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Assessing the Head, Eyes, Ears, Nose, and Throat 

Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Case study: 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 during the past 2 weeks, Lily figured she shouldn\'t take her 3-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.
 

To Prepare
 
•    Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. 

•    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.

 

Below is the template to use.
Episodic/Focused SOAP Note Template
 
Patient Information:
Initials, Age, Sex, Race
S.
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.
Example of Complete ROS:
GENERAL:  No weight loss, fever, chills, weakness or fatigue.
HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.
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 anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
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.
O.
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)
A.
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.
P.  
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 6th edition formatting.
Note: reference should not be more than 5 years old.

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Assessing the Head, Eyes, Ears, Nose, and Throat

Patient Information:  L, 26 years, Female


CC (chief complaint): Sore throat


HPI: Lily a 20-year-old student at a community college presented to the clinic with complaints of sore throat. The patient noted that her sore throat has lasted three days and she got concerned because her friends and classmates informed her about an outbreak of flu-like symptoms sweeping her campus during the past 2 weeks. The patient indicates that she is experiencing appetite loss, pain with swallowing, and headaches. The voice is hoarse, she has a runny nose, but no congestion. The patient does not report any relieving or exacerbating factors. The patient has not taken any medication. Based on the pain scale, she describes the severity of her pain as 6/10.

Current Medications: No medication
Allergies: No reported allergies
PMHx: Last flu immunization September 2020, tetanus vaccine June 2019, no history of surgery or major illness

Soc Hx: Student currently living in a hostel. Goes out occasionally with friends but does not drink alcohol or take drugs. Exercises three times a week and prefers home meals to fast food. Uses a seat belt all the time and does not own a car. The patient denies smoking or engaging in other unhealthy habits common with young people.

She is the firstborn in a family of 3, both parents alive and living together. The patient has health insurance coverage


Fam Hx: grandmother has arthritis and high blood pressure, grandfather has high blood pressure. Great grandmother died of diabetes-related complications and great grandfather died of a heart attack. Mother has diabetes.


ROS
GENERAL: No weight loss, no fever
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose: runny nose, Throat: possible sore throat
SKIN: No rash or itching. Inflammation on the throat
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 blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, 3/25/2021.
NEUROLOGICAL: Headache present; No 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.
O.
 

General: A&O x3, dressed appropriately for the weather, appears fatigued

Head: No head injuries

EE: No blurred vision or visual loss; No ear infection, hearing is good;

Nose: Runny nose

Throat: Inflamed posterior pharynx is red

Neck: Tender lymph nodes on the tonsillar areas

Chest/Lungs: Lungs clear on auscultation

Heart/Peripheral Vascular: 3R 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: Warm, No rashes; no palpable nodes, well-perfused

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Diagnostic results:

Rapid antigen detection test (RADT)– negative for group A strep (GAS)
 

 

A.

Differential Diagnoses

1. Tonsilitis

2. Pharyngitis

3. Strep Throat

4. Peritonsillar abscess

5. Allergic Rhinitis

Differential Diagnosis

The primary diagnosis is tonsilitis, which commonly occurs in children and young adults. The condition is commonly caused by a virus but in rare cases can also be out of bacterial infection (Nitek, 2017). The clinical manifestations of tonsilitis include inflammation of the lymph nodes with tenderness on touching. Similarly, two swollen oval-shaped tissues can be observed at the back of the throat. Another symptom of tonsilitis is dysphagia (Stelter, 2014). Other symptoms include headache, sore throat, fever, and hoarseness of the voice. The symptoms described by the patient and observed during the assessment are consistent with the clinical manifestations of tonsilitis. Given that people around the college have also complained about the same symptoms, there could be a viral outbreak since the condition is contagiously transmittable through the air or objects touched by an infected person (Shah, 2020).

The second possible diagnosis is pharyngitis. Pharyngitis is a condition associated with a sore throat, which can either be viral or bacterial. The clinical manifestations are a pain when swallowing, swollen pharynx, headache, fever, fatigue, and nasal congestion. Most of the symptoms are similar to what the patient described during the assessment. The disease occurs from the common cold and is easily transmitted through tiny air droplets (Ball, Dains, Flynn, Solomon, & Stewart, 2019). This is also a consideration because assessment information indicates a possible outbreak. The rapid test for strep A is negative meaning that the cause is not bacterial. The absence of congestion in the nasal passage, sneezing, and cough make this a less preferable diagnosis. The third differential diagnosis in this case study is strep throat, a bacterial infection that commonly occurs in children and young adults (Dains, Baumann, & Scheibel, 2016). The strep through is contracted by coming into contact with an infected person’s sore. The clinical manifestations include swollen lymph nodes, sore throat, and fever. The symptoms are close to what is observed in the assessment of the patient. However, fever is a characteristic of bacterial infection, which is lacking in this case (Ball, Dains, Flynn, Solomon, & Stewart, 2019). In addition, the rapid strep test is negative for strep A (GAS), which causes strep throat.

The fourth possible diagnosis is a peritonsillar abscess. Peritonsillar abscess is another condition common in young adults, children, and adolescents. The condition is characterized by swollen pockets filled with pus near the tonsils. The condition occurs when tonsilitis or strep throat remains untreated causing it to spread beyond the tonsils and into the chest and neck (Rughani, 2019). Thus, it can cause blockage to the airway and other serious complications. The symptoms include sore throat, swallowing difficulties, and fever. Assessment information shows that the patient presents with some of these symptoms. However, tests confirm the absence of bacterial, and since the condition is bacterial, its likelihood, in this case, is low. Finally, the fifth differential diagnosis is allergic rhinitis, which is an allergic reaction that causes runny nose, sneezing, itchiness, redness, and watery eyes (Wheatley & Togias, 2015). The condition occurs due to a reaction to allergens in the air. In this case, the patient denies being allergic hence, the condition is unlikely the cause of the patient’s chief complainant.

 

 

References

Ball, J. W., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2019). Seidel's Guide to Physical Examination. 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.

Nitek, S. (2017). Differential diagnosis of tonsillitis, tonsillar detritus accumulation, and tonsillar keratin cysts. Medical Research Archives, 5(3). DOI: 10.18103/mra.v5i3.936.

Rughani, S. (2019). Case-based learning: sore throat. Pharmaceutical Journal, https://pharmaceutical-journal.com/article/ld/case-based-learning-sore-throat.

Shah, U. K. (2020). Tonsillitis and Peritonsillar Abscess. Medscape, https://emedicine.medscape.com/article/871977-overview.

Stelter, K. (2014). Tonsillitis and sore throat in children. GMS Curr Top Otorhinolaryngol Head Neck Surg, 13, Doc07.

Wheatley, L. M., & Togias, A. (2015). Allergic Rhinitis. N Engl J Med, 372(5), 456–463. doi: 10.1056/NEJMcp1412282.

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