 For the Assignment: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Title: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Patient Information:
L.T.20 yrs.-old, female, white,
CC: Sore throat.
HPI: L.T. is a 20-year-old white female student at the local community college. Developed a sore throat three days ago and wanted to come in to get evaluated because some of her friends have come down with a flu like illness over the past two weeks. She also complains she has a runny nose and a slight hoarseness in her voice but doesn’t sound congested like similar cases seen in the clinic she also has decreased appetite, headaches, and pain with swallowing.
Location: throat
Onset: 3 days ago
Character: feels like razor blades are in her throat when she swallows
Associated signs and symptoms/Additional Symptoms: runny nose and slight hoarseness, decreased appetite, headaches and pain with swallowing
Timing: the last three days
Exacerbating/ relieving factors: Advil health the sore throat
Severity: 6/10 pain scale
Current Medications: drospirenone and ethinyl estradiol 3mg-0.03mg daily at 0800 (birth control), Multivitamin 1-tab po daily, Advil 400mg q6hours for sore throat.
Allergies: No allergies to food or drugs
PMHx: Tdap 2016, Meningitis 2016, and did not get flu shot this flu season, No history of illness, surgeries, or hospitalizations.
Soc Hx: negative tobacco history, practices safe sex, consumes alcohol on the weekend with friends usually with have 4-6 drinks on a Saturday night. Has a boyfriend for about a month. Has a good support system at home and has a good group of friends she can also go to for support. Has a part time job at Starbucks.
Fam Hx: Both of her grandfathers have high blood pressure. Her paternal grandfather has high cholesterol. Both grandmothers are heathy that she knows of and both parents are healthy. She states she has a younger brother that has not had any health issues either.
ROS:
GENERAL: No weight loss, fever, chills, fatigue
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, but does have a runny nose and sore throat as well as hoarseness.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No nausea, vomiting or diarrhea. No abdominal pain or blood, but does have a loss of appetite.
GENITOURINARY: No burning on urination. No previous pregnancy. Last menstrual period, 12/10/2018.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
VS: BP: 110/62 P:76 R:18 T: 99.8 O2: 99% Wt: 142lbs Ht: 63in
Physical exam:
General- A&O x3. Patient appears calm and tired. States the last few days feels more tired at the end of the day
HEENT: No History of head injury. Eyes: Sees eye doctor annually wears glasses. Ears : Hearing good, no teninitis, no infection, Throat: No bleeding gums noted. Posterior pharynx is red with some post nasal drip. Neck: Tender lymph nodes on the both tonsillar areas.
Chest/Lungs: Lungs are clear to auscultation and percussion bilaterally
Heart/Peripheral Vascular: RRR without murmur, rub, or gallop; pulses+2 bilat pedal and +2 radial
ABD: benign, nabs x 4, no organomegaly, No abdominal tenderness
Skin/Lymph Nodes: No rashes; no palpable nodes
Diagnostic results: depending on whether the patient has had a fever or not I would run a flu test.
- A.
Addition questions: Has patient had a fever? Did the hoarseness start with the sore throat and does it get worse throughout the day? What were her friends diagnosed with?
Differential Diagnoses
- Acute viral rhinitis
- Acute laryngitis secondary of viral infection
- Influenza Virus
- Strep Throat
- Allergic Rhinitis
I believe that L.T. has a viral syndrome from the information given to me without a fever I would believe it is not the flu. Acute viral rhinitis has associated symptoms are usually runny nose with clear mucous, sore throat and can be accompanied with hoarseness, and headache (McCoul, 2015). Acute laryngitis can occur with a viral syndrome and rarely with strep throat (Dains, Baumann, & Scheibel, 2016). Flu symptoms include fever or feeling feverish/chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, and fatigue (tiredness) but not all people have a fever and L.T has associated symptoms with the flu (Center for Disease Control and Prevention, 2018). L.T. could have allergic rhinitis because of the sore throat, hoarseness and clear nasal drainage which can all be associated with allergies (Dains, Baumann, & Scheibel, 2016).
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Center for Disease Control and Prevention. (2018, September 18). Flu symptoms & complications. Retrieved from https://www.cdc.gov/flu/consumer/symptoms.htm
Dains, J. E., Baumann, L. C., Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby
McCoul, E. D. (2015, February 17). Upper respiratory infections. Retrieved from http://care.american-rhinologic.org/upper_respiratory_infections
A Sample Answer 4 For the Assignment: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Title: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Patient Information:
RM, 50 year old Caucasian male
CC: RM presents with nasal congestion, sneezing, rhinorrhea, and postnasal drainage. Complains of itchy nose, eyes, palate, and ears for five days.
HPI: 50 year old Caucasian male is pale, has nasal congestion, sneezing, rhinorrhea, and post nasal drainage. Itchy nose, eyes, palate and ears for 5 days. Boggy nasal mucosa with clear thin secretions. Mucinex OTC provided minimal improvement in nasal congestion during sleep. Mildy erythematous throat. Sensitivity to light.
Current Medications: Mucinex OTC at night for nasal congestion – recommended dosage
Simvastatin 40mg PO qHS
Allergies: Penicillin – causes rash.
PMHX: Flu and pneumonia vaccines current. Unknown date of last tetanus. History of right knee replacement in May 2016 with no complications. Hypercholesteremia – taking Simvastatin for three months. Reports no side effects.
Soc Hx: RM is a retired firefighter who enjoys fishing, hunting, and video games. Denies current tobacco and alcohol use. Reports smoking cigarettes and drinking vodka twenty years ago and quit in 1988. Grandmother died one year after having stroke at the age of 78. Two biologic children are alive and healthy.
ROS:
General: Denies unintended weight gain or loss, reports fatigue mid day to late afternoon for the last five days.
HEENT: Eyes: wears glasses, denies blurred vision w/ glasses, denies double vision, sclera are red. No drainage from ears, denies ringing in ears or hearing loss. Itchy nose, palate, face, and at time ears. Reports sore throat for last five days.
Skin: Denies itching, no rashes
Cardiovascular: Denies chest pain, pressure or discomfort. Reports “my heart skips a beat sometimes”. No edema
Respiratory: Reports nasal congestion, denies shortness of breath, cough, sputum. Lung sounds clears all lobes.
Gastrointestinal: Reports daily bowel movements, denies nausea, vomiting, diahrea. Denies abdominal pain. Denies blood in stool.
Genitourinary: Reports steady stream, no dribbling, urgency, or getting up at night
Neurological: Reports headaches “a few times” this past week – “feels like pressure in my forehead”, otherwise no regular headaches. Denies dizziness on standing, numbing or tingling in the extremities. No change in bowel or bladder control.
Musculoskeletal: Right knee replacement two years ago. Denies back pain, joint pain, report stiffness in fingers “I can’t grip things like I used to”.
Hematologic: No anemia, bleeding, or bruising.
Lymphatics: Enlarged parietal nodes. No history of spleenectomy.
Psychiatric: Reports having periods of feeling “blue”, but “I usually snap out of it within a few days. Happens sometimes in the winter”.
Endocrinologic: Denies unusual sweating, cold or heat intolerance. Denies excess thirst and excessive urination.
Allergies: Denies history of asthma, hives, eczema.
Physical Exam: 50 year old Caucasian male presents as generally not feeling well. His face is pale, red nose with clear drainage. Red, puffy eyes with frequent tearing. RM rubbing itchy nose and face. RM reports “It feels like I have a bad cold”. Lungs clear all lobes, grossly intact review of systems.
Diagnostic results: Diagnostic tests have no cost/benefit effect in diagnosing the common cold (Arcangelo & Peterson, 2013). The rapid influenza diagnostic test is negative.
Differential diagnosis:
1. The common cold – According to Arcangelo & Peterson, Symptoms of the common cold are rhinorrhea, nasal obstruction, otitis media, headache, sore throat, malaise, myalgia, fever, chest congestion, sneezing and watery eyes (2013).
2. Seasonal allergies – According to Burchum & Rosenthal, symptoms of seasonal allergies are head congestion/runny nose, sneezing, itchy, watery eyes, and cough (2016).
3. Sinusitis – According to Seidels Guide to Physical Examination, symptoms are frontal headache, facial pain or pressure, nasal congestion, persistent cough (2016).
4. Respiratory infection – According to Arcangelo & Peterson, symptoms of a respiratory infection are pain in the sinuses, nasal congestion, post nasal drip, stuffy nose, cough, irritation of the tonsils, sore throat, cough, headache, inflammation of the ear, phlegm, swollen lymph nodes (2013).
5. Flu – According to Burchum & Rosenthal, flu symptoms include sore throat, runny nose, congestion, cough, fever, headache, and muscle soreness (2016).
References
Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for advanced practice:
A practical approach. St Louis, MO: Mosby
Burchum, J. R., & Rosenthal, L. D. (2016). Lehne’s pharmacology for nursing care (9th ed.).
ELSEVIER: Mosby
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., and Stewart, R. W. (2015). Seidel’s
Guide to physical examination (8th ed.). ELSEVIER; Mosby
A Sample Answer 5 For the Assignment: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Title: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Patient Information:
J.S., 11, Male, Caucasian
CC: “Earache.”
HPI: Patient is an 11-year-old Caucasian male who has been experiencing an earache for the past 2 days. The pain is described as “achy” and tender and is rated 2/10 on the 0-10 pain scale. The patient explains that the pain worsens when trying to fall asleep at night. The pain is located in his right ear and is accompanied by muffled earing. The patient has been spending a lot of his time this summer at the pool swimming.
Current Medications: none
Allergies: NKA
PMHx: Negative past medical and surgical history. Immunizations are up-to-date.
Soc Hx: Patient lives with parents in home they own. Patient attends school, currently on summer break spending lots of time at pool swimming, playing baseball, and riding bicycle with friends. Does wear helmet when riding bicycle, wears seat belt in vehicle, and sunscreen outside. Maternal Grandmother here with him today and watches him during the day in the summer months while parents at work. Patient not exposed to tobacco smoke, animals, or other allergens.
Fam Hx: Mother, father, maternal and paternal grandparents still living. Paternal Grandfather has HTN. Maternal Grandmother has hypothyroidism and DM Type 2. No other known genetic predispositions, contagious or chronic illnesses of first degree relatives.
ROS:
General: No weight loss, fever, chills, weakness or fatigue.
HEENT: Head: No history of head injury. Eyes: No visual loss, blurred vision, double vision, yellow sclera, or photophobia. No corrective lenses. Ears: Muffled hearing in right ear. No history of ear trauma. No dizziness or tinnitus. Denies any known recent insect bites, exposure to loud noises, or placing anything in ear. Nose: No sinus tenderness, sneezing, congestion, runny nose, or recent infections. Throat: No sore throat. No loose teeth. Denies swollen or bleeding gums. Has regular dental visits.
Skin: No rash or itching. Denies dermatitis or psoriasis
Cardiovascular: No known cardiac disease.
Respiratory: No shortness of breath, cough, or sputum.
Gastrointestinal: No anorexia, nausea, vomiting, diarrhea, or constipation. No abdominal pain.
Genitourinary: No burning, urgency, frequency, or hematuria.
Neurological: No headache, dizziness, syncope, paralysis, numbness or tingling in the extremities. Musculoskeletal: No muscle, back pain, joint pain, or stiffness. No weakness. No recent falls.
Hematologic: No anemia, bleeding or bruising.
Lymphatics: Denies enlarged nodes.
Psychiatric: No history of psychiatric disorders.
Endocrinologic: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. Denies diabetes.
Allergies: No history of asthma, hives, eczema, or rhinitis.
Physical exam:
Vital signs: BP: 105/62 right arm, sitting, small cuff; P: 88; RR: 16; non-labored; T: 98.9 degrees F, temporal; W: 86.2 lbs; Ht: 4’8.5”; BMI: 19.0
General: A&O x4. Appropriate hygiene, calm, cooperative, clear and appropriate responses.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light and accommodation. Conjunctiva pink, sclera white, no drainage or pain. Extraocular movements intact. Tenderness and inflammation of right external ear canal, pain with manipulation of right pinna and tragus, pinna not displaced, no pain with manipulation of left pinna or tragus. Bilateral examination shows no hemorrhage, no redness or scaling of skin, no white or dark patches, no furuncles or lesions, no swelling behind ears, no tenderness with palpation over TMJ, no clicking with TMJ movement. Preauricular nodes are slightly enlarged bilaterally. Watery discharge from right ear, bilateral canals reddened, left canal slightly less red, right canal edematous with tympanic membrane obscured; left tympanic membrane appears normal. No nasal drainage, nares clear, mucosa pink not bogy, no tenderness in nares, septum midline. No oral lesions, teeth and gums are healthy and in good repair, no broken teeth or swelling in mouth, membranes are dry without enlarged tonsils, no cleft palate.
Neck: Trachea midline, neck supple, thyroid not enlarged, no carotid bruit or JVD.
Lymph Nodes: No enlargement or tenderness to anterior or posterior cervical lymph nodes.
Chest/Lungs: Lung expansion symmetrical, CTA. No cough, tachypnea, no use of accessory muscles.
Heart: Regular rate and rhythm. No murmurs, rubs, gallops. Normal S1, S2.
Peripheral Vascular: No edema, capillary refill less than 3 seconds, pulses palpable 2+
Abdomen: Soft, flat, non-tender, no evidence of trauma, no masses, bowel sounds active.
Genital/Rectal: not examined
Musculoskeletal: No deformities. Normal range of motion. Good muscle tone and strength.
Neurological: Alert and oriented x4, calm, cooperative. Normal sensation in extremities. Normal reflexes.
Skin: Clean, dry, intact. No rashes, bruising, dryness, or edema.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
The diagnosis of otitis externa is made based on clinical presentation of signs and symptoms. Patient’s presentation with pain can vary from mild to severe, and low-grade fever may or may not be present, and severity of symptoms and condition can vary; however, visual examination of canal, tympanic membrane, and external canal assist in distinguishing between other diagnoses. In addition to physical examination, proper gathering of history, medical conditions, surgiers, trauma, environmental exposure, and skin disorders help in the diagnosis of otitis externa (Schaefer, & Baugh, 2012).
Otoscopic examination: Reddened and edematous right canal with tympanic membrane obscured. Slight redness in left canal with normal appearing tympanic membrance.
Whisper test: Left ear: Pass; Right ear: Did not pass
Weber Test: Lateralization to right
Rinne Test: Negative; BC>AC on right; AC>BC on left
- A.
Differential Diagnoses
- Otitis Externa
- Manipulation of pinna increases pain
- Complaints of a “stuffed ear”
- Conductive hearing loss can occur
- Discharge occurs 1-2 days after swimming
- Enlargement of preauricular or postauricular nodes
(Dains, Bauman, & Scheibel, 2016).
- Acute Otitis Media
- Associated more with children
- Associated with ear pain
- Can be painful enough to interfere with sleep
(Dains, Bauman, & Scheibel, 2016).
- Cerumen Impaction
- Patient reports “stuffed-up ear”
- Decreased hearing acuity
- Can produce pain
(Dains, Bauman, & Scheibel, 2016).
- Otitis Media with Effusion
- Common in children
- Associated with conductive hearing loss
- Collection of fluid in ear
(Dains, Bauman, & Scheibel, 2016).
- Conductive Hearing Loss
- Unable to conduct sound properly
- Can be unilateral or bilateral
- Can occur suddenly
- Can be fluctuating; improving or worsening over time
- Can occur due to: cerumen impaction, serous otitis media, damage, tympanic membrane perforation
(Hollier & Hensley, 2011).
References
Dains, J., Bauman, L., Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in
primary care (5th ed.). St. Louis: Missouri: Elsevier.
Hollier, A., & Hensley, R. (2011). Clinical Guidelines in Primary Care: A Reference and Review
Book. Layfayette, LA: Advanced Practice Education Associated, Inc.
Schaefer, P. & Baugh, R. (2012). Acute otitis externa: An update. American Family Physician
86(11), 1055-1061. Retrieved from https://www.aafp.org/afp86
A Sample Answer 6 For the Assignment: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Title: Nurs 6512 Week 5: Assessment of Head, Neck, Eyes, Ears, Nose, and Throat
Patient Information:
JA, 11, male, bi-racial
CC “an earache”
HPI: JA is 11 years old African American male who came to the clinic due to having an earache. The patient stated that “the pain is worse when he attempted to go to sleep”. JA also reported having some difficulty with hearing. JA also stated that he spent a lot of time in the swimming pool during the summer which has caused him to be tan.
Location: ear (right)
Onset: two days
Duration: 10- 15 minutes
Character: pressure and pounding inside his ear
Associated signs and symptoms: trouble with hearing, mild fever
Relieving factors: Being awake
Treatment: Tylenol
Timing: after swimming in the pool
Exacerbating/ relieving factors: worsen with sleep
Severity: 4/10 pain scale
Current Medications: Tylenol 15 ml every 8 hours for fever last 24 hours and children’s chewable multivitamin one daily for in the last 7 years old, frequency, Zyrtec 5ml as needed daily for seasonal allergies.
Allergies: Seasonal allergies to pollens, coughing and sneezing, runny eyes and nose.
PMHx: Immunization records are updated for mumps, measles, rubella, and recommended childhood vaccination. Received annual flu-vaccination, last being November 2018. Seeing and allergies for seasonal allergy for the past 4 years and is taking Zyrtec. Denies any surgical history.
Soc Hx: Attends Silver Lakes middle school, enjoying swimming, and basketball. Has one older brother and one younger sister. Lives with mother, father, siblings, and grandparents. Denies drinking alcohol, denies smoking cigarette and marijuana.
Fam Hx: Grandmother reported that there is a family history of asthma on the father’s side of the family. Siblings are healthy with no substantial medical issues. The grandmother reported that she has hypertension, but that JA mother is having no medical history but smokes a ½ pack of cigarette daily.
ROS:
GENERAL: mild fever reported, denies any weight loss, reported some fatigue and pain.
HEENT: Eyes: denies any issues with seeing, no blur and cloudy vision. Ears, pain in right ears, trouble with hearing, nose no drainage, sneezing nares patent, Throat: denies any coughing but a pain when swallowing
SKIN: intact, no rash and hives noted
CARDIOVASCULAR: denies any pain and pressure in the chest.
RESPIRATORY: denies any problems with breathing
GASTROINTESTINAL: No nausea, vomiting and upset stomach
GENITOURINARY: denies urinary urgency and reference, no burning
NEUROLOGICAL: No headache, dizziness
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No bruising and bleeding.
LYMPHATICS: No enlarged nodes.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: pollens.
BP 117/58, Pulse 79. Temp 38.2 C (oral), Resp. 20, Ht. 162.5cm, Wt. 57.7 kg, BMI 21.85kg
Physical exam: JA is alert, awake and oriented to place, person, time and place. JA is well developed and nourished and has a low-grade fever.
HEENT: head normocephalic and atraumatic
Eyes: no blur vision, pupils are reactive to light
Ears: pain in right ear, difficulty with hearing.
Nose– nares are patent, no drainage noted
Throat: some redness noted and pain when swallowing
Cardiovascular: Normal rate with regular rhythm and intact distal pulse
Lungs: No respiratory distress, no tenderness
Abdominal: No distended, no tenderness, soft and bowel sounds in all quadrants.
Skin: warm to touch, no rash and hives noted.
Diagnostic results
According to the National Institute on Deafness and Other Communication Disorder (NIDCD, 2017) if an ear infection seems likely, the simplest way it to be diagnosed if for a clinician to use a lighted instrument, called an otoscope, to look at the eardrum. A red, bulging eardrum indicates an infection.
A clinician may also use a pneumatic otoscope, which blows a puff of air into the ear canal, to check for fluid behind the eardrum. A normal eardrum will move back and forth more easily than an eardrum with fluid behind it (NIDCD, 2017).
Tympanometry, which uses sound tones and air pressure, is a diagnostic test a clinician might use if the diagnosis still isn’t clear. A tympanometer is a small, soft plug that contains a tiny microphone and speaker as well as a device that varies air pressure in the ear. It measures how flexible the eardrum is at different pressures (NIDCD, 2017).
A clinician would also do an assessment to see if the child has any recent upper respiratory infection. An ear infection usually is caused by bacteria and often begins after a child has a sore throat, cold, or other upper respiratory infection. If the upper respiratory infection is bacterial, these same bacteria may spread to the middle ear; if the upper respiratory infection is caused by a virus, such as a cold, bacteria may be drawn to the microbe-friendly environment and move into the middle ear as a secondary infection. Because of the infection, fluid builds up behind the eardrum (NIDCD, 2017).
Laboratory studies- gram stain and culture of the purulent discharge (Ball, Dains, Flynn, Solomon, & Stewart, 2015
CBC and white count cells- Elevation of white cell count and other blood works is used to confirm infection (Dains, Baumann & Scheibel, 2016).
- A.
Differential Diagnoses
Acute external otitis is an inflammation of the ear canal - which can involve the pinna and the tympanic membrane. The history typically differentiates the presence of predisposing factors or contact with potentially contaminated water (swimmer’s ear) (Fischer and Dietz, 2017). This could be the case in JA because he has been swimming all summer in the pool. Another factor is the onset of AJ pain started two days on an in the case of acute external otitis it is presented with sudden onset with occurrence of ear pain, itching, otorrhea, and a physical examination revealing an inflammation of the ear canal and pain caused by manipulation on the tragus or pulling the pinna are crucial to the diagnosis Fischer, Dietz, 2017). In uncomplicated acute external otitis, without the presence of risk factors, the therapy consists of cleaning the ear canal, application of topical medication and sufficient analgesic therapy. In the presence of a perforated tympanic membrane or the presence of a tympanostomy tube, no ototoxic drugs may be prescribed. In general, the inflammation is responsive to the treatment, within 48-72 hours and is generally resolved after 6-7 days (Fischer, Dietz, 2017).
Acute otitis media (AOM) is the most common ear infection. Parts of the middle ear are infected and swollen and fluid is trapped behind the eardrum (NIDCD, 2017). It causes pain in the ear—commonly called an earache. The child might also have a fever. These symptoms are present in the JA case. Previous diagnostic criteria for AOM were based on symptomatology without otoscopic findings of inflammation. The updated American Academy of Pediatrics guideline endorses more stringent otoscopic criteria for diagnosis. An AOM diagnosis requires moderate to severe bulging of the tympanic membrane new onset of otorrhea not caused by otitis externa, or mild bulging of the tympanic membrane associated with recent onset of ear pain (Harmes, Blackwood, Burrows, Cooke, Harrison, and Passamani (2013) Pneumatic otoscopy is a useful technique for the diagnosis of AOM and OME and is 70% to 90% sensitive and specific for determining the presence of middle ear effusion. By comparison, simple otoscopy is 60% to 70% accurate (Harmes et al. 2013).
A cholesteatoma- usually occurs because of poor eustachian tube function as well as infection in the middle ear. The eustachian tube conveys air from the back of the nose into the middle ear to equalize ear pressure (“clear the ears”) Over time, the cholesteatoma can increase in size and destroy the surrounding delicate bones of the middle ear leading to hearing loss. Initial treatment may consist of careful cleaning of the ear, antibiotics, and eardrops. Therapy aims to stop drainage in the ear by controlling the infection. Hearing and balance tests, and CT scans (3-D x-rays) of the mastoid may be necessary. These tests are performed to determine the hearing level in the ear and the extent of destruction the cholesteatoma has caused. (NIDCD, 2017).
Otosclerosis– is caused by abnormal bone remodeling in the middle ear. Bone remodeling is a lifelong process in which bone tissue renews itself by replacing old tissue with new. (NIDCD, 2017). In otosclerosis, abnormal remodeling disrupts the ability of sound to travel from the middle ear to the inner ear. Hearing loss, the most frequently reported symptom of otosclerosis, usually starts in one ear and then moves to the other (NIDCD, 2017). This loss may appear very gradually. Many people with otosclerosis first notice that they are unable to hear low-pitched sounds or can’t hear some whispers (NIDCD, 2017). The first step in diagnosis is to rule out other diseases or health problems that can cause the same symptoms as otosclerosis. Next steps include hearing tests that measure hearing sensitivity (audiogram) and middle-ear sound conduction (tympanogram). Sometimes, imaging tests—such as a CT scan—are also used to diagnose otosclerosis (NIDCD, 2017).
Barotrauma– Barotrauma results from pressure changes in the middle and inner ear, often aggravated by recent upper respiratory infection or nasal congestion (Dains, Baumann, & Scheibel, 2016). Symptoms are ear pain, tinnitus, or hearing difficulty
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s Guide to
Physical Examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care
(5th ed.). St. Louis, MO: Elsevier Mosby.
Fischer and Dietz (2013). Acute external otitis and its differential diagnoses. American Family
Physician, 88 (7): 435-40.
Harmes K.M, Blackwood R.A, Burrows, H.L, Cooke, J.M, Harrison, R.V, Passamani P.P.
(2013). Otitis media: diagnosis and treatment. Retrieved from https://www.aafp.org/afp/2013/1001/p435.html
National Institute on Deafness and Other Communication Disorder (NIDCD, 2017). Ear
infection in children. Retrieved from https://www.nidcd.nih.gov/health/ear-infections-children
National Institute on Deafness and Other Communication Disorder (NIDCD, 2017).
Otosclerosis. Retrieved from https://www.nidcd.nih.gov/health/otosclerosis