Assignment: NURS 6512 Assessment of Head, Neck, Eyes, Ears, Nose, and Throat

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

Focused SOAP Note for a patient with chest pain

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CC: “nasal congestion and rhinitis * 5 days”

HPI: The patient is a 50-year old person who presented to the clinic suffering from rhinorrhoea, nasal congestion, as well as sneezing. The patient has struggled with the itchy palate, nose, as well as eyes for a period of 5 days. Moreover, he suffers from a pale, boggy nasal mucosa alongside enlarged turbinate as well as clear thin secretions. The tonsils are not enlarged; though, he has mild erythematous in his throat.

Medications: Mucinex

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PMH: No significant medical history. The patient denies having been admitted or undergoing surgical intervention in the last 2 years. He is up to date on his immunization.

FH: Both of the patient’s parents are alive. The patient is married and they have two children aged 14 and 12. He has two siblings who are aged 42 and 46 years. They are all healthy, except the mother who presents with breast cancer.

SH: The patient denies smoking. He indicates that he quit smoking in 2006. On the other hand, he occasionally drinks alcohol. The patient engages actively in religious activities. The patient understands the importance the eating healthy and engaging in regular physical exercise.

Allergies: NKDA, indicates seasonal allergic reactions.

Immunizations: n/a

ROS

The general-The patient is well-groomed and oriented. He denies fever or fatigue. He is AAOX 4.

HEENT: The patient denies headache, but the eyes are itchy and red. There are no changes in the visual acuity. The are intact with no hearing changes. The patient has nasal congestion and itchy nasal mucosal. The nasal turbinate is also enlarged.

Cardiovascular–Negative chest pain, no palpitations.

Gastrointestinal– No nausea, non-distended abdomen.

Pulmonary– negative for dyspnea or hemoptysis.

VS: BP 121/82; P 67; R 20; T 97.8; 02 96% Wt 191lbs; Ht 70”

General-The patient denies weakness or fatigue. He is well-groomed and nourished.

Cardiovascular- No chest pain or cyanosis noted in the patient.

HEENT: Eyes are itchy and red. The tympanic membranes are intact with no discharge. No tonsillitis or purulent discharge was produced. The throat is moderately erythematous. Enlarges nasal turbinate with clear thin secretions.

Gastrointestinal-The abdomen is symmetrical and non-distended.

Pulmonary– Lungs are clear to auscultation, no chest pain or murmuring sound produced.

Diagnostic results: Skin test positive for allergy, Allergen-specific IgE antibody test not done.

Differential Diagnosis:

Allergic rhinitis: The condition is characterized by sneezing and nasal congestion. The condition result from inhalation of allergens. Most of the symptoms indicated by the patient are consistent with the allergic rhinitis and this could be the most possible diagnosis (Hoyte & Nelson, 2018).
Sinusitis: The condition is characterized by the inflammation of the sinuses due to bacterial or viral infection. The common symptoms of the disease include nasal congestion, itchiness, and reddening. Also, the patient may have facial pain and pressure (Almutairi et al., 2018).
Common cold: Common cold is caused influenza virus. The virus is limited to the sinuses and is mainly spread through contact. The symptoms include nasal congestion, fever and headache (Singh et al., 2017). The patient denied fever and headache in this case.

Administer nasal corticosteroids with oral antihistamine (Urrutia Pereira, 2018).

NURS 6512 Assessment of Head, Neck, Eyes, Ears, Nose, and Throat

Episodic/Focused SOAP Note Template

Patient Information:

Name: L.R

Age: 20 years old

Sex: Female

Race: Caucasian

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,

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).

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.

This section explains the procedural knowledge needed to perform eyes, ears, nose, and mouth procedures.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1, 3, 4, and 5)

Shadow Health Support and Orientation Resources

Optional Resource

Use the following resources to guide you through your Shadow Health orientation as well as other support 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.

Assessment of the Head, Neck, Eyes, Ears, Nose, and Throat – Week 5 (29m)

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 the Week 4 Learning Resources area for access instructions on

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

Photo Credit: Getty Images/Blend Images

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.

By Day 6 of Week 5

Submit your Assignment.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the naming convention “WK5Assgn1+last name+first initial.(extension)” as the name.
Click the Week 5 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
Click the Week 5 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK5Assgn1+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:

Week 5 Assignment 1 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 5 Assignment 1 draft and review the originality report.

Submit Your Assignment by Day 6 of Week 5

To participate in this Assignment:

Week 5 Assignment 1

Assignment 2: Digital Clinical Experience: Focused Exam: Cough

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

Photo Credit: Getty Images

To Prepare

Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
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?

Focused Exam: Cough Assignment:

Complete the following in Shadow Health:

Respiratory Concept Lab (Required)
Episodic/Focused Note for Focused Exam: Cough
HEENT (Recommended but not required)

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.

Submission and Grading Information

By Day 7 of Week 5

Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard for your faculty review.
(Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here:
Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
Complete the Code of Conduct Acknowledgement.

Grading Criteria

To access your rubric:

Week 5 Assignment 2 DCE Rubric

Submit Your Assignment by Day 7 of Week 5

To submit your Lab Pass:

Week 5 Lab Pass

To participate in this Assignment:

Week 5 Documentation Notes for Assignment 2

To Submit your Student Acknowledgement:

Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.

What’s Coming Up in Week 6?

Photo Credit: [BrianAJackson]/[iStock / Getty Images Plus]/Getty Images

Next week, you will evaluate abnormal findings in the area of the abdomen and the gastrointestinal system. In addition, you will appraise health assessment techniques and diagnoses for the heart, lungs, and peripheral vascular system as you complete your Lab Assignment in assessing the abdomen in a SOAP note format. You will also take your Midterm Exam, which covers the topics in Weeks 1–6. Please review the previous weekly content and resources to help you prepare for your exam. Plan your time accordingly.

Week 6 Required Media

Photo Credit: [fergregory]/[iStock / Getty Images Plus]/Getty Images

Next week, you will need to view several videos and animations in the Seidel’s Guide to Physical Examination as well as other media, as required, prior to completing your Lab Assignment. There are several videos of various lengths. Please plan ahead to ensure you have time to view these media programs to complete your Assignment on time.

Next Week

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Name: NURS_6512_Week_5_Assignment_1_Rubric

	Excellent	Good	Fair	Poor
Using the Episodic/Focused SOAP Template: · Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.· Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.	Points Range: 45 (45%) – 50 (50%) The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.	Points Range: 39 (39%) – 44 (44%) The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.	Points Range: 33 (33%) – 38 (38%) The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.	Points Range: 0 (0%) – 32 (32%) The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.	Points Range: 30 (30%) – 35 (35%) The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected.	Points Range: 24 (24%) – 29 (29%) The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.	Points Range: 18 (18%) – 23 (23%) The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.	Points Range: 0 (0%) – 17 (17%) The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.	Points Range: 5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.	Points Range: 4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.	Points Range: 3 (3%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.	Points Range: 0 (0%) – 2 (2%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation	Points Range: 5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) grammar, spelling, and punctuation errors.	Points Range: 3 (3%) – 3 (3%) Contains several (3 or 4) grammar, spelling, and punctuation errors.	Points Range: 0 (0%) – 2 (2%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.	Points Range: 5 (5%) – 5 (5%) Uses correct APA format with no errors.	Points Range: 4 (4%) – 4 (4%) Contains a few (1 or 2) APA format errors.	Points Range: 3 (3%) – 3 (3%) Contains several (3 or 4) APA format errors.	Points Range: 0 (0%) – 2 (2%) Contains many (≥ 5) APA format errors.

Total Points: 100

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

Episodic/Focused SOAP Note Template

Patient Information:

Initials: L.M Age: 20 years old Sex: Female Race: Caucasian

CC (chief complaint): “Sore throat.”

HPI: Lily is a 20-year-old Caucasian female patient who came to the clinic complaining of a sore throat that had lasted for the past three days. The patient was taking the sore throat lightly until when there was a flu outbreak at her college about two weeks ago when she got concerned that this incident might be associated with her symptoms. The patient also reported additional symptoms such as headache, pain with swallowing, and decreased appetite. She claims that some of her classmates presented with similar symptoms. She however denies chills or fever. She has not taken any medication for her present condition.

Location: Throat

Onset: 3 days ago

Character: scratchy and sore.

Associated signs and symptoms: decreased appetite, headache, running nose, and pain with swallowing

Timing: Started two weeks after a flu outbreak at her school.

Exacerbating/ relieving factors: swallowing food or drinking water worsens the pain. Gargling with warm water reduces the pain.

Severity: 6/10 pain scale

Current Medications: Multivitamin oral tablets, once daily for the past 6 months.

Allergies: Dust mite. No drug or food allergies.

PMHx: Immunization status is up to date, with the last flu vaccine received in October 2020. Her last tetanus shot was received in June 2019. The patient denies any history of medical diagnosis or surgery.

Soc Hx: The patient is a full-time college student studying economics. She enjoys spending time with his friends and reading comic books. She denies taking alcohol, cigarettes, or any other illicit drug of abuse.

Fam Hx: Patient mother has a history of diabetes and hypertension. His father was diagnosed with Gout. Her paternal grandfather died at the age of 65 years from stroke, with a history of diabetes. Her paternal grandmother is still alive with a history of HTN, and osteoarthritis. She has no information regarding her maternal grandparents.

ROS:

GENERAL: No weight loss, chills. Report fever, weakness, and fatigue. Reports decreased appetite.

HEENT: Head: Reports headache. No signs of trauma or injury. Eyes: No vision changes or double or blurry vision. The sclera has no abnormal discoloration. Ears: No hearing loss. Nose and throat: congestions, or sneezing. The patient complains of a sore and scratchy throat. The patient also reports pain with swallowing that she rates as a 6/10 severity on a pain scale for the past 3 days.

SKIN: No itchiness or rashes.

CARDIOVASCULAR: No chest pressure, pain, or any other discomfort. No edema or palpitations.

RESPIRATORY: Report shortness of breath and cough. No sputum

GASTROINTESTINAL: No nausea or vomiting, anorexia, or diarrhea. No abdominal pain.

GENITOURINARY: No burning on urination, hesitancy, no urgency, no foul odor or urine color.

NEUROLOGICAL: Reports intermittent headache for the past 3 days.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness

HEMATOLOGIC: No bruises, anemia, or bleeding.

LYMPHATICS: No history of splenectomy. Swollen lymph nodes were noted in the neck

PSYCHIATRIC: No history of anxiety or depression. Denies any history of harming self or others.

ENDOCRINOLOGIC: No reports of sweating, heat, or cold intolerance. No polydipsia or polyuria.

ALLERGIES: Dust mites

Physical exam:

General: The patient is alert and cooperative all through the examination period. She displays no signs of distress. Her vitals are T: 98.6, Pls: 85, RR: 19, BP: 105/78, and O2 99% on room air.

HEENT: Head is atraumatic and normocephalic. Pupils are round, equal, and reactive to light. No erythema or effusion on the tympanic membrane. No discharge or swelling was noted in the ear canals. The neck is supple with anterior cervical lymphadenopathy. Throat with mild swelling and exudates. Tonsils are swollen. Nostrils are red and swollen.

Chest/lungs: Breathing sounds clear to auscultation

Heart: Regular heart rate and rhythm with no murmur or gallop.

Abdomen: Soft, non-distended, non-tender abdomen, with bowel sounds present in all four quadrants.

Neurological: Intermittent headache.

Diagnostic results: Complete Blood Count (CBC) 7.9: Red Blood Cells 4.7, Platelets 200, and H/H: 12.6/37.8. Throat swab culture ordered with preliminary findings reveal negative results of Group A streptococcus bacteria.

Influenza: This is a viral infection that affects the lung characterized by upper respiratory symptoms. Patients diagnosed with this condition normally present with several signs and symptoms such as cough, fever, malaise, headache, coryza, respiratory distress, and sore throat (Chow et al., 2019). The patient in the provided case study displays most of these symptoms making it the most appropriate diagnosis. Additionally, the patient might have been infected with the virus during the flu outbreak. However, a throat culture is needed to confirm the presence of the influenza virus.
Acute Pharyngitis: Acute pharyngitis is a medical condition affecting the tonsils or posterior pharynx caused by microorganisms. Common symptoms displayed include sore throat, dysphagia, fever, headaches, abdominal pain, and fetid breath (Sykes et al., 2020). This condition is normally associated with acute pharyngitis. Some of the symptoms were displayed by the patient. However, no signs of abdominal pain, among others were not displayed by the patient.
Acute epiglottitis: This is a severe and rapidly progressing health condition characterized by sore throat, dyspnea, and hoarseness caused by Hemophilus influenza infection (Baird et al., 2018). The patient displayed most of these symptoms, however, a throat culture is needed to confirm this diagnosis.
Acute Sinusitis: This is a bacterial infection characterized by paranasal sinuses. Symptoms include fever, headache, nasal discharge, congestion, and cough that can occur suddenly and become worse over a few days (Ebell et al., 2019). All of these symptoms, some of these symptoms, or even none of these symptoms may occur in individuals with sinusitis, just like the patient in the provided case study.
Laryngitis: This is an inflammation of the larynx that can either be non-infectious or infectious. The most common symptoms associated with laryngitis include hoarseness, voice fatigue, throat pain, a sensation of lumping in the throat, and cough (Lechien et al., 2018). The patient in the provided case study displayed most of these symptoms. However, he also reported a running nose which is not experienced with this diagnosis.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Baird, S. M., Marsh, P. A., Padiglione, A., Trubiano, J., Lyons, B., Hays, A., … & Phillips, D. (2018). Review of epiglottitis in the post Haemophilus influenzae type‐b vaccine era. ANZ journal of surgery, 88(11), 1135-1140.

Chow, E. J., Doyle, J. D., & Uyeki, T. M. (2019). Influenza virus-related critical illness: prevention, diagnosis, treatment. Critical care, 23(1), 1-11.

Ebell, M. H., McKay, B., Dale, A., Guilbault, R., & Ermias, Y. (2019). Accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis and acute bacterial rhinosinusitis. The Annals of Family Medicine, 17(2), 164-172. https://doi.org/10.1370/afm.2354

Lechien, J. R., Saussez, S., & Karkos, P. D. (2018). Laryngopharyngeal reflux disease: clinical presentation, diagnosis and therapeutic challenges in 2018. Current opinion in otolaryngology & head and neck surgery, 26(6), 392-402. doi:10.1097/MOO.0000000000000486

Sykes, E. A., Wu, V., Beyea, M. M., Simpson, M. T., & Beyea, J. A. (2020). Pharyngitis: approach to diagnosis and treatment. Canadian Family Physician, 66(4), 251-257. PMCID:

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