NURS 6512 Week 5 Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
CASE STUDY 1: Focused Nose Exam
NURS 6512 Week 5 Assignment 1.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 NURS 6512 Week 5 Assignment 1, 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 NURS 6512 Week 5 Assignment 1. 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.
NURS 6512 Week 5 Assignment 1 Answer
Nose Focused Exam
Focused SOAP Note
Patient Information: Mr. R.B, a 50-year-old Caucasian male
Subjective Assessment
Chief Complaint: “Nasal Congestion and itching for five days.”
History of Present Illness (HPI): Mr. R.B., a 50-year-old Caucasian male, presents with complaints of nasal congestion, itchy nose, eyes, palate, ears, rhinorrhea, sneezing, and post-nasal drainage for five consecutive days. The patient has been taking Mucinex OTC to improve nighttime breathing, but the problem persists. He denies experiencing headaches or other pains. NURS 6512 Week 5 Assignment 1
Medications: Mucinex OTC 1 tablet orally at night.
Allergies: The patient reports seasonal allergies and has no known drug allergies (NKDA).NURS 6512 Week 5 Assignment 1
Past Medical History (PMH): There is no significant medical history reported. The patient denies any recent diagnoses or surgeries. However, he had a back injury in 2002 following an accident and was hospitalized for treatment. He has received a recent flu shot.
Social History: The patient is married with two children aged 12 and 14, respectively. He used to smoke but quit in 2006. He consumes alcohol on an occasional basis, typically twice per month. He holds a bachelor’s degree in BCOM and operates a consulting firm. He enjoys activities such as snowboarding and surfing with his family. The patient denies using cell phones while driving and emphasizes the use of seat belts. He follows a heart-healthy diet, engages in regular physical exercise, and generally experiences quality sleep. However, he mentions experiencing sleep disturbances in the last five days due to the onset of symptoms.
Family History: The patient’s parents are alive; his father has well-managed hypertension (H.T.N), while his mother had breast cancer and underwent a mastectomy in 1994, with no evidence of recurrence. He has two healthy siblings aged 42 and 46. His two children are also in good health. The patient’s grandparents are deceased, and he is unaware of their medical history or ages.NURS 6512 Week 5 Assignment 1
Review of Systems (ROS):
General: The patient appears well-groomed, denies fatigue, fever, or chills, but he appears tired and fatigued due to a lack of sleep.
HEENT (Head, Eyes, Ears, Nose, Throat): The patient reports itchy and red eyes with PERRLA (pupils equal, round, reactive to light, and accommodation), and no visual variations. He denies headache, with normal hearing and intact tympanic membranes. His nasal mucosa appears pale and boggy with tiny open secretions, congested nose, and elongated nasal turbinates. The throat is slightly erythematous, with non-inflamed tonsils.
Neck: No tracheal deviation or inflamed lymph nodes noted.
Skin: The patient’s skin exhibits clear color and pigmentation with no itching and has remarkable skin turgor.NURS 6512 Week 5 Assignment 1
